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Primary Care and Patient Safety: Opportunities at the Interface

September 28, 2022
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Editor’s Note: Special thanks to Freya Spielberg, MD, MPH, Founder and CEO of Urgent Wellness LLC in Washington, DC; and Jack Westfall, MD, MPH, Director of the Robert Graham Center for Policy Studies in Family Medicine and Primary Care, for their thoughtful interviews on the topic of Primary Care and Patient Safety, which helped lay the groundwork for this Perspective.

Introduction

The Agency for Healthcare Research and Quality (AHRQ) recognizes that revitalizing the nation’s primary care system is foundational to achieving high-quality, safe, accessible, efficient healthcare for all Americans.1,2 AHRQ defines high-quality primary care as “the provision of whole-person, integrated, accessible, and equitable healthcare by interprofessional teams who are accountable for addressing the majority of an individual’s health and wellness needs across settings and through sustained relationships with patients, families, and communities.”3 Setting a definition for primary care, and other important concepts in the essay, allows readers to build a common understanding about their structure, which provides a basis for exploration of their convergence. AHRQ, as one of the lead federal agencies in primary care research, funds research to understand how to implement this vision of primary care throughout the nation.

A strong body of evidence demonstrates that primary care can improve a patient’s overall health status.4 By providing a usual source of care, clinicians can help prevent, diagnose, and manage a wide range of patient conditions. Primary care can address acute problems, diagnose and manage chronic illness, deliver primary and secondary prevention, and provide trusted medical advice to improve health and well-being.

What makes primary care different from most other specialties is its role in coordinating and integrating a patient’s care across the healthcare system. Through primary care, patients can develop a long-standing relationship with their clinician and receive whole-person, comprehensive care. This relationship can enhance communication, manage clinical information, facilitate transitions in care, and engage patients and their families in care. The nature of relationship-based care provides the opportunity to potentially identify many, if not all, of patients’ determinants of health, from the health services themselves to the social and environmental factors that affect their health.

AHRQ is the lead federal agency for patient safety research. AHRQ’s broad definition of patient safety includes “prevention of diagnostic errors, medical errors, injury or other preventable harm to a patient during the process of healthcare, and reduction of risk of unnecessary harm associated with healthcare.” In addition to its role in managing most common patient conditions, primary care can prevent harms such as diagnostic delays, medication-related safety events, and avoidable hospital admissions and readmissions.5,6 Primary care, like other predominantly outpatient-based specialties, is vulnerable to safety issues in the ambulatory care setting. There is an opportunity to begin looking more closely at the alignment between the functions of primary care and patient safety as a component of quality care and at AHRQ’s approach to addressing both.

Primary Care, Quality of Care, and Patient Safety

Primary care plays an important role in avoiding and mitigating common safety issues such as diagnostic delays and errors; medication-related safety events; inadequate communication, including problems with care transitions or reporting and follow-up of laboratory and other diagnostic tests; unnecessary tests or procedures; and lack of access to care. For example, primary care providers can improve diagnostic safety through the use of relationship-based principles, e.g., promoting enhanced caring and listening. Strategies such as judicious application of technology, like clinical decision support tools, can be employed to reduce inappropriate medication use. Primary care practices can consider using systems engineering methods or lean workflow redesigns to improve communication processes and performance.

Quality healthcare is defined by the Institute of Medicine as the delivery of safe, effective, patient-centered, timely, efficient, and equitable care.7 These six aims of quality are interdependent, and they share underlying drivers to achieve high-quality care. When one or more aims are not met, these interdependencies can also create negative outcomes. For example, if a patient receives the correct medications for a particular condition (effectiveness aim met), but they stop taking the medications because of side effects (patient-centered aim not met), their health may then be negatively affected (safety aim not met). A patient safety event can be the furthest downstream outcome of a series of events that starts with the intention of providing effective care. When optimally delivered, primary care, in its role of providing integrated and accessible healthcare services, can address each of the healthcare quality aims. Examining the functions and goals of primary care illustrates how they relate to these healthcare quality aims.

