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Medical Care blog

Comments from the scientific community regarding Medical Care.

Saturday, February 13, 2016


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Thursday, February 4, 2016

by Alexa Ortiz, MSN

Personally, I find patient portals to be convenient. It’s an easy way to send healthcare-related questions to my provider such as, “does this medication have any side effects?” or, “can you please refill my prescription?”  I perceive the primary benefit as not having to schedule an appointment or wait on hold for 15 minutes to get an answer.  Quick, easy, and a great method of communicating with your healthcare provider given our constantly on-the-go society.  However, 64% of American adults within the U.S. don’t use their online patient portal [1].  With portals being such an easy way for patients to get answers for their healthcare questions, what’s hindering their use?

For this post, I wanted to elaborate on patient portal barriers discussed in the article Patient-Initiated Electronic Messages and Quality of Care for Patients with Diabetes and Hypertension in a Large Fee-for-Service Medical Group: Results from a Natural Experiment based on my experience using patient portals as a healthcare worker.  To provide some background, the article focuses on patients diagnosed with hypertension or diabetes within a large, multispecialty, fee-for-service practice [2].  The occurrence of e-messaging was measured by patient-initiated threads to their providers [2].  Ultimately, the authors did not find a consistent association between e-messaging and improved clinical outcomes [2].

One reason provided to describe patients’ non-improving clinical outcomes is that clinicians primarily used e-messages to address simple questions rather than to provide complex clinical advice [2].  As a nurse, I can corroborate that straightforward questions, such as communicating to patients their normal lab values, were the simplest to address using e-messages and most frequent.  Complex clinical advice typically required multiple exchanges through the portal, and the majority of patients found it easiest to call the office or schedule an appointment when they had several concerns to address with their provider.

The studied practice setting was fee-for-service [2]. Clinicians were compensated $3 to $5 per message [2].  Since this was significantly less than the provider compensation for an office visit, the authors proposed that clinicians might have encouraged office visits for patients with issues not able to be addressed through limited e-messaging [2].  In comparison, the practice I worked for did not provide compensation to clinicians for e-messaging.  However, regardless of the length or detail of a patient’s portal communication, it’s difficult to get a full picture of their current condition without an in-person assessment.  Many of the clinicians I worked with requested office visits in lieu of e-messaging because to change a patient’s medication or order additional diagnostic testing without an in-person assessment was simply unsafe.

Beyond the limitations to e-messaging discussed in the prior article.  Authors Ronda, Dijkhorst-Oei, & Rutten also discuss the barriers to patient portals within Reasons and Barriers for Using a Patient Portal: Survey among Patients with Diabetes [3].  The article surveyed Netherlands-based diabetic patients at 1 outpatient hospital clinic and 62 primary care practices [3].  Of those patients surveyed, the main barrier to patient portal enrollment was unawareness [3].  Despite the study occurring in the Netherlands, the results are comparable to patients within the U.S.  Of the 2,017 US adults surveyed for the Annual Xerox EHR Survey (2014) 35% were unaware of the patient portal’s availability and 31% stated their provider had never discussed the patient portal with them [1].  

With the expansion of Meaningful Use, patient portals are becoming an increasingly important feature in many patient’s healthcare experience.  As the popularity of portals continues to rise, it’s the responsibility of each provider and patient to find the blurry line separating e-message vs. office visit.


Alexa Ortiz is a Registered Nurse and Health IT Scientist at RTI International.  The views expressed are those of the author and do not necessarily reflect those of RTI International.



[1] Xerox (2014). Annual xerox EHR survey: Americans open to viewing test results, handing healthcare online. Retrieved from

[2] McClellan, S. R., Panattoni, L., Chan, A. S., & Tai-Seale, M. (2016). Patient-initiated electronic messages and quality of care for patients with diabetes and hypertension in a large fee-for-service medical group: Results from a natural experiment. Medical Care. doi:10.1097/MLR.0000000000000483

[3] Ronda, M. C., Dijkhorst-Oei, L., & Rutten, G. E. (2014). Reasons and barriers for using a patient portal: Survey among patients with diabetes mellitus. Journal of Medical Internet Research, 16(11). doi:10.2196/jmir.3457

Image obtained from:

Thursday, January 28, 2016

By Gregory D. Stevens, PhD, MHS

According to data out this month from the Kaiser Family Foundation, there are 2 male doctors for every 1 female in practice in the US. This translates to about 300,000 fewer women than men in practice today. This gender difference is a disparity that many in health care may think has resolved, but in fact has smoldered rather quietly for years.

