Nowels David, Nowels Molly A, Sheffler Julia L, Kunihiro Susan, Lum Hillary D
From University of Colorado School of Medicine, Aurora, CO (DN, MAN, HDL); Rutgers University Institute For Health, Health Care Policy, and Aging Research, New Brunswick, NJ (MAN); Florida State University College of Medicine, Tallahassee, FL (JLS); Emory University School of Medicine, Atlanta, GA (SK); Veterans Affairs Eastern Colorado Geriatric Research Education and Clinical Center, Aurora, Colorado (HDL).
J Am Board Fam Med. 2019 Nov-Dec;32(6):835-846. doi: 10.3122/jabfm.2019.06.190017.
Primary care practices are essential settings for Advance Care Planning (ACP) conversations with patients. We hypothesized that such conversations occur more routinely in Advanced Primary Care/Patient Centered Medical Home (APCP/PCMH) Practices using practice transformation strategies.
We analyzed characteristics of physician respondents and their practices associated with ACP discussions in older and sicker patients using US data from the 2015 Commonwealth Fund International Survey of Primary Care Physicians in 10 Nations. The primary outcome was how routinely these ACP conversations are reported. We developed an index of APCP/PCMH features as a practice covariable.
Respondents (N = 1001) were predominantly male (60%) and ≥45 years old (74%). Multivariable analyses showed that suburban practice location was associated with fewer ACP conversations; working in a practice commonly seeing patients with multiple chronic conditions or who have palliative care needs, and working in a practice from which home visits are made, were associated with more ACP conversations. Physicians compensated in part by capitation were more likely to report ACP conversations. No association was found between a single item asking if the practice was an APCP/PCMH and having ACP conversations. However, higher scores on an index of APCP/PCMH features were associated with more ACP conversations.
In this sample of US primary care physicians, the types of patients seen, practice location, and physician compensation influenced whether physicians routinely discuss ACP with patients who are older and sicker. Practices demonstrating more features of APCP/PCMH models of primary care are also associated with ACP discussions.
基层医疗实践是与患者进行预先护理计划（ACP）对话的重要场所。我们假设，在采用实践转型策略的高级基层医疗/以患者为中心的医疗之家（APCP/PCMH）实践中，此类对话会更常规地发生。
我们使用2015年英联邦基金对10个国家的基层医疗医生进行的国际调查中的美国数据，分析了与老年和病情较重患者的ACP讨论相关的医生受访者及其实践的特征。主要结果是这些ACP对话被报告的常规程度。我们制定了一个APCP/PCMH特征指数作为实践协变量。
受访者（N = 1001）主要为男性（60%）且年龄≥45岁（74%）。多变量分析表明，郊区的实践地点与较少的ACP对话相关；在通常接待患有多种慢性病或有姑息治疗需求患者的实践中工作，以及在进行家访的实践中工作，与较多的ACP对话相关。按人头付费部分补偿的医生更有可能报告ACP对话。询问实践是否为APCP/PCMH的单个项目与进行ACP对话之间未发现关联。然而，APCP/PCMH特征指数得分较高与较多的ACP对话相关。
在这个美国基层医疗医生样本中，所诊治患者的类型、实践地点和医生薪酬影响了医生是否常规地与老年和病情较重的患者讨论ACP。展示更多APCP/PCMH基层医疗模式特征的实践也与ACP讨论相关。
