The Issue in Brief

Perceived Vulnerability to Heart Disease in Patients With Familial Hypercholesterolemia: A Qualitative Interview Study

Jan C. Frich, MD, MSc, and colleagues

Background Patients' perceptions of how likely they are to get a disease in the future can influence their attitudes toward medical treatment and preventive health measures. This study explores how patients with familial hypercholesterolemia (an inherited condition that causes high cholesterol) view their risk of getting coronary heart disease, which commonly results from the condition.

What This Study Found In this study of 40 patients, family health history influences the ways in which participants' perceive their genetic and inherited risk of coronary heart disease, and the age at which they expect to develop symptoms. They compare themselves with other family members, focusing on sex, cholesterol levels, use of cholesterol-lowering medication, and lifestyle. Experiences such as cardiac illness in the family, other illness experiences, or becoming a parent cause a shift in some participants' sense of vulnerability to heart disease.

Implications

• Among people with familial hypercholesterolemia, unique life experiences and social factors help shape a sense of risk of developing coronary heart disease.
• Knowing how patients understand their family health history and risk of disease can help doctors (1) understand patients' level of readiness for preventive medical care, and (2) tailor medical care to patients' individual needs.

Patients' Perceptions of Cholesterol, Cardiovascular Disease Risk, and Risk Communication Strategies

Roberta E. Goldman, PhD, and colleagues

Background High cholesterol levels can contribute to cardiovascular (heart) disease, the leading cause of death in the United States. This study uses focus groups to explore people's knowledge of and attitudes toward cholesterol and the risk of cardiovascular disease, as well as their reactions to different methods of communicating the risk of cardiovascular disease.

What This Study Found All participants were aware that high cholesterol levels can harm health, but few were knowledgeable about hypercholesterolemia (high blood cholesterol level) or the risk of cardiovascular disease associated with it. Most participants did not know their own cholesterol numbers and did not think that knowing their numbers would motivate them to change their health habits. Many assumed they had been tested and their cholesterol levels were healthy, even if their physicians had not mentioned it. Participants felt that a communication method that told them their "heart age" was clear and easy to remember, and might motivate people to make healthful changes. (Heart age considers how your cholesterol levels, family health history, and certain aspects of your personal health history affect your risk of having a heart attack. Based on this information, you are assigned a heart age, which may be higher or lower than your actual age.)

Implications

• Complex explanations about cholesterol and cardiovascular disease risk do not appear to be effective in motivating patients to change their health habits. Patients prefer individualized, personally meaningful information that can help them make health care and lifestyle decisions.
• Providing patients with information they can identify with about their personal risk of cardiovascular disease related to cholesterol may help them to understand and make use of other, more general cholesterol education programs.

Readiness to Change in Primary Care Patients Who Screen Positive for Alcohol Misuse

Emily C. Williams, MPH, and colleagues

Background Alcohol misuse is widespread, and one of the most costly public health problems in the United States. This study of more than 6,000 male patients who reported alcohol misuse in the past year evaluates the participants' readiness to change their alcohol habits.

What This Study Found Most participants indicated some readiness to change. Contrary to a stereotype that patients with alcohol misuse will deny concerns about their drinking, most patients in this study who reported alcohol misuse indicated that they drank more than they should or had considered or tried decreasing drinking. Those with more severe alcohol misuse were more likely to report readiness to change.

Implications

• Primary care clinicians sometimes expect patients to deny their alcohol misuse. Such denial is often thought to be common among patients with the most severe alcohol dependence. The findings in this study suggest that the opposite is true. The more a patient drinks and the more severe his problems because of drinking, the more likely he will report considering or wanting to change his drinking.
• Based on this and other research, the authors suggest that patients with the least severe alcohol misuse may benefit most from brief alcohol-related advice from their primary care clinicians.

