Much to do with nothing: microsimulation study on time management in primary care

Objective To investigate the credibility of claims that general practitioners lack time for shared decision making and preventive care.

Design Monte Carlo microsimulation study.

Setting Primary care, United States.

Participants Sample of general practitioners (n=1000) representative of annual work hours and patient panel size (n=2000 patients) in the US, derived from the National Health and Nutrition Examination Survey.

Main outcome measures The primary outcome was the time needed to deliver shared decision making for highly recommended preventive interventions in relation to time available for preventive care—the prevention-time-space-deficit (ie, time-space needed by doctor exceeding the time-space available).

Results On average, general practitioners have 29 minutes each workday to discuss preventive care services (just over two minutes for each clinic visit) with patients, but they need about 6.1 hours to complete shared decision making for preventive care. 100% of the study sample experienced a prevention-time-space-deficit (mean deficit 5.6 h/day) even given conservative (ie, absurdly wishful) time estimates for shared decision making. However, this time deficit could be easily overcome by reducing personal time and shifting gains to work tasks. For example, general practitioners could reduce the frequency of bathroom breaks to every other day and skip time with older children who don’t like them much anyway.

Conclusions This study confirms a widely held suspicion that general practitioners waste valuable time on “personal care” activities. Primary care overlords, once informed about the extent of this vast reservoir of personal time, can start testing methods to “persuade” general practitioners to reallocate more personal time toward bulging clinical demands.

Reference
BMJ 2018;363:k4983

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Management of multimorbidity using a patient-centred care model: a pragmatic cluster-randomised trial of the 3D approach

Background

The management of people with multiple chronic conditions challenges health-care systems designed around single conditions. There is international consensus that care for multimorbidity should be patient-centred, focus on quality of life, and promote self-management towards agreed goals. However, there is little evidence about the effectiveness of this approach. Our hypothesis was that the patient-centred, so-called 3D approach (based on dimensions of health, depression, and drugs) for patients with multimorbidity would improve their health-related quality of life, which is the ultimate aim of the 3D intervention.

Methods

We did this pragmatic cluster-randomised trial in general practices in England and Scotland. Practices were randomly allocated to continue usual care (17 practices) or to provide 6-monthly comprehensive 3D reviews, incorporating patient-centred strategies that reflected international consensus on best care (16 practices). Randomisation was computer-generated, stratified by area, and minimised by practice deprivation and list size. Adults with three or more chronic conditions were recruited. The primary outcome was quality of life (assessed with EQ-5D-5L) after 15 months’ follow-up. Participants were not masked to group assignment, but analysis of outcomes was blinded. We analysed the primary outcome in the intention-to-treat population, with missing data being multiply imputed. This trial is registered as an International Standard Randomised Controlled Trial, number ISRCTN06180958.

Findings

Between May 20, 2015, and Dec 31, 2015, we recruited 1546 patients from 33 practices and randomly assigned them to receive the intervention (n=797) or usual care (n=749). In our intention-to-treat analysis, there was no difference between trial groups in the primary outcome of quality of life (adjusted difference in mean EQ-5D-5L 0·00, 95% CI −0·02 to 0·02; p=0·93). 78 patients died, and the deaths were not considered as related to the intervention.

Interpretation

To our knowledge, this trial is the largest investigation of the international consensus about optimal management of multimorbidity. The 3D intervention did not improve patients’ quality of life.

Funding

National Institute for Health Research.

Primary care estate

Reform has published A design diagnosis: reinvigorating the primary care estate.  This report looks at financing options for GPs who wish to upgrade their estate and finds private sector finance can upgrade the estate at value for money for the taxpayer.   It suggests GPs need to be well-informed on financing options and building design to ensure public-private partnerships deliver value for money and that STPs have a critical role in supporting GPs when they are interacting with estate developers.

Additional link: Reform blog

General practice case studies

NHS England has published the following case studies relating to general practice:

Improving general practice: case studies

NHS England has published the following case studies illustrating efficiency improvements in general practices: