Monthly Archives: November 2015

Improve primary care access? Let’s start with transparency of office hours

I have yet to meet a family physician who does not believe, through a delusion or not, that they are providing tremendous access to their patients.

Certainly the recent results from the Health Quality Ontario report on quality indicators in primary care were controversial, including 44% of patients reporting they can get an appointment the same or next day, and only 78% could get a same-day response to a phone call.

The responses you heard from physicians were along the lines of “I always have appointments available, my patients just go straight to walk-in clinics”.

So we have a disconnect. Some patients believe they can’t see their physician, or even get a phone call response. Some physicians say that’s not true, the patients just aren’t trying hard enough to get a hold of them. I think that it’s possible that they’re both right. Many physicians are indeed available, and many patients just don’t know that they’re available. (I am going to casually sidestep the issue of physicians who don’t actually provide good access).

Let’s start with a painfully simple solution. Let’s provide accurate hours of operation to our patients on a weekly basis, available online on our practice websites.

There really is no rationale for why this shouldn’t be easily available for our patients. If they are ill, they should know exactly how and when they can get a hold of us. The available schedule should include hours where you see patients, hours where your phones are answered, and who patients should call after your hours of operation. Updated on Sunday evenings, ready for patients to see what their physician’s schedule looks like for the week. Away at a conference? Taking the afternoon off for a family event? This should be accounted for on a weekly schedule, where patients can quickly reference. Nearly every other service industry provides detailed hours of availability, and there is no reasonable explanation for why we can’t provide transparency.

For this article, I did a quick perusal of some practice websites of physicians who I know are providing great access, but their hours listed and contact information on the websites are still not clear. We must approach this from the perspective of a patient who is looking for care and wants to know where to turn. Make it crystal clear for them to know who to call when, either during hours or after hours, when messages are appropriate, and the locations and addresses of the clinics involved. If messages are returned on weekends to book patients for Saturday or Sunday morning clinics, this should be clearly outlined. If you’re on holiday, the contact information for your coverage should be clear, with expectations for what type of conditions will be seen urgently, and what can wait, and when you will respond to requests. Highlight clearly if you offer same-day appointments, in BIG BOLD LETTERS. And maybe a quick explanation about what THAS is and when/how they should call THAS.

Some physicians already do this. Some do it sporadically, then forget about their website for months at a time. But if we make it a systemic, formalized approach, we can gradually train all of our patients to collectively know where they should turn for their first point of care.

And let’s reward physicians for complying. A monthly component of the existing capitation fee tied to successfully keeping updated online hours, subject to a collectively bargained process for auditing compliance.

For seniors or others who don’t have access to the Internet, the Telehealth staff (or even ER staff or other health care workers) would also be able to access the physician’s hours online, and guide the patient to the appropriate available resource.

Apart from improving patient knowledge of our availability, my hope is that this type of transparency with hours would lead physicians who are underperforming in their provided access to improve their availability, or at least work towards a mechanism for their patients to access other members of their team.

Such a simple, almost trivial issue. But perhaps a solution that can begin the path towards improved patient perception of access to primary care.

Treating to target in gout: absence of evidence

I understand that my title alone is considered infurating to rheumatologists. Hear me out.

My interest in gout targets was peaked this summer when I encountered this article from the Journal of Rheumatology. Its results showed that 55% of long-term gout patients had their uric acid checked in the past 5 years, and the uric acid was at target in 22% of patients.

The study’s conclusion? “Gout is managed poorly in Australian primary care”. Wait, what? Where are the outcome measures? Making conclusions based on a surrogate marker? This surrogate marker better be good….

Most papers which discuss treating to target in gout simply reference the EULAR task force and the British Society of Rheumatology guidelines, but we need to dig a bit deeper.

There’s no doubt that there appears to be a correlation between lower uric acid levels and lower rates of flares. But what about prospective trials of treating to target <360 compared to a higher target, or compared to treating to outcome? Not a single trial exists. The target they have chosen was based on initial basic science dissolution studies, but that is miles away from the prospective evidence needed to justify militantly recommending specific targets.

