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Frequency and Criticality of Diagnoses in Family Medicine Practices: from the National Ambulatory Medical Care Survey (NAMCS)

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Frequency and Criticality of Diagnoses in Family Medicine Practices: from the National Ambulatory Medical Care Survey (NAMCS) J Am Board Fam Med: first published as 10.3122/jabfm.2018.01.170209 on 12 January 2018. Downloaded from ORIGINAL RESEARCH Frequency and Criticality of Diagnoses in Family Medicine Practices: From the National Ambulatory Medical Care Survey (NAMCS) Michael R. Peabody, PhD, Thomas R. O’Neill, PhD, Keith L. Stelter, MD, MMM, and James C. Puffer, MD Background: Family medicine is a specialty of breadth, providing comprehensive health care for the individual and the family that integrates the broad scope of clinical, social, and behavioral sciences. As such, the scope of practice (SOP) for family medicine is extensive; however, over time many family phy- sicians narrow their SOP. We sought to provide a nationally representative description of the most com- mon and the most critical diagnoses that family physicians see in their practice. Methods: Data were extracted from the 2012 National Ambulatory Medical Care Survey (NAMCS) to select all ICD-9 codes reported by family physicians. A panel of family physicians then reviewed 1893 ICD-9 codes to place each code into an American Board of Family Medicine Family Medicine Certifica- tion Examination test plan specifications (TPS) category and provide a rating for an Index of Harm (IoH). Results: An analysis of all 1893 ICD-9 codes seen by family physicians in the 2012 NAMCS found that 198 ICD-9 codes could not be assigned a TPS category, leaving 1695 ICD-9 codes in the dataset. Top 10 lists of ICD-9 codes by TPS category were created for both frequency and IoH. Conclusions: This study provides a nationally representative description of the most common diag- copyright. noses that family physicians are seeing in their practice and the criticality of these diagnoses. These results provide insight into the domain of the specialty of family medicine. Medical educators may use these results to better tailor education and training to practice. (J Am Board Fam Med 2018;31: 126–138.) Keywords: Ambulatory Care, Behavioral Sciences, Certification, Comprehensive Health Care, Family Physicians, Health Care Surveys, International Classification of Diseases http://www.jabfm.org/ Family medicine is a specialty of breadth, providing requirements2 and the American Board of Family comprehensive health care for both the individual Medicine (ABFM) certification examination blue- and the family that integrates the broad scope of print.3 clinical, social, and behavioral sciences.1 As such, Although family physicians are trained to ad- the scope of practice (SOP) for family medicine is dress a wide variety of medical problems, over time extensive. Generally speaking, the scope of the spe- many family physicians narrow their SOP. Cur- on 23 September 2021 by guest. Protected cialty has been characterized by the Accreditation rently, fewer family physicians are providing ob- Council for Graduate Medical Education training stetric care4, women’s health5, and pediatric care6 than they have in the past. Narrowing of a physi- This article was externally peer reviewed. cian’s SOP can occur for a variety of reasons, such Submitted 24 May 2017; revised 16 August 2017; accepted as needs of the community, physician preference, 24 August 2017. From the American Board of Family Medicine, Lexington, or employer requirements. KY (MRP, TRO, JCP); University of Minnesota Mankato In some cases, a physician may have narrowed Family Medicine Residency Program, Mankato, MN (KLS). Funding: none. his or her SOP while still believing she or he Conflict of interest: none declared. predominantly practices full-scope family medi- Corresponding author: Michael R. Peabody, PhD, Ameri- can Board of Family Medicine, 1648 McGrathiana Pkwy, ste cine. Cognitive psychology describes a phenome- 550, Lexington, KY ͑E-mail: [email protected]). non called the Availability Heuristic7, which causes 126 JABFM January–February 2018 Vol. 31 No. 1 http://www.jabfm.org J Am Board Fam Med: first published as 10.3122/jabfm.2018.01.170209 on 12 January 2018. Downloaded from people to make judgments about the likelihood of nosing or incorrectly treating each diagnosis was an event based on how easily an example comes to derived from ratings made by a panel of family mind. Being able to easily recall a few patients who physicians. Because of the large number of ICD-9 seemingly represent full-spectrum care would make codes available, it may be of some utility to aggre- a physician believe she or he is practicing full- gate them into clinically relevant categories. We spectrum care when, in fact, she or he is not. The chose to use the ABFM’s Family Medicine Certi- availability of information in memory also under- fication Examination (FMCE) test plan specifica- lies the Representativeness Heuristic.8 With the tions (TPS) because approximately 85% of active Representativeness Heuristic, people judge the