A recent study by Dahrouge and colleagues (published on Medical Care’s website on January 13, 2016) adds some fuel to the fire. Analyses of nearly 4,200 family doctors and 6.3 million patients in Ontario, Canada suggest that the gender disparity may hurt quality of care. The authors found that patients of female doctors were more likely to get the right preventive care and have better management of diabetes and congestive heart failure (if they had one of those conditions). They were also less likely to visit a hospital or emergency room during the study period.

The authors are cautious in offering explanations. If the results are generalizable—and studies dating back to the early 1990s, such as this one, suggest they might be—the policy prescriptions are complicated.

The authors (and others) offer variations on the idea that female doctors may take more time with patients, be more attuned to what patients want, or use clinical guidelines more often. (Are men more devil-may-care in this regard? Interesting idea, but at least one study suggests not.) It is also likely that patients respond differently to female and male doctors based on their own comfort, perceived empathy, and trust.

In my own work on primary care among patients with diabetes, only women reported benefitting—in terms of health and quality of life—from receiving higher quality primary care. We wondered whether women might have made better use of the time they spent with their doctors (for example, by asking more questions during visits). We didn’t consider the gender of the doctor, which now seems an oversight.

One obvious policy prescription we might draw from these findings is that more women should be encouraged to enter medicine, particularly primary care. However, the US has already seen increasing numbers of women in medicine. In 2014, women made up roughly 47% of all medical school graduates, although this still amounts to more than 900 fewer women than men graduating. Women also make up larger percentages in particular specialties, such as obstetrics/gynecology (85% female), pediatrics (75%), and family medicine (58%), and there are more than 2 female physician assistants for every male.

A second approach might be to observe how encounters with female doctors are actually different from encounters with male doctors and see what lessons can be drawn for male providers. A third is to push harder for the use of clinical guidelines across the board.

These are not easy issues. The work of Dahrouge and colleagues reminds us of the need to extinguish the flames, rather than let these gender disparities in quality continue to smolder.

Gregory D. Stevens, Ph.D., MHS is health policy researcher, writer, teacher and advocate. He is an Associate Professor of Family Medicine and Preventive Medicine at the Keck School of Medicine of the University of Southern California.

Thursday, January 7, 2016

by Alexa Ortiz MSN

Hospitalized patients rely on their nurses 24 hours per day, 365 days per year.  Nurses are the primary caregivers and the first line of observation if a patient’s condition is starting to worsen.  A recent article in Medical Care discusses how decreasing nurse-to-patient ratios in medical-surgical units as well as improving work environments is associated with increased patient survival following an in-hospital cardiac arrest (IHCA) [1].  The authors found that hospitalized patients receiving care in poor nursing work environments had a 16% lower likelihood of survival [1].  Moreover, for each extra patient a medical-surgical nurse took on, their patient’s odds of surviving an IHCA decreased by 5% [1].  However, reading this article did raise some questions about nurse staffing ratios and what signifies a good working environment.  After doing some initial searching, here is what I learned.


What signifies an improved working environment for nurses?

McHugh and colleagues partially answer this question within the previously mentioned article [1].  The  authors state that one avenue for achieving an improved working environment is for hospitals to obtain Magnet status through the American Nurses Credentialing Center (ANCC) [1].  After reviewing the ANCC site, it can be concluded that Magnet status is a high quality credential to receive.  Achieving Magnet status is a performance driven recognition based on goals outlined by the ANCC, such as creating a setting that supports professional practice, encouraging excellence in nursing care, and dissemination of best nursing practices [2].   


Would lowering nurse-to-patient ratios singlehandedly have an impact on patient outcomes?    

It’s easy to think more nurses with fewer patients = higher quality of patient care; however, this might not always be the case.  A 2011 article in Medical Care found that patient outcomes dramatically improved when low nurse-to-patient staffing ratios were accompanied by good working environments [3].  On the other hand, low nurse-to-patient staffing ratios had no impact on patient outcomes when combined with poor working environments [3].

What are the current laws surrounding nurse-to-patient staffing ratios?

The federal regulation 42 CFR 482.23 – Condition of Participation: Nursing Services states, “The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed” [4, 5].  In addition, according to the American Nurses Association, there are currently 14 states with laws/regulations regarding nurse staffing: California, Connecticut, Illinois, Massachusetts, Minnesota, Nevada, New Jersey, New York, Ohio, Oregon, Rhode Island, Texas, Vermont, and Washington [5].  Of those, California is the only one that has a law outlining the minimum nurse-to-patient ratio based on the type of care unit (i.e., intensive care unit, medical surgical, step-down) [5, 6].  Outside of California, Massachusetts also has a law regulating nurse-to-patient ratios; however, it only applies to the intensive care unit [5, 7].


