Patient care outside of office visits in primary care: Two key topics

INTRODUCTION: Much of a primary care physician's work occurs outside of thee context of face-to-face office visits with patients. Two key areas for study are understanding the patient care coordination that generalists perform outside of office visits as well as investigating the curbside consultation process between generalists and specialists.;MANUSCRIPT I - Patient Care Outside of Office Visits: A Primary Care Physician Time Study;BACKGROUND: Patient care provided by primary care physicians outside of office visits is important for care coordination and may serve as a substitute for office visits.;OBJECTIVES: Study objectives are to describe primary care physicians' patient care activities outside of office visits ("AOVs") and their perceptions of the extent to which AOVs substitute for visits and may be performed by support staff.;METHODS: A cross-sectional direct observational study of 33 general internists in 20 practices in 2 healthcare systems (one private, one public) was conducted. Each participant was shadowed for one day of ambulatory practice to document their AOVs. Two questionnaires and an interview were also administered. Data collected included duration of AOVs; AOV categorization by activity and whether it pertained to a patient visit on the study day (visit specific) or not (non-visit specific); physician perceptions of the extent that non-visit specific AOVs substituted for visits, of the extent that visits which occurred could have been substituted for by AOVs, and of the potential role of support staff in AOVs. Data was analyzed descriptive statistics.;RESULTS: Physicians spent 20% of their workday performing AOVs. They perceived that a median of 37% of non-visit specific AOV time substituted for visits, representing a potential 5 daily visits saved. They also perceived that 15% of total AOV time (excluding charting) could be performed by support staff. Forty-two percent of physicians indicated that one or more visits on the study day could be substituted for by AOVs.;DISCUSSION: Though AOVs are generally not reimbursable, primary care general internists spent substantial time performing AOVs that may save office visits and that mostly could not be performed by other staff. Policies reimbursing and supporting AOVs may enable further use of AOVs, hence reducing health care costs, saving time, and improving care coordination.;MANUSCRIPT II - Curbside Consultations between Primary Care Physicians and Specialists: A Review of the Literature;BACKGROUND: With the advent of managed care and concern over the effects of formal specialty consultations on health care costs and access to care, the use of informal or curbside consultations (CSCs) in clinical practice has become an area of research interest.;METHODS: Prior literature was compiled and reviewed to assess the frequency, use, outcomes, and limitations of CSCs.;RESULTS: Primary care physicians and specialists commonly engaged in CSCs. CSCs were used most commonly to answer specific patient care management questions and to determine the need for formal consultations. A minority of CSCs resulted in formal consultations, and three studies suggested that CSCs substituted for more costly and time-consuming formal consultations. However, incomplete exchange of information during CSCs, lack of documentation, liability concerns, and lack of reimbursement were limitations of CSCs.;DISCUSSION: Future research is recommended to assess trends in nationwide and organizational variation in CSC use, characteristics of patients more likely to receive CSCs than formal consultations, appropriateness of and adherence to specialists' CSC recommendations, patient care outcomes and quality measures following CSCs, and extent to which CSCs may substitute for formal consultations.;OVERALL CONCLUSIONS: Understanding the nature and value of the often invisible care coordination and curbside consultations that physicians perform outside of office visits may be helpful in maximizing efficiency, controlling costs, and ultimately improving primary care.