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An inadequate supply of primary care providers is leading to a crisis in access. Pressures are being placed on primary care practices to increase panel sizes. The impact of these pressures on clinical processes, patient satisfaction and waiting times is largely unknown, although evidence from recent literature shows that longer waiting time results in higher mortality rates and other adverse outcomes. FY2004, Department of Veterans Affairs primary care patient data are used. GLIMMIX and other generalized linear model models illustrate how expanded panel sizes are correlated with clinical process indicators, patient satisfaction and waiting times, controlling for practice, provider and patient characteristics. We generally find that larger panel sizes are related to statistically significant increases in waiting time. However, larger panel sizes appear to have generally small effects on patient process indicators and satisfaction. Panels with more support staff have lower waiting times and small, improved outcomes. We find panels with older and clinically riskier patients have, on average, slightly lower waiting times and increased likelihoods of positive outcomes than panels with younger, healthier veterans. Female veterans appear to have reduced likelihoods of positive outcomes. Higher priority and female veterans also have lower satisfaction. Further study is needed to analyse the impact of potential panel size endogeneity in this system.

A high proportion of the US primary care workforce reports burnout, which is associated with negative consequences for clinicians and patients. Many protective factors from burnout are characteristics of patient-centered medical home (PCMH) models, though even positive organizational transformation is often stressful. The existing literature on the effects of PCMH on burnout is limited, with most findings based on small-scale demonstration projects with data collected only among physicians, and the results are mixed.To determine if components of PCMH related to team-based care were associated with lower burnout among primary care team members participating in a national medical home transformation, the VA Patient Aligned Care Team (PACT).Web-based, cross-sectional survey and administrative data from May 2012.A total of 4,539 VA primary care personnel from 588 VA primary care clinics.The dependent variable was burnout, and the independent variables were measures of team-based care: team functioning, time spent in huddles, team staffing, delegation of clinical responsibilities, working to top of competency, and collective self-efficacy. We also included administrative measures of workload and patient comorbidity.Overall, 39 % of respondents reported burnout. Participatory decision making (OR 0.65, 95 % CI 0.57, 0.74) and having a fully staffed PACT (OR 0.79, 95 % CI 0.68, 0.93) were associated with lower burnout, while being assigned to a PACT (OR 1.46, 95 % CI 1.11, 1.93), spending time on work someone with less training could do (OR 1.29, 95 % CI 1.07, 1.57) and a stressful, fast-moving work environment (OR 4.33, 95 % CI 3.78, 4.96) were associated with higher burnout. Longer tenure and occupation were also correlated with burnout.Lower burnout may be achieved by medical home models that are appropriately staffed, emphasize participatory decision making, and increase the proportion of time team members spend working to the top of their competency level.

Human intrusion can be a serious problem for birds because it can cause displacement, prevent access to resources, and reduce reproduction and survival. The factors that influence avian tolerance to intrusion are poorly understood. We studied passerine responses to intrusion in Wyoming montane forests during the breeding season by using two indices of intrusion tolerance: detectability period, the amount of time that a bird remains near its initial flush point; and approach distance, how close one can get to a bird before it flushes. A solitary observer experimentally approached focal individuals and recorded detectability period, approach distance, the seasonal and daily timing of intrusion, number of nearby conspecifics, number of nearby heterospecific individuals, and surrounding vegetation conditions. Using data from the literature, we also assessed influences of migratory status, body mass, conspicuousness, and height above the ground at which species are active during the breeding season. Detectability period was significantly shorter, indicating intrusion tolerance was lower, when fewer conspecifics were nearby. Approach distance was significantly longer, indicating tolerance was lower, for more-conspicuous species and for species that are active closer to the ground. Effects of other variables studied were not significant. These results demonstrate that social and biological factors can influence tolerance to intrusion. Intrusion-induced behaviors such as nest abandonment and decreased nest attentiveness have led to reduced reproduction and survival in species that are intolerant of intrusion. With knowledge of factors that influence tolerance, the risk of disturbing birds that are sensitive to intrusion could be reduced.

Team-based care is central to the patient-centered medical home (PCMH), but most PCMH evaluations measure team structure exclusively. We assessed team-based care in terms of team structure, process and effectiveness, and the association with improvements in teams׳ abilities to deliver patient-centered care.We fielded a cross-sectional survey among 913 VA primary care clinics implementing a PCMH model in 2012. The dependent variable was clinic-level respondent-reported improvements in delivery of patient-centered care. Independent variables included three sets of measures: (1) team structure, (2) team process, and (3) team effectiveness. We adjusted for clinic workload and patient comorbidity.4819 surveys were returned (25% estimated response rate). The highest ratings were for team structure (median of 89% of respondents being assigned to a teamlet, i.e., a PCP working with the same clinical associate, nurse care manager and clerk) and lowest for team process (median of 10% of respondents reporting the lowest level of stress/chaos). In multivariable regression, perceived improvements in patient-centered care were most strongly associated with participatory decision making (β=32, P0.0001) and history of change in the clinic (β=18, P=0008) (both team processes). A stressful/chaotic clinic environment was associated with higher barriers to patient centered care (β=0.16-0.34, P=0.0001), and lower improvements in patient-centered care (β=-0.19, P=0.001).Team process and effectiveness measures, often omitted from PCMH evaluations, had stronger associations with perceived improvements in patient-centered care than team structure measures.Team process and effectiveness measures may facilitate synthesis of evaluation findings and help identify positive outlier clinics.