A good analogy to the uric acid story is treating LDL with statins. We know that 80mg of simvastatin does provide a small, but measurable decrease in cardiovascular events compared to 10mg of simvastatin. Does every patient need to be on a higher dose of statin to achieve an LDL target? We have no prospective evidence to support treating to LDL targets, and after years of debate, we are finally moving away from LDL targets in cardiovascular risk management. The same argument can be made with uric acid targets. Does treating with higher doses of allopurinol decrease risk of flares more than lower doses? Likely yes. But will lower doses of allopurinol likely suffice for the majority of patients, regardless of uric acid level? Also likely yes.

I hope we can move in the same direction with gout management that we have with lipids. Treat to outcomes, and intensify treatment should patients continue to flare on lower doses. Stop being a slave to uric targets that don’t have a solid evidence base.


Accountability measures tied to funding must be based on process, not outcome

Most reasonable primary care physicians would agree that as we strive to provide high-quality care to our patients, certain performance measures should be evaluated and that tying performance to specific funding is not an unreasonable proposal. This is certainly a hot-button topic in Ontario, with a government moving forward with primary care reform, yet no clearly articulated vision for how to connect performance and funding most efficiently.

Any discussion about primary care performance measures must start with the terrific document that Health Quality Ontario unveiled in fall 2014, A Primary Care Performance Measurement Framework for Ontario. Over 100 stakeholders from across the Ontario primary care spectrum collaborated to create this document which outlines 112 practice-level and 179 system-level measures. This is as thorough a document as you will see on the topic, and is a must-read for anyone with any interest in performance and quality in primary care.

Part of my disappointment with the proposed New Grad Entry Program was that of all of the available performance measures that the ministry could tie to funding, they chose three highly flawed measures. Percentage of patients with same day/next day appointments is a laudable goal, but is prone to reporting bias and may miss other forms of access provided. Preventative care targets provide a perverse disincentive for physicians to take on complex patients who are unlikely to complete screening measures. And patient experience surveys…c’mon now.

We can do better. We can take the work done by HQO and create a set of measures that primary care physicians agree have value, and should be tied to funding. With one small caveat.

We should always reward the process, not the outcome.

Here’s an example. The ministry wants colorectal screening to be maximized, and provides financial incentives based on the percentage of completed fecal occult testing. I am fortunate that I have a motivated patient population, and consistently meet the maximum targets. But what about a physician serving immigrant or homeless populations, who may find it impossible to meet the ministry targets? Should we not reward the fact that the physician discussed and offered colorectal screening, rather than the completion?

This same argument can be made to any proposed intervention and measure. Reward the process. Make the measures self-report. Allow for external auditing with an agreed-upon process to ensure honesty. And set the bar high for the targets.

Pap smears, colorectal screening, breast screening, flu shots, and childhood immunizations. Set the bar at 95% for offering the intervention to all patients. Meet the standard, get the money. Don’t meet the standard, get nothing.

I’ll add a few other measures I see as useful to tie to chunks of funding. Offering a yearly medication review to those over 65. Offering a periodic health review to all patients once a year (can be part of regular visit) where BP and weight are done, with an update of medications, immunizations, screening, family history, social history and other recent changes in health. If a patient refuses to come in, that’s fine, but it was offered, and that’s what is measured. Offering pneumococcal vaccination to targeted populations. Offering appropriately timed visits to those with diabetes and COPD. Offering statins when appropriately. Again, never rewarding whether the patient took the statin or not, because that financial incentive will result in coercive, non-patient-centred medicine. And of course, tying certain funding to participation in EMR Maturity Model & Reporting.

The ministry is quite fond of 30-day re-admission numbers and primary care follow-up visits within 7 days. What they fail to understand is that whether my patient is readmitted to hospital is largely out of my hands. We are largely helpless to the ultimate outcome. But again, could we reward the process instead? Incentivize a mandatory medication review following discharge, and rather than continue the E080 code, make it a tracking code that measures any contact (phone or in person) in the 7 days following hospital discharge. Many physicians object to mandatory visits within 7 days of discharge (eg. they were the admitting physician in hospital, or the diagnosis does not require follow-up), but this simple change to the E080 would be a compromise.

