Journal of Pediatric Rehabilitation Medicine: An Interdisciplinary Approach 7 (2014) 63–70 DOI 10.3233/PRM-140275 IOS Press
63
Transition of adolescents with chronic health conditions to adult primary care: Factors associated with physician acceptance Suzanne Elizabeth McLaughlina,∗, Jason Machanb , Phillip Fournierc, Tamara Changd, Katelyn Evene and Matthew Sadoff a
Departments of Pediatrics and Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA Departments of Orthopedics and Surgery, Warren Alpert Medical School of Brown University, Providence, RI, USA c Department of Family Medicine and Community Health, University of Massachusetts Medical School, Worcester, MA, USA d Department of Oncology, St. Jude’s Children’s Research Hospital, Memphis, TN, USA e University of Massachusetts Medical School, Worcester, MA, USA f Baystate Children’s Hospital, Springfield, MA, USA b
Accepted 5 September 2013
Abstract. PURPOSE: To assess the willingness of adult primary-care physicians to transfer young adults with special health care needs (YASHCN) into their practices, and the relative impact of patient characteristics and transition supports. METHODS: Survey of primary care internists and family practitioners using randomized patient characteristics and transition supports in clinical vignettes to assess physician willingness to accept a YASHCN into their practice. RESULTS: 404 responses were received from 601 surveys (response rate 67%). Only 44% rated themselves “willing” or “enthusiastic” to accept a YASHCN. Using four-way ANOVA testing, provider and practice characteristics significantly associated with willingness to accept included gender, years in practice, presence of YASHCN in current practice and whether the practice was accepting new patients. Patient condition and transition support significantly affected willingness to accept; training in internal medicine versus family practice did not. CONCLUSION: Physicians providing primary care for adults express limited willingness to accept YASHCN into their practices. Provider, practice and patient characteristics affected willingness to accept. Although transition supports affected willingness to accept, effects varied markedly across diagnoses and physician gender. Findings have implications for patients and healthcare teams and policy planners. Keywords: Health care transition, transition to adult care, adolescents with special health care needs
1. Introduction
∗ Corresponding author: Suzanne McLaughlin, Warren Alpert Medical School of Brown University. 593 Eddy Street, Physicians’ Office Building, Suite #230. Providence, RI 02903, USA. Tel.: +1 401 444 7486; Fax: +1 401 444 8804; E-mail: smclaughlin1@ lifespan.org.
The improved long-term survival of children with special health care needs has created a growing population of young adults with chronic health conditions in need of adult-oriented health care services [1–3] Preparation for adulthood is a national core performance outcome for systems of care for children with
c 2014 – IOS Press and the authors. All rights reserved 1874-5393/14/$27.50
64
S.E. McLaughlin et al. / Adult physicians’ acceptance of adolescents with chronic health conditions
special health care needs, yet less than half of ageappropriate patients meet this goal [4]. Identifying providers willing to accept these young adults with chronic conditions is a challenge for patients, families and pediatric healthcare teams [5–13]. In surveys and focus groups, physicians for adults have identified patient, physician and system factors that present challenges to transition including: lack of knowledge in the care of childhood-onset chronic conditions, anticipated difficulties in interactions with patients and family members, time demands of care coordination and inadequate reimbursement [8]. To what extent do these challenges affect physicians’ behavior? The practical question for an individual patient is: Are they willing to become my adult primary care doctor [5,14–17]? This study assesses the willingness of Massachusetts primary care physicians for adults to accept a young adult with a chronic health condition into their practice. We hypothesized that the willingness to accept would vary based on provider characteristics and sought to quantify the effects of patient condition and transition supports.