family physicians are certified by the ABFM11, probability of an event belonging to a certain class making it quite possibly the most widely applicable based on the degree to which the event resembles framework available. the class; however, this neglects the probability of the class occurring in the first place. Physicians also Methods change practice patterns and scope gradually so Design changes in their SOP are not noticeable, unless This study used the 2012 NAMCS data to identify they have a method to benchmark their practice ICD-9 codes that were reported by family physi- against a standard. It would be helpful for these cians. These ICD-9 codes were included on a sur- physicians to have information about the domain of vey that was administered to physicians so that the family medicine that they could compare with their ICD-9 codes could be linked to the ABFM’s own practice to get a more accurate picture of their FMCE TPS categories. Each ICD-9 code was ei- individual SOP. ther linked to a TPS category or excluded for being Furthermore, it would be helpful for medical too vague. NAMCS provides a weight for each visit educators in family medicine to have accurate in- in the sample (called a patient weight), allowing for formation about the domain of family medicine to the calculation of the frequency with which each copyright. more fully target their training to reflect the con- ICD-9 was reported in the population. The top 10 ditions that their residents will be expected to treat most frequently seen ICD-9 codes for each TPS once they are no longer under the residency pro- category are reported. In addition, the survey also gram’s supervision. Finally, in constructing an ex- asked the physicians about the likely degree of amination designed to certify family physicians, it is harm that would be caused by misdiagnosing or critical that the construct adequately, accurately, incorrectly treating the ICD-9 code. This informa- and fairly assess the domain of family medicine. tion was transformed into an Index of Harm (IoH) The National Center for Health Statistics con- scale. ducts the National Ambulatory Medical Care Sur- http://www.jabfm.org/ vey (NAMCS) annually.9 NAMCS is a large, rep- resentative, national sample survey that provides NAMCS Data information about ambulatory care delivered in the The sampling frame for the 2012 NAMCS was United States. This publicly available dataset in- composed of all physicians contained in the Amer- cludes the physician reported International Classi- ican Medical Association and the American Osteo- fication of Diseases, Ninth Revision, Clinical Mod- pathic Association master files who were office ification (ICD-9)10 codes for each patient visit in based; principally engaged in patient care activities; on 23 September 2021 by guest. Protected the sample and permits stratification by physician nonfederally employed; not in the specialties of specialty. This dataset is well suited to describing anesthesiology, pathology, and radiology; and the patient visits commonly seen by family physi- younger than 85 years of age at the time of the cians. survey. Using the NAMCS dataset, this article will pro- The 2012 NAMCS sample included 15,740 phy- vide a nationally representative description of the sicians: 14,931 allopathic physicians and 809 osteo- types of diagnoses that were seen by family physi- pathic physicians. Physicians included in the sam- cians in ambulatory care settings in 2012 and esti- ple were screened at the time of the survey to assure mates of the prevalence of those diagnoses. To that they met the above-mentioned criteria. A total supplement this perspective, an indicator of the of 6166 physicians did not meet all the criteria and degree of harm that would be caused by misdiag- were ruled ineligible for the study. Of the 9,574 doi: 10.3122/jabfm.2018.01.170209 Diagnosis Frequency and Criticality in Family Medicine 127 J Am Board Fam Med: first published as 10.3122/jabfm.2018.01.170209 on 12 January 2018. Downloaded from eligible physicians, 3,583 participated in the In addition to providing a TPS category for each NAMCS survey. For these, data were collected for ICD-9 code, panelists were also asked to answer, 76,330 visits, either by a NAMCS representative “How critical is the diagnosis and treatment of this (74,647 visits) or by physicians or their staffs (1,683 condition?” using a 4-point Likert-type rating scale visits).12 (Minimally, Moderately, Somewhat, Very). These We restricted our sample to those physicians data were used to create an Index of Harm (IoH) whose self-identified specialty was family practice scale. or general practice, as defined by NAMCS. Of the 76,330 Patient Record Forms (PRF) and 3,583 Survey Data Collection Design physicians, there remained 12,897 PRFs provided Because asking panelists to review all 1893 ICD-9 by 551 physicians following the implementation of codes from the master survey would be burden- the inclusion criterion. NAMCS contains a patient some and time consuming, each panelist was asked weight estimate that is used to obtain visit estimates to review only a subset of the codes.
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