The functions of primary care have been described as the “4C’s”: first point of contact (access to care), continuity (long-term healing relationships, providing longitudinal care), comprehensiveness (whole-person care), and coordination (tracking all of a patient’s health issues across various settings).8 Others have since added patient-centeredness and cost-effectiveness, among others, to the 4C’s, describing 7C’s,9 9C’s,10 or even 10C’s.11 These models all identify functions that ultimately lead to improved access, equity, and quality care, at a lower cost for patients—similar to the six quality aims outlined by the Institute of Medicine—and all of the models have distinct implications for patient safety. (See table 1.)

Table 1. Functions of primary care, how they map to the six aims of quality, and the potential impact on patient safety
Editor’s note: This table is adapted from the “Six Aims of Quality Healthcare” framework, as cited in Crossing the Quality Chasm: A New Health System for the 21st Century).7 The reader may notice duplicative criteria under some elements of the framework. This duplication is purposefully intended by the authors, because multiple factors that influence quality healthcare may affect patient outcomes.

Six Aims of Quality Healthcare
(as cited in Crossing the Quality Chasm: A New Health System for the 21st Century and reflected on the AHRQ website)7,12

Functions of Primary Care That Meet the Six Aims of Quality Healthcare

Ultimate Potential Implications for Patient Safety if Quality Healthcare Aim Is not Achieved

“Healthcare Should Be Safe” – Avoiding harm to patients from the care that is intended to help them.

  • Patient-clinician communication
  • Coordination across settings of care
  • Continuity of care
  • Access to care
  • Inadequate communication, poorly coordinated transitions between care settings, lack of current clinical information, and delayed access to care all have the potential to lead to harm.

(Editor’s note: Although access to care traditionally has not been considered a patient safety issue, the authors of this piece feel strongly that access can create a cascade of healthcare-related issues, ultimately affecting patient safety.)

Healthcare Should Be Effective – Providing services based on scientific knowledge to all who could benefit, and refraining from providing services to those not likely to benefit (avoiding underuse, overuse, and misuse)

  • Comprehensiveness and ethical allocation of resources in systems with finite resources
  • Evidence-based or evidence-informed care, avoidance of low-value care
  • Ineffective allocation of resources could lead to “harm” to the affordability of healthcare, causing delayed or avoided care with potential patient harm as a result13; use of evidence-based care can help avoid “toxic cascades” of unnecessary tests, reducing exposure to unnecessary risk of harm from unnecessary procedures.

Healthcare Should Be Patient-Centered – Providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions.

  • Patient and family engagement
  • Use of shared decision making
  • Providing most patients’ healthcare needs (comprehensiveness) and providing whole-person care
  • Understanding how determinants of health such as social and environmental factors may impact patients’ health outcomes, and helping address inequities in health attributable to such determinants
  • Lack of patient and family engagement, not accounting for patient values/preferences, and not addressing health inequities attributable to social factors can lead to avoidable harm, such as when a patient does not feel comfortable sharing their disagreement with treatment options because their values, preferences, and experiences are not considered.

Healthcare Should Be Timely – Facilitating access to care; reducing waits and harmful delays for those who receive and those who give care

  • Providing effective access, ensuring care is available when needed
  • Serving as the first point of contact for health concerns and as a facilitator to access other parts of the healthcare system (first contact)
  • Expanded access by implementing evening and weekend hours
  • Implementing telehealth services
  • Lack of access to and unplanned, avoidable delays in care may lead to avoidable harm for patients and potentially provider and caregiver burnout.


 

Healthcare Should Be Efficient – Avoiding waste, including waste of equipment, supplies, ideas, and energy. Avoiding misuse of scarce workforce and other resources as well as missed opportunity costs.

  • Recognizing the limits imposed by the costs of care and avoiding care that provides low or no value (cost-effectiveness)
  • Engaging in value-based care
  • Inefficient care delivery may lead to the need for providers to see higher volumes of patients to cover overhead costs, decreasing the time spent with patients and potentially increasing likelihood of errors, lapses, and mistakes.14
  • “Ghost networks”15 of care, whereby providers are not providing care or unable to provide care, make it harder for patients to find providers and lead to delays in care.

Healthcare Should Be Equitable – Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, or socioeconomic status

  • Working with patients to help them overcome barriers to equitable care, such as access and social and environmental factors that may impact health outcomes; for example, facilitating transportation to appointments
  • Issues such as lack of access to transportation may lead to missed care or delayed diagnoses; patients with lower health literacy are more likely to experience medication-related safety events.