2. Methods 2.1. Design and setting We sought to approximate the experience of an individual seeking to establish care with a new primary adult-care practice. We constructed clinical vignettes to assess primary care physicians’ willingness to accept a young adult with a chronic health condition into their practice. Studies have validated the use of clinical vignette-based surveys to measure variation in physicians’ clinical behavior [18–20]. The vignette described a 22 year old male with a chronic condition seeking an adult primary care provider. Four clinical conditions and six transition supports were used to represent factors identified by primary care physicians as resources for and barriers to providing health care for adults with childhood onset conditions [5,14–17]. The patient condition and transition support were varied systematically to create multiple versions of the vignette. The versions were randomly distributed. Physicians were asked to respond to a single version only, to avoid unconscious bias or anchoring. Supports represented actual options or services available in the state at the time of the survey. Vignettes were reviewed for clinical accuracy by mem-
bers of the state chapter of the American Academy of Pediatrics Committee on Disabilities. Physician and practice variables included: gender, years in practice, specialty, percent of time providing clinical primary care, practice characteristics, nonclinical work activities and whether the practice currently cared for young adults with chronic health conditions. The outcome variable was self-reported willingness to accept the patient into the physician’s practice, assessed on a numbered scale anchored by phrases. The institutional review board of the University of Massachusetts School of Medicine approved this study. 2.2. Participants and survey sample Random samples of 1000 internists and 500 family practitioners were identified from the Massachusetts Board of Registration in Medicine’s publicly-accessible comprehensive list of state-licensed physicians. The website promotes the Physician Profiles as “a comprehensive reference source to help consumers find a particular physician, find physicians in the consumer’s local area, or to look for physicians in a specific specialty” [21]. Preliminary screening suggested 1/3rd of internists and 2/3rds of family practitioners in the physician registry would be eligible. An a priori power analysis indicated a sample size of 150 from each specialty would suffice to identify a half-point variation in willingness to accept. We projected a minimum survey response rate of 55%. and sought to enroll 300 eligible primary care physicians within each specialty. Figure 1 summarizes the enrollment process. Physicians were excluded from the study if their profile noted a subspecialty licensure, a primary practice address other than Massachusetts, their inactive license status, or did not provide a phone contact. Eligible physicians’ practices were contacted by telephone to confirm accurate mailing information and whether the physician was currently providing adult primary care services. Physicians were excluded if the screening indicated they were not currently providing primary care or were doing so in a setting that would exclude enrollment of young adults from the general population (for example, a Veterans Administration site, nursing home, college health service or correctional facility). Surveys were mailed to eligible physicians between November, 2008-January, 2009. Mailings included a cover letter, clinical vignette, brief closed-ended response items and a $2 incentive for survey return. The
S.E. McLaughlin et al. / Adult physicians’ acceptance of adolescents with chronic health conditions N=6899
N=1506
State board of licensure site (accessed 11/4/2008)
State board of licensure site (accessed 11/4/2008)
N=1000
N=455
Randomly selected
Randomly selected
N=306 Eligible respondents were mailed surveys
N=169 completed surveys
N=694 excluded (outof-state address, no contact informaon, license not acve, phone contact indicated not adult primary care provider, or primary care to restricted populaon)
N=20 Ineligible
N= 117 No
N=295 Eligible respondents were mailed
N=195 completed surveys
65
N=155 excluded (outof-state address, no contact informaon, license not acve, phone contact indicated not adult primary care provider, or primary care to restricted populaon)
N=17 ineligible responses
N=83 No
responses (did not rate willingness)
Fig. 1. Planned study design showing identification of physician sample.
survey was pilot tested on a convenience sample of internists and family practitioners. The mailing methodology and revised survey were pre-tested on practicing internists and family practitioners in the University of Massachusetts Medical Group. 2.3. Statistical analysis Statistical analyses were carried out using SAS version 9.3 using proc glimmix (The SAS Institute Inc., Cary, NC). Responses of physicians to the vignettes were modeled using general linear models, fit using restricted maximum likelihood (REML). The effects of condition and support, as well as their interaction were contained in all models to represent the primary effects of interest. Three models were used to test whether the way in which condition and support interacted varied (were moderated) by gender, years in practice, or specialty. This was accomplished by adding all three terms along with condition, support, and condition x support, and rotating each of the three in their own model as ad-
ditionally interacting with condition, support, and condition x support. Higher order models were avoided owing to the small size of model cells that would be created. Follow-up a priori planned comparisons were carried out using orthogonal contrasts.
3. Results Responses were received from 404 of 601 mailed surveys (response rate 67%). Table 1 reports respondent characteristics. A range of provider and practice characteristics is reflected. Notably, only 55% of primary care providers’ offices reported they were accepting new patients. Only 12% of providers reported currently caring for YASHCN. Mean reported willingness to accept YASHCN was 3.13, with a standard deviation of 1.3 on a 5-point Likert scale. Table 2 reports the frequency distribution of responses. Willingness to accept, stratified by physician-reported personal and practice characteristics is detailed in Table 3.
