Primary Care Providers' Experiences Caring for Complex Patients in Primary Care

Danielle F. Loeb; Elizabeth A. Bayliss; Carey Candrian; Frank V. deGruy; Ingrid A. Binswanger

Disclosures

BMC Fam Pract. 2016;17(34) 

In This Article

Methods

Study Design, Setting, Population and Recruitment

Using a general inductive approach, our qualitative research study was guided by an interpretive epistemology. Because interpretive traditions take human interpretation as a starting point for developing knowledge about the social world, discourse, and its resulting accomplishments, was central to this study to understand participants' values, beliefs and motivations. Therefore, we conducted a qualitative study of PCPs using previously described open-ended in-depth interviews.[18,19] Briefly, we recruited 15 internists from two university-based clinics (UCs) and three safety net community health clinics (CHCs) affiliated with the University of Colorado School of Medicine. We invited participation by sending email notices to all physicians in the practices (34 and 28 physicians from the UCs and the CHCs, respectively). We used systematic non-probabilistic sampling[20] to achieve an even distribution of gender, years in practice, and practice location. In line with interpretative and participatory forms of research, participants were viewed as active agents participating in the actual co-construction of meaning, rather than mere subjects representing and reproducing meaning. This distinction mattered for how we classified, organized, and interpreted the data focusing on meaning and intentionality over and above casual explanations. We came to agreement about what is real intersubjectivly, which informed our ability to generate solutions, grounded in lived experience, for handling complex patients. We completed the interview process after 15 interviews with 8 UC and 7 CHC participants after reaching thematic saturation.

Instrument and Interview Procedures

The interview instrument was developed by the Primary Investigator (D.F.L) and revised iteratively through input from the full research team and other qualitative and health services researchers. It was then refined after three pilot interviews. The interview guide was designed to elicit PCPs' views of patient factors, physician competence, and healthcare system issues associated with caring for complex patients (Fig. 1). The guide also included questions about the role of mental illness in patient complexity. Because we were specifically interested in interpreting facilitators and barriers to care, our analysis sought to identify PCP strategies employed to improve care. We started the interviews by providing participants with a definition of complexity (Fig. 2), thereby allowing us to define a common focus of study (i.e., patient complexity) while allowing underlying experiences or processes related to complexity to also emerge from the data.

Figure 1.

Interview Guide: Sample Questions

Figure 2.

Definition of complex patient provided to participants [1]

Participants were asked to bring de-identified clinical notes from three patients who met the definition to the interview to keep the discussion focused on concrete cases seen in clinical practice rather than broad generalization. Participants were also asked to complete a brief demographic survey.

The Primary Investigator (D.F.L.), a PCP, and another investigator (C.C.), conducted the interviews from July through December 2010. The one-on-one interview format was selected to allow deep exploration of individual clinician experiences and reactions to these experiences in a confidential setting.[21] Participants were not compensated. Interviews were conducted in a private space, lasted approximately 60 min, were digitally recorded, uploaded to a secure drive, and professionally transcribed.

Analysis

Interview transcripts and a demographic survey were our primary data sources. Transcript files were entered into qualitative data analysis software (ATLAS.ti Scientific Software Development GmbH, Berlin, Germany). We used an interpretive and participatory approach to explore patterns and themes.[22,23] Members of the team included health services researchers, including: two general internists (D.F.L and I.A.B) and two family medicine physicians (E.A.B. and F.V.D.) and a Doctor of Health Communication (C.C.). The PI (D.F.L.) and another team-member (C.C.) conducted the interviews. Recognizing our unique positions and our own interpretive frameworks, the analysis was guided by qualitative research ethics that allowed us to interpret interviews not simply as representational of all PCPs. Rather, since the research team consisted of PCPs and health services researchers, our interpretation involved a generative discussion of meaning with the potential to better understand our shared situation around complex patients.[24]

D.F.L. performed initial coding using an inductive coding approach.[22] Codes were initially broadly categorized according to the domains of patient care explored in the interviews.[25] Then, two other team members (I.A.B. and E.A.B.) independently coded two of the interviews and worked with the primary coder to resolve differences and create the final codebook. Other team members (C.C. and F.V.D.) reviewed a subset of transcripts. The full team met to discuss emerging themes and discrepancies. We coded data for manifest content meaning (surface content, e.g., PCPs shared that helping complex patients avoid hospitalizations was rewarding for them) and latent content meaning (underlying meaning, e.g., grouping the activity of helping patients avoid hospitalization into the category of optimal care).[26]

COREG checklist can be viewed online (Additional file 1). This study was approved by the Colorado Multiple Institutional Review Board. All participants signed written consent to participate in the study.

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