» Back to list of all Management eBriefs
|Issue 158||August 2019|
The report is a product of the VA/HSR&D Evidence Synthesis Program.
Systematic Review: What is the Optimal Panel Size in Primary Care?
In 2009, the VA Handbook 1101.02—Primary Care Management Module (PCMM) established a baseline panel size of 1,200 patients for a full-time physician in a Patient Aligned Care Team (PACT). This number could be adjusted up or down based on the availability of support staff, number of examination rooms, and patient complexity. After adjustment for these factors, panels ranged from 1,000 to 1,400. In 2017, VA Directive 1406—Patient-Centered Management Module (PCMM) for Primary Care reaffirmed both the baseline panel numbers and adjustment parameters.
Primary care providers (PCPs) want to provide high-quality, comprehensive care to their panel of patients. However, determining the right size panel - to ensure that providers have the time to do all their tasks - is a problem that has yet to be solved. External factors like physician shortages contribute to the problem when systems suggest that panel sizes need to be increased to cover more patients in the face of inadequate numbers of PCPs. Such processes may contribute to burnout by not allowing providers adequate time to perform their required tasks. Thus, determining the right or optimal panel size for a full-time physician and team is a complex undertaking that requires balancing the demands of the system (i.e., patient access to care, clinical effectiveness or quality, patient experience, and cost) with the needs of the provider team (i.e., physician/team satisfaction, adequate time for care, and avoidance of physician/team burnout). Further, a standard method for determining panel size does not account for the tasks that occur outside of traditional face-to-face clinical visits, including patient communication (i.e., telephone calls, emails, and form completion), test follow-up, panel management activities, and care coordination.
Investigators with VA's Evidence Synthesis Program in West Los Angeles, CA conducted a systematic review to help inform an expert panel that will consider issues about determining VA primary care panel size. Investigators conducted searches in PubMed (inception to 3/8/19), Web of Science (inception to 3/10/19), as well as Scopus and Embase (1/1/18 to 3/8/19). Using Google, they also searched the gray literature. The literature search produced 462 potentially relevant articles; of these, 30 publications met initial inclusion criteria, including 16 hypothesis-testing studies that assessed the association of panel size with an outcome of interest, 11 studies of models, and 3 of toolkits.
For this systematic review, the Institute of Medicine (IOM) framework for quality healthcare was used as the source of potential measures that could be considered for optimization. The IOM framework has six "Aims for Improvement;" healthcare must be: 1) safe, 2) effective (operationalized to include clinical quality), 3) patient-centered (which included patient experience measures), 4) timely (operationalized to include access and continuity), 5) efficient (operationalized to include cost), and 6) equitable. To these six aims, investigators added reducing provider burnout.
Summary of Review
Applicability to VA Patients
Evidence also is needed regarding primary care provider burnout - and about the appropriate visit frequency or follow-up time, and format (i.e., face-to-face, video or telephone, or secure messaging), for patients with chronic conditions. Most currently used visit frequencies or follow-up times (such as a visit frequency of twice a year for a patient with well-controlled diabetes and hypertension) are based on historical norms, are variable between physicians, and lack evidence that a particular frequency produces better outcomes than some other frequency.
View the full report — **VA Intranet only**:
Related HSR&D Research Topics:
Please feel free to forward this information to others!
Read past HSR&D Management e-Briefs on the HSR&D website.
ESP is currently soliciting review topics from the broader VA community. Nominations will be accepted electronically using the online Topic Submission Form. If your topic is selected for a synthesis, you will be contacted by an ESP Center to refine the questions and determine a timeline for the report.
This Management e-Brief is provided to inform you about recent HSR&D findings that may be of interest. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. If you have any questions or comments about this Brief, please email CIDER. The Center for Information Dissemination and Education Resources (CIDER) is a VA HSR&D Resource Center charged with disseminating important HSR&D findings and information to policy makers, managers, clinicians, and researchers working to improve the health and care of Veterans.
This report is a product of VA/HSR&D's Evidence Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers – and to disseminate these reports throughout VA.
See all reports online.