Health and Science

Many doctors can't manage multiple chronic conditions

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Primary care doctors are the first line of defense in the American health-care system. But a new report suggests that many of them feel they aren't equipped to handle their most challenging patients.

Up to one in four U.S. primary care doctors believe their practices aren't well prepared to manage care for patients with multiple chronic conditions, according to the report issued Monday by the Commonwealth Fund, a health-care research foundation.

That finding comes as the overall U.S. population is aging and as nearly 70 percent of recipients people 65 years or older covered by Medicare — the federal health insurance program for senior citizens — are reported to have multiple chronic conditions.

Separately, the Commonwealth Fund survey also found that a large majority of primary care doctors — 84 percent — say they aren't well prepared to deal with patients with severe mental illness.

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The survey, which is being published in the journal Health Affairs, also found that a very low percentage of primary care doctors — only 16 percent — believe the U.S. health system is working well.

Many of them said they aren't notified when one of their patients leaves the hospital or is admitted to an emergency department — which can lead to a gap in getting people follow-up care, a particularly serious concern for patients with multiple chronic conditions.

Fewer than one of every three primary care doctors in the U.S. said they get such notifications of hospital discharges, and emergency admissions of their patients.

"Primary care is the hub of patients' health-care experiences. If it isn't strong and working efficiently, patients won't get the best possible care," said Dr. David Blumenthal, president of the Commonwealth Fund.

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The report is based on a survey of more than 11,000 primary care doctors and looked at the U.S. and nine other major industrialized countries. The other countries examined were Australia, Canada, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland and the United Kingdom.

The report found that all of those nations face "challenges" in taking care of patients with complex medical conditions.

Those challenges are being exacerbated by increased cases of dementia and physical frailty, growing numbers of people at risk for chronic illness, as well as advances in medical science that are letting people live longer with "multiple serious chronic health conditions," the report said.

How the US stacks up with other countries

The problem is particularly pressing in the United States, which, despite having a younger population than the other countries surveyed, "has a higher share of patients with multiple chronic illnesses than any of the other nine nations," the Commonwealth Fund noted.

The U.S., in comparison to the other countries, tends to have the lowest or some of the lowest rates of primary care doctors who say their practices were well prepared to deal with patients with dementia, those who need long-term home care, who require social services, and or those with substance use-related health issues.

Only about half of U.S. primary care doctors said their practice routinely communicates with their patients' home care providers, and just 43 percent frequently coordinate with their patients' social services providers. The United States has the lowest rate, 39 percent, of primary care physicians who have arrangements for patients to get after-hours care without going to the emergency room.

Other countries still make house calls

The United States also has, by far, the lowest incidence of primary care staff who make home visits to patients. Only 6 percent of U.S. primary care staff make house calls, the report found. That is 13 percentage points less than the next lowest country in the survey, Canada.

The U.S. dramatically lags some developed nations when it comes to house calls. For instance, 88 percent of primary care staff in the Netherlands and 84 percent in the United Kingdom report that they frequently make house calls.

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"We need a strong primary care infrastructure, and we don't have it, and we haven't had it for a long time," said Blumenthal. "It's actually getting worse."

"The primary care system in the United States is failing, and that's not the case, and hasn't been the case" in many other countries, Blumenthal said.

He said that the growth of walk-in health clinics in CVS pharmacies, Wal-Marts and elsewhere reflects that failure of the primary care system.

Robin Osborn, lead author of the report and a Commonwealth Fund vice president, said that the other countries examined in the study "have had much stronger primary care infrastructure," in some cases requiring patients to register with a primary care practice that can act as gate-keepers for their care.

A bright spot

The survey did identify one bright spot for the U.S. primary care doctors in the area of health information technology. The U.S. has seen a marked increase in the rate of adoption of electronic medical records, relatively high use of email to communicate with patients, and the highest percentage of any surveyed country of patients able to access medical records — 60 percent.

Despite that, the U.S. had the second-lowest rate of satisfaction among doctors with their electronic medical records — just 52 percent, followed only by Sweden at 37 percent.