A Cross-Cultural Study of Physician Treatment Decisions for Demented Nursing Home Patients Who Develop Pneumonia

Margaret R. Helton, MD, and colleagues

Background There are many differences between US and Dutch approaches to care of nursing home patients. In this study, US and Dutch physicians were interviewed about factors that are important in their treatment decisions for nursing home patients with dementia who develop pneumonia.

What This Study Found Physicians view their patient care roles differently, with Dutch physicians taking active responsibility for treatment decisions and US physicians deferring to family wishes. Dutch physicians base decisions on an intimate knowledge of the patient; American physicians report more limited knowledge of their nursing home patients as a result of limited time with them.

Implications

• Physicians are shaped by broad social factors. For American doctors, these factors include technological medical training, a lack of emphasis on care of nursing home patients, a high value of personal autonomy, and fear of lawsuits. Dutch doctors are influenced by the Netherlands' public discussion about end-of-life care, a strong national focus on and training in nursing home care, and less emphasis on technology in medicine.
• Efforts to improve care of nursing home patients with dementia and pneumonia must consider social values, physician training, and processes by which physicians determine and negotiate patient and family preferences regarding care.
• These study findings should be considered in debates about how to best care for patients with poor quality of life who lack decision-making capacity.

Vaginal Birth After Cesarean in California: Before and After a Change in Guideline

John Zweifler, MD, MPH, and colleagues

Background In 1999, the American College of Obstetricians and Gynecologists adopted more-restrictive guidelines for vaginal birth after cesarean delivery (VBAC), requiring a physician to be immediately available to perform emergency care, if needed. This study looks at trends in VBAC in California before and after the 1999 guideline revision.

What This Study Found The percentage of women attempting vaginal birth after cesarean delivery fell significantly, from 24 percent before the guideline revision to 13.5 percent after guideline revision. This decline, however, seems to continue a national trend that began in 1997. Although rates of repeat delivery by cesarean section increased during the years following the guideline revision, death rates among infants and mothers did not improve.

Implications

• The 1999 guideline revision reflects concern for the safety of VBAC deliveries and may have accelerated the trend away from VBAC and toward repeat cesarean deliveries, particularly at rural hospitals.
• This study found that, in delivery of normal or large birth weight infants, the infant death rate for VBAC was similar to the death rate for repeat cesarean delivery.
• The authors recommend that, when counseling pregnant patients who have had a previous cesarean delivery, physicians offer a balanced presentation of risk and inform them of the encouraging outcomes found in this study.

How Primary Care Networks Can Help Integrate Academic and Service Initiatives in Primary Care

Paul Thomas, MD, FRCGP, and colleagues

Background Primary care research networks (PCRNs) are groups of primary care medical practices in the United Kingdom that promote and facilitate research in clinical practice. This study looked at the performance of four PCRNs in order to draw lessons about ideal ways to organize PCRNs.

What This Study Found The ways in which PCRNs organize themselves is influenced by the circumstances in which they are formed. Different types of PCRN organization are associated with different results. A PCRN that uses a "top down, hierarchical" approach, based on relationships with other institutions and university expertise, attracts more research funding and has the highest percentage of local participation among the networks studied. A "bottom up, individualistic" network, which centers its authority in its steering group, has a strong focus on medical practice and the highest number of projects that only involve general practices. A "whole system" PCRN has little primary care collaboration but has the most partnerships between general practices and other organizations.

Implications

• By encouraging shared leadership of projects, networks can help integrate research and development initiatives.
• Networks can gain funding and stability through strategic alliances with other institutions.
• Local medical practices have the potential to be centers of research activity in which multidisciplinary teams reflect on concerns that relate to primary care practice.
• A whole system approach, which brings together participants from throughout the system, may offer a way for PCRNs to address participants' varied interests.

The US Medical Liability System: Evidence for Legislative Reform

Janelle M. Guirguis-Blake, MD, and colleagues

Background It is widely believed that increases in malpractice insurance premiums, high awards in malpractice cases, and doctors' fear of lawsuits have contributed to rising US health care costs. This study analyzes all payments made to settle malpractice claims or satisfy malpractice judgments on behalf of doctors in the United States from 1999 through 2001.

