Transcript Epidemiology of Primary Care and relation to preventive

Epidemiology of Primary Care
in relation to preventive medicine - public health
CMG Buttery MB BS MPH
Fall 2007
Figure 1. Percent of office visits by physician specialty: United
States, 2000
24.1
29.4
General & Family
Practice
Internal Medicine
Pediatrics
Ob/Gyn
Opthalmology
15.2
5.6
Orthopedic Surgey
All Other
5.2
7.9
12.6
10 Advance Data No. 328 + June 5, 2002
Table 1. Number, percent distribution, and annual rate of office
visits with corresponding standard errors, by selected physician
practice characteristics: United States, 2000
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Physician practice characteristic
All visits
Physician specialty
General and family practice
Internal medicine
Pediatrics
Obstetrics and gynecology
Orthopedic surgery
Ophthalmology
Dermatology
Psychiatry
Cardiovascular diseases
Urology
General surgery
Otolaryngology
Neurology
All other specialties
Number of visits
in thousands
823,542
198,578
125,556
103,734
65,135
46,155
42,735
34,509
28,864
21,598
18,703
16,897
16,399
8,411
96,269
>50% of ALL office visits are to primary care physicians.
Advance Data No. 328 June 5, 2002
Table 3. Number, percent distribution, and annual
rate of office visits by patient’s age, sex, and race:
United States, 2000
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Patient’s age, sex, and race
Number of visits in thousands
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All visits
Under 15 years
15–24 years
25–44 years
45–64 years
65–74 years
75 years and
over
823,542 Age
142,466
67,172
196,833
216,783
102,447
97,842
16 Advance Data No. 328,June 5, 2002
Table 9. Number and percent distribution of office by the 20 principal
reasons for visit most frequently mentioned by patients, United
States, 2000
Number of visits in
thousands
823,542
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Principal reason for visit and RVC code1
All visits
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General medical examination*
Progress visit, not otherwise specifiedT800
Cough
X100
S440
63,952
32,776
22,360
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Routine prenatal examination*
Postoperative visit
Symptoms referable to throat
Skin rash
Vision dysfunctions
Knee symptoms
Back symptoms
X205
T205
S455
S860
S305
S925
S905
22,085
21,178
17,519
13,365
12,965
12,533
12,464
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Well-baby examination*
Stomach pain, cramps, and spasms
Medication, other and unspecified kinds
Earache or ear infection
Hypertension
Depression
Headache, pain in head
Nasal congestion
Chest pain and related symptoms
Fever
All other reasons
X105
S545
T115
S355
D510
S110
S210
S400
S050
S010
488,
12,457
12,275
11,424
11,288
10,398
10,043
9,320
8,857
8,833
8,801
650
*
Prevention visits
Advance Data No. 328,June 5, 2002
Table 16. Number and percent of office, by therapeutic
and preventive services ordered or provided,
United States, 2000
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Number of Therapeutic and preventive visits
in services ordered or provided
All visits
None
Counseling/education Diet
Exercise
Injury prevention
Growth/development
Stress management
Prenatal instructions
Mental health
Tobacco use/exposure
Breast self-examination
Skin cancer prevention
Family planning/contraception
HIV/STD transmission
Other therapy
Complementary and alternative
medicine
Physiotherapy
Psycho-pharmacotherapy
Psychotherapy
thousands
823,542
515,550
26,988
80,839
24,610
21,460
18,403
18,396
18,221
18,213
17,827
14,311
9,564
5,190
31,589
22,273
19,947
18,669
Table 26. Mean time spent with physician by physician
specialty: United States, 2000
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Mean time spent with physician (Mins.)
Physician specialty
All visits
Psychiatry
Neurology
Cardiovascular diseases
Internal medicine
General surgery
Obstetrics-gynecology
Orthopedic surgery
General, family practice
Ophthalmology
Otolaryngology
Urology
Dermatology
Pediatrics
All other specialties
18.9
36.0
28.0
21.5
19.7
19.0
18.2
17.1
17.0
16.9
16.8
16.2
15.8
15.4
23.5
PRIMARY CARE PROBLEMS IDENTIFIED BY PRIMARY
PRACTITIONERS
Prepared for NAPCRAG meeting in 1984
TOTAL NUMBER OF
PROBLEMS
IDENTIFIED
(have ICD code)
TOTAL COMMON
PROBLEMS as
PERCENT OF TOTAL
PROBLEMS
FP
591
159/26.9
GIM
520
147/28.3
PED
353
90/25.5
OBG
277
69/24.9
NUMBER AND PROPORTION OF COMMON PROBLEMS SEEN
BY PHYSICIAN B AS
A SUBSET OF TOTAL COMMON PROBLEMS
SEEN BY PHYSICIAN A
Physician A
Physician B
FP
GIM
PED
OBG
FP
159/100
110/73.8
74/83.1
41/61.2
GIM
110/69.2
147/100
53/59.6
33/49.3
PED
74/46.9
53/35.6
90/100
27/40.3
OBG
41/25.8
33/22.1
27/30.3
69/100
Types of Prevention
• Primary
– Before signs or symptoms of disease
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Immunization
Diet
Exercise
Aspirin to reduce stroke events
Prevention
(Continued)
• Secondary
– Signs and symptoms present but early
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Lower Blood Pressure
Reduce Smoking
Reduce Weight
Reduce Stress
Reduce Salt Intake
INH for TB Infection
Prevention (Continued)
• Tertiary
– Late disease, intent to delay progress
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Physical Therapy after Injury
Anticoagulant after Stroke
Weight Reduction for Morbid Obesity
HAART Therapy for PWA
Tamoxifen after Breast Cancer Surgery
Insulin Pump for Type 1 Diabetic
PROPORTION OF OFFICE VISITS FOR DIAGNOSES
AMENABLE TO PRIMARY OR SECONDARY
PREVENTION
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MD
FP
GIM
PED
OBG
Prim
29.8
31.9
31.8
54.1
Sec
5.4
l0.6
0.2
0.9
How do we improve the links between
Primary Care and Public Health/Prevention
• Pay for Prevention Services
• Add Physician Extenders to Practice
– NP, PA, H.Ed., MH Counsellor
• Use of Computerized Records that
– Remind need of Immunizations
– Remind Need for Routine Management
– Provide Health Ed. Material
– Computer links to patients.
PC – PH Prevention Links
• Closer Health Department – Practicing
physician ties.
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Weekly or monthly surveillance reports
Databases of Community Health Status
Prevention talks at Hospital meetings
Epidemiologic Surveys of patient records
• CASA/CDC
– Periodic review of death records with Rx for
prevention activities
– Place PHNs in Physician’s offices
How many Doctors?
Current US population:
Approximately 300Mn.
AFP Recommended patient load:
1 FP/2000 patients
How Many Doctors -II
For 300 Million People: 150,000 FPs.
Assume 48 work weeks per MD
Assume 10% will be in nonproductive
positions teaching.
Need =200,000
Outside the US maximum ratio of
Specialist to PCPs is 1:1
How Many Doctors III
Maximum number of physicians needed
400,000
According to AMA practicing non-federal
Physicians
814776 non-federal
How Many Doctors - IV
• Most physicians are in Patient Care (80.0%).
Patient Care includes: Office-Based physicians
• Full-Time Hospital Staff (9.2%), and
Residents/Fellows (14.0%).
• Physicians not in Patient Care are in Other
Professional Activity, which includes:
Administration (1.9%), Teaching(1.2%),
Research (1.7%), and Other (0.5%).
• None of these percentages has changed
significantly over the last 30 years.