A Closer Focus on Access and its Impact on Patient Safety

In addition to enhancing diagnostic safety, preventing medication-related patient safety events, and thoughtful design of care processes, primary care helps ensure patients can access care when needed to prevent harm. Ideally, primary care is the patient’s first contact with the healthcare system for health concerns or health maintenance activities. This encounter establishes a relationship from which the other functions can occur (i.e., continuity of care). Access is often affected by elements that are frequently beyond the control of the provider, including insurance status and geographic location.16,17 Some of the rising demand for emergent and urgent care services can be attributed to access barriers to primary care, and to the fact that many of the patients seen in emergency departments could be treated in alternative, and more optimal, healthcare settings.18,19 Although patients may get appropriate short-term care for their chronic conditions (or ambulatory-sensitive conditions) in these alternative settings, care can quickly become disjointed, making continuity difficult to achieve and leading to patient safety events like diagnostic delays and medication-related harms.

There are three components to improving access to comprehensive, quality healthcare services: adequacy of insurance coverage, availability of health services, and timeliness of care. The remainder of the discussion focuses on interventions that target the availability of health services and timeliness of care components, both of which align with the functions of primary care. For this discussion, the term “health services” includes providing a usual and ongoing source of care to the patient and providing comprehensive services in the context of the community and family.20 Timeliness is the ability to provide care at the right time, reducing delays and potential harms caused by those delays.

Primary Care Workforce Innovations to Expand Access

In the context of primary care provider shortages, especially in rural and underserved communities, increasing access can be achieved by increasing and sustaining the primary care workforce, expanding the use of team-based care, liberalizing the scope of practice for advanced-practice nurses and physician assistants, and incorporating community health workers who are embedded in primary care clinics within communities that have low rates of primary care access. The deployment of health support staff directly within the community—typically staff who are embedded within the community—can help address individual barriers to primary care access and strengthen care. By working directly with patients, community health workers can establish customized, patient-centered solutions. These solutions may include initial screenings for symptoms of chronic health conditions, such as high blood pressure, or education about the benefits of preventive services, such as vaccinations and wellness visits.21,22

Integration of Primary Care Into Community Programs

Another approach is the incorporation of primary care services into existing health-related programs that serve populations with access challenges. For example, behavioral health programs that address substance misuse and mental health conditions might also be equipped to provide primary care. Conversely, an alternative model integrates behavioral health services into primary care practices while primary care providers prescribe medications for patients with substance use disorders. Research has found that integrating these services improves mental health outcomes and increases use of preventive services among patient populations.23

Increased Use of Telehealth Services

Increased use of telehealth services to reduce some of the barriers to primary care represents a third possible approach, which has been reinforced by the COVID‑19 pandemic. In particular, use of telehealth services can eliminate the need for travel to a primary care facility, and may benefit individuals with access barriers such as caring for a child or elderly relative at home. However, there are challenges associated with comprehensive access to telehealth services. To avoid introducing new patient safety issues, care must be taken to understand which visits can safely be conducted via telehealth.24 Communication and relationship building with patients, both critical functions of safe primary care, may also be more difficult via telehealth.25 Technical considerations, such as the availability of broadband internet service, access to a computer or smart device, and technology use among older adults may limit the effectiveness of this approach for some patients and may exacerbate disparities.26

Health Equity and Access to Healthcare

Determinants of health that exist outside the influence of providers often play a more prominent role in safe, high-quality care than the health services themselves. In her seminal work, Dr. Barbara Starfield described this phenomenon, which is supported by recent research27: “The health of individuals or populations is predestined by genetic structure heavily modified by the social and physical environment, by behaviors that are culturally or socially determined, and by the nature of the healthcare provided.”28 For example, take a patient who has hypertension that is controlled and who has good access to care and to medications: The patient’s health is maintained and overall quality of care is achieved in this context. In contrast, consider a patient with hypertension who lacks access to care or to medications: The patient’s health is in jeopardy, and there is high potential for resultant harm in this context. For patients to have equitable access to healthcare and avoid harms, we must make equity determinants of health just as important and integrated into patient care as we do the health services themselves.