66
S.E. McLaughlin et al. / Adult physicians’ acceptance of adolescents with chronic health conditions Table 1 Respondent characteristics Characteristic Gender Specialty
Female Family Medicine Internal Medicine
% 45.2 53.6 46.4
n 160 195 169
Years since completion of residency
63
Transition of adolescents with chronic health conditions to adult primary care: Factors associated with physician acceptance Suzanne Elizabeth McLaughlina,∗, Jason Machanb , Phillip Fournierc, Tamara Changd, Katelyn Evene and Matthew Sadoff a
Departments of Pediatrics and Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA Departments of Orthopedics and Surgery, Warren Alpert Medical School of Brown University, Providence, RI, USA c Department of Family Medicine and Community Health, University of Massachusetts Medical School, Worcester, MA, USA d Department of Oncology, St. Jude’s Children’s Research Hospital, Memphis, TN, USA e University of Massachusetts Medical School, Worcester, MA, USA f Baystate Children’s Hospital, Springfield, MA, USA b
Accepted 5 September 2013
Abstract. PURPOSE: To assess the willingness of adult primary-care physicians to transfer young adults with special health care needs (YASHCN) into their practices, and the relative impact of patient characteristics and transition supports. METHODS: Survey of primary care internists and family practitioners using randomized patient characteristics and transition supports in clinical vignettes to assess physician willingness to accept a YASHCN into their practice. RESULTS: 404 responses were received from 601 surveys (response rate 67%). Only 44% rated themselves “willing” or “enthusiastic” to accept a YASHCN. Using four-way ANOVA testing, provider and practice characteristics significantly associated with willingness to accept included gender, years in practice, presence of YASHCN in current practice and whether the practice was accepting new patients. Patient condition and transition support significantly affected willingness to accept; training in internal medicine versus family practice did not. CONCLUSION: Physicians providing primary care for adults express limited willingness to accept YASHCN into their practices. Provider, practice and patient characteristics affected willingness to accept. Although transition supports affected willingness to accept, effects varied markedly across diagnoses and physician gender. Findings have implications for patients and healthcare teams and policy planners. Keywords: Health care transition, transition to adult care, adolescents with special health care needs
1. Introduction
∗ Corresponding author: Suzanne McLaughlin, Warren Alpert Medical School of Brown University. 593 Eddy Street, Physicians’ Office Building, Suite #230. Providence, RI 02903, USA. Tel.: +1 401 444 7486; Fax: +1 401 444 8804; E-mail: smclaughlin1@ lifespan.org.
The improved long-term survival of children with special health care needs has created a growing population of young adults with chronic health conditions in need of adult-oriented health care services [1–3] Preparation for adulthood is a national core performance outcome for systems of care for children with
c 2014 – IOS Press and the authors. All rights reserved 1874-5393/14/$27.50
64
S.E. McLaughlin et al. / Adult physicians’ acceptance of adolescents with chronic health conditions
special health care needs, yet less than half of ageappropriate patients meet this goal [4]. Identifying providers willing to accept these young adults with chronic conditions is a challenge for patients, families and pediatric healthcare teams [5–13]. In surveys and focus groups, physicians for adults have identified patient, physician and system factors that present challenges to transition including: lack of knowledge in the care of childhood-onset chronic conditions, anticipated difficulties in interactions with patients and family members, time demands of care coordination and inadequate reimbursement [8]. To what extent do these challenges affect physicians’ behavior? The practical question for an individual patient is: Are they willing to become my adult primary care doctor [5,14–17]? This study assesses the willingness of Massachusetts primary care physicians for adults to accept a young adult with a chronic health condition into their practice. We hypothesized that the willingness to accept would vary based on provider characteristics and sought to quantify the effects of patient condition and transition supports.
