By Heather Liszka, M.D., and colleagues Background: Prehypertension is a blood pressure category in which systolic blood pressure (the first number in a blood pressure) is between 120-139 mm Hg or diastolic blood pressure (the second blood pressure number) is 80-89 mm Hg. People with prehypertension are considered to be at greater risk of developing high blood pressure. This study examined whether they also have a higher risk of developing cardiovascular diseases, such as stroke and heart failure, than people with normal blood pressure. What This Study Found: People with prehypertension are at greater risk of having a major cardiovascular condition than people with normal blood pressure. Most people with prehypertension also have other conditions that increase their risk of cardiovascular disease.
Implications:
• Prehypertension can serve as an early warning to patients and doctors to watch for high blood pressure and cardiovascular diseases.
• The risk of high blood pressure and cardiovascular disease can be reduced by lifestyle changes, such as improved diet and exercise. In an editorial (titled “Prehypertension, Patient Outcomes, and the Knowledge Base of Family Medicine”) in this issue of the Annals of Family Medicine, Lee Green, MD, asks primary care doctors to think about what they can do in their practices and their communities to help patients develop healthy lifestyles.
Impact of an Electronic Medical Record on Diabetes Quality of Care
By Patrick J. O’Connor, M.D., M.P.H., and colleagues Background: It is widely believed that electronic medical records (EMRs) can help manage medical information and improve care of diseases, such as diabetes. EMRs can identify patients with diabetes, determine whether they are due for tests or procedures, and identify whether they have high blood sugar, high blood pressure, and other related conditions. This study looked at whether use of an EMR improved the quality of care of patients with diabetes. What This Study Found: The use of EMRs improved the process of caring for patients with diabetes, but it did not lead to better health results for diabetes patients. Patients in a clinic using EMRs received more tests for long-term blood sugar control and bad cholesterol levels than patients in a clinic that did not use EMRs. However, diabetes patients in the EMR clinic did not have better control of their blood sugars compared with other patients.
Implications: • EMRs need more capabilities to help doctors make decisions about diabetes care and to help educate and activate patients.
• At this time, other methods, which are less expensive and less disruptive, may be as effective as EMRs in improving the care of patients with chronic diseases.
Implementing an Electronic Medical Record in a Family Medicine Practice: Communication, Decision
Making, and Conflict
By Jesse C. Crosson, Ph.D., and colleagues Background: Although electronic medical records (EMRs) are thought to have many
advantages over paper medical records, they are not widely used in primary care practices. This
study examined how a primary care doctors’ office implemented an EMR.
What This Study Found: Members of the practice had different views about the value
of the EMR and how it should be used. The practice had a “top down” decision-making style, so
decisions about the EMR were made by one practice leader. Because other staff weren’t involved in
planning for the EMR, there were disruptions in practice functions, such as scheduling patients. In
addition, reminder systems that were used in the paper medical records were not transferred to the
EMRs. Implications:
• Successfully implementing an EMR requires planning and communication.
• Practice members are likely to have different points of view about large-scale
organizational changes, such as implementing EMRs. Primary care practices that recognize and work
with different viewpoints are best able to make changes.
• Each primary care practice has unique issues that must be taken into account before, during,
and after the implementation of an EMR. During the implementation process, conflicts should be
allowed to arise safely and communication should be encouraged.
Increasing Capacity for Innovation in Bureaucratic Primary Care Organizations: A Whole System
Participatory Action Research Project
By Paul Thomas, F.R.C.G.P., M.D., and colleagues Background: This study looked at how Primary Care Groups (clusters of general
practices in the United Kingdom) encouraged innovation and change in their organizations.
What This Study Found: Five features increase the ability of Primary Care Groups
to innovate and change: (1) clear organizational structures and rules, and leadership that wants the
organization to learn and change; (2) opportunities for people at all levels of the organization to
reflect and learn, and sharing of what is learned, so that innovative thinking in one part of the
organization can be built on elsewhere; (3) medical professionals and managers in leadership roles
and encouragement of participation; (4) a change initiative at the right time and tailored to the
needs of the local group; and (5) instructors/leaders from outside the organization, who can be
useful if they help people make sense of their experiences and guide them in achieving their change
plans.
Implications:
• When combined, these features may support innovation in health care organizations.
• Primary care organizations can increase their ability to learn when people from different
backgrounds develop innovative interpretations of new information.
Stories from Frequent Attenders: A Qualitative Study in Primary Care
By Paula Hodgson, Ph.D., B.Sc., and colleagues Background: Patients who make frequent visits to the family doctor can cause a
strain on the work load and resources of the doctor’s office. This study interviewed such patients
about how often they visit the doctor, what they expect from the visit, and their relationship with
the medical team.
What This Study Found: Most patients interviewed were not able to clearly say how
often they visit the doctor. Although they had a lot of respect for their family doctors, many
patients were dissatisfied with their medical treatment. They also reported problems making
appointments, such as difficulties getting through to the doctor’s office by phone.
Implications: • Patients who make frequent visits to the doctor may have a different view of the appropriate
rate of visits, compared with family doctors and researchers.
• Communication problems between doctors and patients may lead some patients to visit the
doctor more often.
• Patients who make frequent visits want their family doctor to acknowledge their symptoms and
provide reassurance.
Predicting Persistently High Primary Care Use
By John M. Naessens, M.P.H., and colleagues Background: Previous research has shown that a small percentage of patients incur
a high amount of health care costs overall. This study set out to better understand the
characteristics of patients who use high levels of primary care resources.