Access to care is a cornerstone of high-quality, equitable primary care.29 Researchers believe that inequity in access to primary care is one reason for inequity in health outcomes between people who are White, people who are Black, and other minorities. As far back as the Heckler Report,30 data has indicated that preventable, manageable health conditions (e.g., diabetes, hypertension) make up the majority of deaths among minority racial and ethnic groups.31

Identifying the areas in which primary care has the most impact—for example, access—and then developing targeted programs and interventions to address the needs in these areas can lead to improved care. It can also foster efficiencies with provider resources—most importantly, providers’ time. Given its role in leading both patient safety and primary care research, AHRQ is ideally situated to continue to support research at the interface of primary care and patient safety to ensure broader access, higher quality, and safe primary care.

AHRQ Resources That Support Safety in Primary Care

Authors

Sarah E. Mossburg, RN, PhD
Senior Researcher

AIR

Crystal City, VA

Paul Dowell, PharmD, PhD
Senior Researcher

AIR

Columbia, MD

Patrick O’Malley, MD, MPH
Director

National Center for Excellence in Primary Care Research

AHRQ

Rockville, MD

Bob McNellis, PA, MPH
Senior Advisor for Disease Prevention

National Institutes of Health

Office of Disease Prevention

Emily Chew, MPH
Health Scientist Administrator

Agency for Healthcare Research and Quality

Center for Quality Improvement and Patient Safety

References

1. Meyers DS, Clancy CM. Primary care: too important to fail. Ann Intern Med. 2009;150(4):272-273. doi:10.7326/0003-4819-150-4-200902170-00009

2. Meyers D, Miller T, Genevro J, et al. EvidenceNOW: balancing primary care implementation and implementation research. Ann Fam Med. 2018;16(Suppl 1):S5-S11. Accessed August 11, 2022. https://doi.org/10.1370/afm.2196

4. Starfield B, Shi L, Machinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83:457‑502. Accessed March 4, 2022. https://doi.org/10.1111/j.1468-0009.2005.00409.x

5. Agency for Healthcare Research and Quality Patient Safety Network. Patient safety in primary care. 2020. Accessed March 10, 2022. https://psnet.ahrq.gov/perspective/patient-safety-primary-care

6. Hochman M, Bourgoin, A, Saluja S, et al. Environmental Scan of Primary Care-Based Efforts to Reduce Readmissions. Agency for Healthcare Research and Quality; 2019. Accessed March 10, 2022. https://www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/primary-care-based-efforts.pdf

7. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. National Academies Press; 2001. Accessed March 4, 2022. https://doi.org/10.17226/10027

8. Starfield B. Primary Care: Balancing Health Needs, Services, and Technology. 2nd ed. Oxford University Press, Incorporated; 1998.

9. Bazemore A, Grunert T. Sailing the 7C’s: Starfield revisited as a foundation of family medicine residency redesign. Fam Med. 2021;53(7):506-515. doi:10.22454/FamMed.2021.383659

10. Doer T. The nine C’s of successful accountable primary care delivery. The Health Care Blog. Posted February 4, 2013. Accessed March 10, 2022. https://thehealthcareblog.com/blog/2013/02/04/the-nine-c%E2%80%99s-of-successful-accountable-primary-care-delive/

11. Kroenke K. The many C’s of primary care. J Gen Intern Med. 2004 Jun;19(6):708-709. doi:10.1111/j.1525-1497.2004.40401.x

12. Agency for Healthcare Research and Quality. Six Domains of Health Care Quality. Page last reviewed November 2018. Accessed August 10, 2022. https://www.ahrq.gov/talkingquality/measures/six-domains.html

13. Montero A, Kearney A, Hamel L, Brodie M. Americans’ challenges with health care costs. Kaiser Family Foundation. Published July 14, 2022. Accessed August 10, 2022. https://www.kff.org/health-costs/issue-brief/americans-challenges-with-health-care-costs/

14. Grant S, Guthrie B. Efficiency and thoroughness trade-offs in high-volume organisational routines: an ethnographic study of prescribing safety in primary care. BMJ Qual Saf. 2018;27(3):199-206. https://doi.org/10.1136/bmjqs-2017-006917

15. Burman A. (2021). Laying ghost networks to rest: combatting deceptive health plan provider directories. Yale Law Policy Rev. 2021;40(1):78-148.