What are the pros and cons for laws/regulations mandating specific nurse-to-patient ratios?

A number of the pros and cons were based on the experiences and lessons learned after California’s implementation of nurse staffing legislation.  A few of the key points were as follows [8]:


Pros: Mandating specific nurse-to-patient staffing ratios allowed nurses in California to spend more time with their patients.  In addition, procedural errors declined and patient outcomes improved since nurses were finally able to slow down and not rush patient care.


Cons: More Nurses = Higher Costs.  Since hospitals in California were not able to meet the mandated nurse staffing ratios, they were required to hire more nurses. Consequently, the healthcare system’s overall costs continued to rise.  Patients may also end up experiencing longer wait times with nurse staffing regulations.  A large influx of patients might not receive immediate treatment since the hospital is required to keep nurse-to-patient ratios at a certain level.   


What are the key takeaway points regarding nurse staffing and working environment?

Laws and regulations guiding nurse-to-patient ratios are beneficial, but they come at a price.  Nurses may be able to spend more time with their patients, but healthcare costs may continue to rise.  Furthermore, a lower nurse-to-patient ratio doesn’t automatically mean an improvement in patient outcomes.  Changes to nurse staffing ratios must also be accompanied by improved working conditions for patient outcomes to be positively impacted.


Alexa Ortiz is a Registered Nurse and Health IT Scientist at RTI International.  The views expressed are those of the author and do not necessarily reflect those of RTI International.



[1] Mchugh, M. D., Rochman, M. F., Sloane, D. M., Berg, R. A., Mancini, M. E., Nadkarni, V. M., . . . Aiken, L. H., American Heart Association’s Get With The Guidelines-Resuscitation Investigators (2016). Better nurse staffing and nurse work environments associated with increased survival of in-hospital cardiac arrest patients. Medical Care, 54(1), 74-80. doi:10.1097/MLR.0000000000000456


[2] ANCC Magnet Recognition Program®. American Nurses Credentialing Center. Retrieved from:


[3] Aiken, L. H., Cimiotti, J. P., Sloane, D. M., Smith, H. L., Flynn, L., & Neff, D. F. (2011). Effects of nurse staffing and nurse education on patient deaths and hospitals with different nurse work environments. Medical Care, 49(12), 1047-1053. doi:10.1097/MLR.0b013e3182330b6e


[4] 42 CFR 482.23 – Condition of Participation: Nursing Services. U.S Government Publishing Office.  Retrieved from:


[5] Nurse Staffing.  American Nurses Association. Retrieved from


[6] Nurse-to-Patient Staffing Ratio Regulations. California Department of Public Health.  Retrieved from


[7] HPC Regulation 958 CMR 8.00 to Implement the ICU Nurse Staffing Law.  Administration and Finance. Retrieved from:


[8] Health Experts Debate the Merits of Nurse-Staffing Ratio Law. Retrieved from:

Image obtained from:

Thursday, December 24, 2015

by Amanda A. Honeycutt, PhD

As a parent of two young children with a chronic illness, I know first-hand the importance of having a medical home that provides access to primary care doctors who coordinate testing and care across specialists, treatment facilities, pharmacies, and labs. Fortunately, our pediatrician has taken on the role of care coordinator, ensuring that my children receive the testing and treatment they need when they need it while avoiding gaps in treatment and unnecessary/duplicative testing. This type of family- and patient-centered medical home model has been recommended for the care of children with special health care needs for over 45 years (1). Thanks in no small part to its effective use, my children’s disease is being adequately managed. They are able to do ballet, play basketball and violin, and attend and fully participate in school—in other words, just be normal kids.

A similar type of patient-centered medical home (PCMH) model is now being held up as a way to improve all patients’ experiences and outcomes and reduce healthcare spending. PCMH models vary in their implementation, but generally encompass “wide-ranging team-based care, patient-centered orientation toward the whole person, care that is coordinated across all elements of the health care system and the patient’s community, enhanced access to care that uses alternative methods of communication, and a systems-based approach to quality and safety” (2; p. 2). These PCMH models build on coordinated care approaches that have worked for people with chronic conditions, such as diabetes and asthma (3, 4, 5).