What This Study Found There are wide variations among states in malpractice payments. Total payments for the 3-year period ranged from $15.4 million in Wyoming to more than $1.8 billion in New York. Caps on total payments and on payments for noneconomic damages are associated with lower payments. Total caps on payments are also associated with lower insurance premiums.

Implications

• The wide state-to-state variations in malpractice payments suggest that compensation for injured patients is unequal.
• Significant reductions in malpractice payments could be achieved if caps on total malpractice payments or caps on noneconomic damages are in effect nationally in the United States. Hard caps on noneconomic damages and total damages might contribute to lower insurance premiums. If tied to a comprehensive plan for reform, these reductions could be used to benefit patients, employers, physicians, and hospitals.
• The authors suggest that a broader solution to the inequities in the current liability system requires strategies aimed at improving the quality and safety of the health care system.

Development of a Measure to Assess Patient Trust in Medical Researchers

Arch G. Mainous III, PhD, and colleagues

Background Many research studies find it difficult to recruit individuals, particularly minorities, for participation. Mistrust of research and researchers may be one reason why a person declines to participate. The purpose of this study is to develop a scale for assessing trust in medical researchers.

What This Study Found The Trust in Medical Researchers Scale is successful in assessing a person's trust in medical researchers. It may be useful in recruiting minority groups for research studies. The scale can help researchers examine community belief systems and concerns, and then tailor recruitment efforts and community education for the project accordingly.

Implications

• As primary care researchers become more aware of the need to include diverse populations in studies that truly represent primary care patients, the issue of barriers to recruitment and participation takes on greater importance. This scale appears to be a useful tool for researchers.

Efficacy and Safety of Inhaled Corticosteroids in Patients With COPD: A Systematic Review and Meta-Analysis of Health Outcomes

Gerald Gartlehener, MD, MPH, and colleagues

Background Chronic obstructive pulmonary disease (COPD) is a leading causes of illness and death worldwide. Caused primarily by smoking, COPD refers to a group of lung diseases in which airflow to and within the lungs becomes partially blocked, making it hard to breathe. This study examines existing research to determine the risks and benefits of inhaled corticosteroids in treating COPD.

What This Study Found Inhaled corticosteroids appear to help patients with moderate to severe COPD. Patients treated with inhaled corticosteroids experienced 33 percent fewer exacerbations (a sudden worsening of COPD symptoms) than patients who received a placebo. Inhaled corticosteroids do not appear to benefit patients with mild COPD.

Implications

• This study is the first comprehensive assessment of the risks and benefits of treating COPD with inhaled corticosteroids. The findings contribute information to the ongoing controversy about the use of inhaled corticosteroids in treatment of patients with COPD.

Thoughts on communication

Paul R. Gordon, MD, MPH

This essay depicts a physician's experience in another country where he does not speak the native language and its transforming effect on his views of the importance of communication. The author's experiences offer lessons on communicating with patients who do not speak the same language.

Patient Choice Vaginal Delivery?

Lawrence M. Leeman, MD, MPH, and colleague

This essay argues that, with cesarean delivery rates consistently on the rise (from 4.5 percent in 1965 to 26.1 percent in 2002), a woman's option to choose vaginal childbirth should be preserved, specifically after a previous cesarean delivery or with a breech presentation. The authors question why cesarean delivery is framed as a woman's choice, whereas vaginal delivery often is not. The choice of a cesarean delivery can effect a woman's reproductive future, with a higher risk of certain pregnancy complications. The authors suggest that before a universal right of women to choose elective primary cesarean delivery is adopted, studies should be conducted to compare the risks of cesarean and vaginal delivery. They conclude that, if the issue is one of patient choice, then the choice of vaginal birth must be accepted and available.