16. Agency for Healthcare Research and Quality. 2019 National Healthcare Quality & Disparities Report. AHRQ Pub. No. 20(21)-0045-EF. Published 2020. Accessed March 10, 2022. https://www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2019qdr.pdf

17. Kirby JB, Yabroff KR. Rural-urban differences in access to primary care: beyond the usual source of care provider. Am J Prev Med. 2020;58(1):89-96. doi:10.1016/j.amepre.2019.08.026

18. Coster JE, Turner JK, Bradbury D, Cantrell A. Why do people choose emergency and urgent care services? A rapid review utilizing a systematic literature search and narrative synthesis. Acad Emerg Med. 2017;24(9):1137-1149. doi:10.1111/acem.13220

19. Hefner JL, Wexler R, McAlearney AS. Primary care access barriers as reported by nonurgent emergency department users: implications for the US primary care infrastructure. Am J Med Qual. 2015;30(2):135-140. doi:10.1177/1062860614521278

20. National Academies of Sciences, Engineering, and Medicine. 2021. Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. National Academies Press; 2021. Accessed March 4, 2022. https://doi.org/10.17226/25983

21. Community Preventive Services Task Force. TFFRS – Diabetes prevention: Interventions engaging community health workers. Community Preventive Services Task Force Finding and Rationale Statement; ratified August 2016. Accessed March 10, 2022. https://www.thecommunityguide.org/content/tffrs-diabetes-prevention-interventions-engaging-community-health-workers

22. Community Preventive Services Task Force. TFFRS – Heart disease and stroke prevention: interventions engaging community health workers. Community Preventive Services Task Force Finding and Rationale Statement; ratified March 2015. Accessed March 10, 2022. https://www.thecommunityguide.org/content/tffrs-heart-disease-stroke-prevention-interventions-engaging-community-health-workers

23. Gerrity M. Integrating Primary Care into Behavioral Health Settings: What Works for Individuals with Serious Mental Illness. Milbank Memorial Fund; December 17, 2014. Accessed March 4, 2022. https://www.milbank.org/publications/integrating-primary-care-into-behavioral-health-settings-what-works-for-individuals-with-serious-mental-illness

24. Jabbarpour Y, Jetty A, Westfall M, Westfall J. Not Telehealth: Which primary care visits need in-person care? J Am Board Fam Med. 2021;35(Suppl):S162-S169. Accessed March 10, 2022. https://www.jabfm.org/content/jabfp/34/Supplement/S162.full.pdf

25. AHRQ PSNet. In conversation with… Joel Willis, DO, PA, MA, MPhil and Neal Sikka, MD. Posted May 14, 2020. Accessed May 17, 2022. https://psnet.ahrq.gov/perspective/conversation-joel-willis-do-pa-ma-mphil-and-neal-sikka-md

26. Gajarawala SN, Pelkowski JN. Telehealth benefits and barriers. J Nurse Pract. 2021;17(2):218-221. doi:10.1016/j.nurpra.2020.09.013

27. Samuelson K. Black adults’ high cardiovascular disease risk not due to race itself. Northwestern Now. May 25, 2022. Accessed June 23, 2022. https://news.northwestern.edu/stories/2022/05/black-adults-high-cardiovascular-disease-risk-not-due-to-race-itself/

28. Starfield B. Primary Care: Balancing Health Needs, Services, and Technology. 2nd ed. Oxford, UK: Oxford University Press, Incorporated; 1998. 448 p.

29. National Academies of Sciences, Engineering, and Medicine. Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. National Academies Press; 2021. Accessed March 4, 2022. https://doi.org/10.17226/25983

30. US Department of Health and Human Services. Report of the Secretary’s Task Force on Black and Minority Health. Vol. 1, Executive Summary; August 1985.

31. Centers for Disease Control and Prevention. Leading Causes of Death – Males – by Race and Hispanic Origin – United States, 2017. Page last reviewed September 27, 2019. Accessed March 10, 2022. https://www.cdc.gov/healthequity/lcod/men/2017/byraceandhispanic/index.htm

This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The authors are solely responsible for this report’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this report. View AHRQ Disclaimers
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