A 2012 Agency for Healthcare Research and Quality (AHRQ) report identified evidence that PCMH models can improve patient experiences and the process of care for preventive services, but found insufficient evidence of an impact on clinical and economic outcomes (2). The report also noted the need to understand the effect of the PCMH model in “more broadly representative primary care samples” (2; p. 15). In a recent Medical Care article (6), researchers Meredith Rosenthal, Anna Sinaiko, and collaborators address this need through their evaluation of the Rochester Medical Home Initiative (RMHI).

RMHI was a pilot program in which 7 primary care practices in Rochester, NY, implemented a patient-centered medical home (PCMH) model beginning in 2009. The RMHI model involved implementing a coordinated clinical care approach and changing reimbursement to compensate for time spent on PCMH activities. The Rosenthal et al. (2015) analysis included patients 18 years and older who had insurance through a commercial plan or through Medicare or Medicaid HMO plans. Although many prior analyses have focused on outcomes only among Medicare or Medicaid beneficiaries or people with chronic conditions (see Damika Barr’s February 2015 blog post for examples), Rosenthal and team analyzed the impacts of PCMH for all adult patients in a primary care practice, which is important for understanding the average impact of PCMH if implemented for a broad mix of patients.

The researchers found a statistically significant, but modest, increase in breast cancer screening and LDL testing among patients with diabetes (3% to 4% higher rates than in the pre-RMHI period). They also found a significant, but very small, impact on reducing avoidable hospitalizations and no significant impact on total spending. These findings are suggestive that the PCMH model may improve health care delivery without increasing spending, but it also raises an important question of whether PCMH approaches are worthwhile for healthy adults. Should the intensive PCMH approach be used only for patients with chronic illness, where it has been shown to have desirable impacts? Rosenthal and team did not provide results for subgroups with chronic conditions or Medicaid/Medicare insurance. Yet, their finding of a limited positive effect of PCMH across all patients suggests that while PCMH approaches may significantly improve outcomes for patients with chronic conditions, they may have little impact and even raise spending for healthier patients. And because it is costly for practices to adopt a PCMH model (7), we need to ask whether the PCMH framework should be extended to all patients. For which patients is the PCMH model cost effective and how can a PCMH approach be most efficiently applied?     

The ultimate goal of the PCMH approach is to improve and extend patients’ lives through providing better quality health care. Recent and ongoing research on PCMH implementation and impacts, such as the Rosenthal et al. study, are contributing to a better understanding of the broad impact of PCMH approaches. But we still have a lot to learn about which components of the PCMH model are most important for success, which patients stand to benefit the most, and under what circumstances a PCMH approach is cost effective.

Image result for patient medical home


Amanda A. Honeycutt, PhD, Director of the Public Health Economics Program at RTI International


  1. American Academy of Pediatrics, Council on Pediatric Practice. Chronic illness. In: Standards of Child Health Care. Evanston, IL: American Academy of Pediatrics; 1967:36–40.

  2. Williams JW, GL Jackson, BJ Powers, R Chatterjee, J Prvu BEttger, AR Kemper, V Hasselblad, RJ Dolor, RJ Irvine, BL Heidenfelder, AS Kendrick, and R Gray. The Patient-Centered Medical Home. Closing the Quality Gap: Revisiting the State of the Science. Evidence Report/Technology Assessment No. 208. (Prepared by the Duke Evidence-based Practice Center under Contract No. 290-2008-10066-I.) AHRQ Publication No. 12-E008-0EF. Rockville, MD. Agency for Healthcare Research and Quality. July 2012.      

  3. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness: the chronic care model, Part 2. JAMA. 2002;288(15):1909–14.

  4. Coleman K, Austin BT, Brach C, et al. Evidence on the Chronic Care Model in the new millennium. Health Aff (Millwood) 2009;28(1):75–85. [PubMed]

  5. Flottemesch, TJ, SH Scholle, PJ O’Connor, LI Solberg, S Asche, and LG Pawlson.  

Are Characteristics of the Medical Home Associated with Diabetes Care Costs? Medical Care. 2012. 50(8): 676-684.

6.   Rosenthal, MB, AD Sinaiko, D Eastman, B Chapman, and G Partridge. Impact of the Rochester Medical Home Initiative on Primary Care Practices, Quality, Utilization, and Costs. Medical Care. 2015. 53(11): 967-973 (

7.   Nocon, RS, R Sharma, JM Birnberg, Q Ngo_Metzger, SM Lee, and MH Chin. Association Between Patient-Centered Medical Home Rating and Operating Cost at Federally Funded Health Centers.  JAMA, 2012. 308(1): 60-66.