I would argue that the measures in the HQO report related to patient-centredness are best addressed by providing the physician-level data privately, with no ties to funding, with physicians having the ability to reflect personally on their opportunities for improvement in their practice.

As for tying access to funding…that’s the million dollar question that I won’t pretend to have the answer to. We need to continue to have open discussions about what access should look like, how it should be measured, and how culpable physicians should be for patient demand.

Physicians would be happy to be accountable to certain primary care measures. But judge us on what we can control, and primary care physicians will rise to the occasion.

It’s time to re-establish the lustre of the family physician

As physicians descend on Toronto this week for Family Medicine Forum, these past few months have been demoralizing for family physicians in Ontario.

Unilateral cuts from the Liberal government in January. Unilateral cuts again in October. Sweeping primary care reform being implemented without the involvement of physician leadership. Daily slanderous claims from the government about being overpaid. An active lawsuit against the government. An editorial from the CEO of the Registered Nurses’ Association of Ontario (RNAO) parroting the government’s rhetoric against physicians, in an attempt to argue for higher nurse practitioner salaries. A report today from Health Quality Ontario painting a picture of family physicians providing poor access to patients. And the latest from this week, Health Minister Eric Hoskins has sent an official referral to the Health Professions Regulatory Advisory Council (HPRAC) confirming the government’s intent to allow RN prescribing, and seeking consultation of which model to move forward with.

So to summarize, Ontario family physicians are working for a government that won’t negotiate with us, won’t tell us what they are planning, with seemingly indefinite cuts, with nurse practitioners already demanding a greater piece of the clinical pie, with RNs assuming another portion of our role, and a government that is very friendly to nursing groups.

Feeling alone yet?

We all know that everything taking place around us is absurd. We know that all of the proposed changes will only add red tape and bureaucracy to our health care system, and make an already overly politicized system even more politicized. We know that family physicians are best positioned to lead the primary care system. We understand health policy, we understand what our patients need, and we are always willing to make the sacrifices necessary to make our system more sustainable. But we’re being elbowed out of the picture.

I’m not sure how government spawned the idea that family physicians are an expendable resource. They seem all too keen to parse out all of our skills and responsibilities to other health professionals, leaving us with an unknown role in the future. Unfortunately, physicians have unknowingly been complicit in this transformation, showing a naïve keenness to delegate as many tasks as possible.

But it’s time to re-establish our brand. Time to re-establish the role of the comprehensive family physician: a cost-effective, efficient, skilled, and irreplaceable resource in our health care system. No one can match our abilities. It’s time to start showing that again.

This starts with our relationships with our patients. They need to see us as an integral part of their lives. They need to see our offices like the bar from Cheers. Everyone knows their name, and they feel welcome. Find unique ways to engage them. Provide them superb access. If you are one of the physicians in Ontario who can’t provide a visit within 1-2 days, or who isn’t responding to your patients’ same-day phone calls, I have bad news for you. Your patients see you as very replaceable. Be present in the office. We all need to take necessary breaks from our clinical work, but remember that the more time your office is closed, the more patients begin to find ways of managing without you. And if your patients don’t value you, the government will value you even less.

Broaden your skills. The more talents you can bring to the table, the more value you will have as a family physician in our changing system. Procedural skills, comfort with complex cases, pharmacotherapy management, palliative care, house calls…look at your practice now, and decide how you can comfortably become more comprehensive.

If you aren’t forced to delegate a task, either because of logistics or time constraints, then don’t. Do the little things in your practice that patients still see value in. You can’t afford to be the office manager sitting in the background, while other health professionals get the most face time with patients. You need to foster those relationships, so look for small opportunities with even simple tasks. Give the immunization. Do the pap. Syringe that ear. It may be a financially losing strategy in the short-term, but the goal has to be your long-term connection with your patients, and their sense of value for family physicians.

I don’t know what family medicine will look like in Ontario for the rest of my career. I’d be lying if I said this situation doesn’t frighten me. But the only thing truly in my power is to provide my patients with the best quality care, and to continue to foster relationships with my patients. Even if the government is too short-sighted to appreciate our value, I know that our patients have far more sense, and will advocate for care that they appreciate and can’t live without. It may take years to re-establish the brand of family medicine, but we can’t afford to take our position for granted any longer.