What This Study Found:
During 1 year, 2% of patients accounted for 18% of visits to their primary care doctors and 11% of
total paid insurance claims. Patients who make frequent doctor visits include those with unstable
chronic medical conditions (such as rheumatoid arthritis), conditions involving the mind and body
(such as stress), and minor medical symptoms (such as headache).
Implications: • Many patients in this study made repeated doctor visits for relatively minor medical
conditions. They are therefore “overserviced” but “underserved” by the medical system.
• Although the medical system focused on easing their physical symptoms, such patients might
benefit more from social support, stress reduction programs, psychological treatment, and attention
to nonmedical issues.
Do Patients Treated With Dignity Report Higher Satisfaction, Adherence, and Receipt of
Preventive Care?
By Mary Catherine Beach, M.D., M.P.H., and colleagues Background: This study looked at whether patients who felt that they were treated
with dignity were more satisfied with their medical care, more likely to follow medical advice, and
whether they received appropriate preventive medical tests (such as mammograms and cholesterol
tests).
What This Study Found: Patients who were treated with dignity and who were
involved in decisions about their health care treatment were more satisfied with their care, more
likely to follow medical advice, and more likely to receive preventive medical services. White
patients who were involved in decisions were more likely to follow medical advice. Racial and ethnic
minorities were more likely to follow medical advice if they were treated with dignity.
Implications: • It is important for doctors to not only involve their patients in decisions but also to
treat them with dignity.
• Involving patients in decision making is not necessarily the same as treating them with
dignity and respect. Both are important to patients.
Trust in One’s Physician: The Role of Ethnic Match, Autonomy, Acculturation, and Religiosity
Among Japanese and Japanese Americans
By Derjung M. Tarn, M.D., M.S, and colleagues Background: Do cultural factors affect trust in the relationship between patient
and doctor? This study examined a variety of factors related to trust in the patient-doctor
relationship for Japanese individuals from Japan and for Japanese Americans.
What This Study Found:
Among Japanese and Japanese Americans, the following characteristics are related to having more
trust in their doctor: being married, being more religious, having a longer relationship with a
doctor, and being less interested in making independent medical decisions. For Japanese Americans,
adapting to Western culture and being of an ethnic background similar that of the doctor were
related to having more trust, while having to change doctors because of insurance was related to
less trust.
Implications: • These characteristics can alert doctors to patients who might have lower levels of trust.
• Doctors may need to make special efforts to build trust with patients who are of different
ethnic backgrounds.
• Training doctors to understand and accept different cultural norms may help them build trust
with patients of different ethnic backgrounds.
The Doctor Who Cried: A Qualitative Study About the Doctor’s Vulnerability
By Kirsti Malterud, M.D. Ph.D., and colleagues Background: Doctors often believe they are not supposed to show emotions to
patients, yet many patients want a doctor who cares. This study explored how doctors can use their
emotions and personal experiences to best serve patients. Participants in the study were family
doctors, sociologists, and a psychologist.
What This Study Found:
Under certain conditions, doctors’ emotions and personal experiences can help patients. This
includes a spontaneous, unplanned show of emotion by the doctor as well as a conscious decision by
the doctor to share a personal experience. Doctors in the study consider sharing of emotions and
experiences to be exceptions to their usual interactions with patients.
Implications: • Personal sharing by a doctor has the potential to benefit patients.
• The findings of this study can be a springboard for exploration of the following areas:
- Do patients feel they benefit from personal sharing by their doctors?
- Under what circumstances?
- How can doctors share personal information in ways that are responsible and responsive?
Continuity of Care: Is the Personal Doctor Still Important? A Survey of General Practitioners
and Family Physicians in England and Wales, the United States, and the Netherlands
By Tim Stokes, Ph.D., M.P.H., M.B.Ch.B., and colleagues Background: Although patients often want an ongoing relationship with a medical
professional (referred to as personal continuity of care), changes in health care policies and the
way that health care is organized have made it more difficult to maintain such relationships. This
study surveyed 1,523 general practitioners and family physicians in England and Wales, the
Netherlands, and the United States on their views of continuity of care.
What This Study Found: Doctors in all 4 countries feel strongly that personal
continuity of care (the ongoing relationship between a patient and a medical professional) is an
important part of good quality care. Most doctors surveyed think that personal continuity cannot be
replaced by continuity in other areas, such as medical information or management of a patient’s
medical condition.
Implications: • Even in very different health care systems, with different patient expectations and cultural
influences, doctors place a high value on maintaining the patient-physician relationship through
personal continuity.
• The importance of personal continuity to patients and doctors should be taken into account
by policy makers.
Enhance Your Team-Based Qualitative Research
By Douglas Fernald, M.A., and colleagues Background: Research using qualitative approaches often involves the collaboration
of a team. This article discusses teamwork issues and tools and techniques used to improve
qualitative research by teams.
What This Study Found: Building effective research teams requires attention by the
team leader, a commitment to early and regular team meetings, and discussion of the roles,
responsibilities and expectations of team members. Team members should discuss differences in styles
of analyzing data and managing information. Teams can capture ideas and insights that develop by
using common tools (such as summary forms) and common methods of coding data, keeping the data
analysis moving along, and writing down ideas, assignments, and decisions.
Implications: • In team research, little should be left to chance.
• Processes and documentation are key elements of teamwork.
• Tools and strategies for qualitative team research do not have to be rigid or highly
structured, but they do need to be documented and systematic.