2. Methods 2.1. Design and setting We sought to approximate the experience of an individual seeking to establish care with a new primary adult-care practice. We constructed clinical vignettes to assess primary care physicians’ willingness to accept a young adult with a chronic health condition into their practice. Studies have validated the use of clinical vignette-based surveys to measure variation in physicians’ clinical behavior [18–20]. The vignette described a 22 year old male with a chronic condition seeking an adult primary care provider. Four clinical conditions and six transition supports were used to represent factors identified by primary care physicians as resources for and barriers to providing health care for adults with childhood onset conditions [5,14–17]. The patient condition and transition support were varied systematically to create multiple versions of the vignette. The versions were randomly distributed. Physicians were asked to respond to a single version only, to avoid unconscious bias or anchoring. Supports represented actual options or services available in the state at the time of the survey. Vignettes were reviewed for clinical accuracy by mem-
bers of the state chapter of the American Academy of Pediatrics Committee on Disabilities. Physician and practice variables included: gender, years in practice, specialty, percent of time providing clinical primary care, practice characteristics, nonclinical work activities and whether the practice currently cared for young adults with chronic health conditions. The outcome variable was self-reported willingness to accept the patient into the physician’s practice, assessed on a numbered scale anchored by phrases. The institutional review board of the University of Massachusetts School of Medicine approved this study. 2.2. Participants and survey sample Random samples of 1000 internists and 500 family practitioners were identified from the Massachusetts Board of Registration in Medicine’s publicly-accessible comprehensive list of state-licensed physicians. The website promotes the Physician Profiles as “a comprehensive reference source to help consumers find a particular physician, find physicians in the consumer’s local area, or to look for physicians in a specific specialty” [21]. Preliminary screening suggested 1/3rd of internists and 2/3rds of family practitioners in the physician registry would be eligible. An a priori power analysis indicated a sample size of 150 from each specialty would suffice to identify a half-point variation in willingness to accept. We projected a minimum survey response rate of 55%. and sought to enroll 300 eligible primary care physicians within each specialty. Figure 1 summarizes the enrollment process. Physicians were excluded from the study if their profile noted a subspecialty licensure, a primary practice address other than Massachusetts, their inactive license status, or did not provide a phone contact. Eligible physicians’ practices were contacted by telephone to confirm accurate mailing information and whether the physician was currently providing adult primary care services. Physicians were excluded if the screening indicated they were not currently providing primary care or were doing so in a setting that would exclude enrollment of young adults from the general population (for example, a Veterans Administration site, nursing home, college health service or correctional facility). Surveys were mailed to eligible physicians between November, 2008-January, 2009. Mailings included a cover letter, clinical vignette, brief closed-ended response items and a $2 incentive for survey return. The
S.E. McLaughlin et al. / Adult physicians’ acceptance of adolescents with chronic health conditions N=6899
N=1506
State board of licensure site (accessed 11/4/2008)
State board of licensure site (accessed 11/4/2008)
N=1000
N=455
Randomly selected
Randomly selected
N=306 Eligible respondents were mailed surveys
N=169 completed surveys
N=694 excluded (outof-state address, no contact informaon, license not acve, phone contact indicated not adult primary care provider, or primary care to restricted populaon)
N=20 Ineligible
N= 117 No
N=295 Eligible respondents were mailed
N=195 completed surveys
65
N=155 excluded (outof-state address, no contact informaon, license not acve, phone contact indicated not adult primary care provider, or primary care to restricted populaon)
N=17 ineligible responses
N=83 No
responses (did not rate willingness)
Fig. 1. Planned study design showing identification of physician sample.
survey was pilot tested on a convenience sample of internists and family practitioners. The mailing methodology and revised survey were pre-tested on practicing internists and family practitioners in the University of Massachusetts Medical Group. 2.3. Statistical analysis Statistical analyses were carried out using SAS version 9.3 using proc glimmix (The SAS Institute Inc., Cary, NC). Responses of physicians to the vignettes were modeled using general linear models, fit using restricted maximum likelihood (REML). The effects of condition and support, as well as their interaction were contained in all models to represent the primary effects of interest. Three models were used to test whether the way in which condition and support interacted varied (were moderated) by gender, years in practice, or specialty. This was accomplished by adding all three terms along with condition, support, and condition x support, and rotating each of the three in their own model as ad-
ditionally interacting with condition, support, and condition x support. Higher order models were avoided owing to the small size of model cells that would be created. Follow-up a priori planned comparisons were carried out using orthogonal contrasts.
3. Results Responses were received from 404 of 601 mailed surveys (response rate 67%). Table 1 reports respondent characteristics. A range of provider and practice characteristics is reflected. Notably, only 55% of primary care providers’ offices reported they were accepting new patients. Only 12% of providers reported currently caring for YASHCN. Mean reported willingness to accept YASHCN was 3.13, with a standard deviation of 1.3 on a 5-point Likert scale. Table 2 reports the frequency distribution of responses. Willingness to accept, stratified by physician-reported personal and practice characteristics is detailed in Table 3.
66
S.E. McLaughlin et al. / Adult physicians’ acceptance of adolescents with chronic health conditions Table 1 Respondent characteristics Characteristic Gender Specialty
Female Family Medicine Internal Medicine
% 45.2 53.6 46.4
n 160 195 169
Years since completion of residency
