The Issue in Brief

Short-Term Impacts of Coverage Loss in a Medicaid Population: Early Results From a Prospective Cohort Study of the Oregon Health Plan

Matthew J. Carlson, PhD, and colleagues

Background The expansion of Medicaid programs over the past 20 years has improved access to health care for millions of low-income Americans. In recent years, however, states have reduced Medicaid spending to save costs. This study examines the immediate effects of disrupted or lost medical coverage on adults enrolled in Medicaid. In particular, the study looks at the effect of changes in Medicaid in the Oregon Health Plan (OHP) implemented in February, 2003.

What This Study Found Nearly one half (45%) of those enrolled in the OHP Standard plan experienced disrupted or lost medical coverage in the first 10 months after the plan was redesigned. In contrast, during the same period 1 year earlier, enrollment declined by only 3%. Those who lost coverage reported significantly worse access to health care and medication and higher medical debt than those with stable coverage. In addition, those whose insurance coverage was disrupted were less likely to get needed medical care and less likely to be able to afford needed prescription medicine than those with stable coverage.

Implications

• Changes in the Oregon Health Plan resulted in immediate loss of medical coverage, unmet health care needs, and increased debt for many low-income adults.
• Even short gaps in medical coverage can result in less access to health care and more financial burden.
• Those whose access to health care and medications is reduced in the short-term may have worse health with time, and may be more likely to need emergency department or hospital services.
• Because most states in the US have made changes to their Medicaid programs similar to those in Oregon, this research has national implications.

Primary Care Physicians' Perceptions of the Effect of Insurance Status on Clinical Decision Making

David S. Meyers, MD, and colleagues

Background It is widely recognized that Americans without health insurance receive fewer health services and have worse health than those with insurance. Until now, however, there has been little research into whether patients’ insurance status affects doctors’ medical decision making during office visits. In this study, primary care doctors share their perspectives on whether patients’ insurance status affects their medical management of patients during office visits.

What This Study Found Twenty-five doctors in Washington, DC, completed surveys of 409 office visits. Twenty-two (88%) of the doctors reported making at least 1 change in their medical management of patients because of the patients’ insurance status. Doctors took patients’ insurance into account during 193 (47.2%) of 409 office visits. Visits by uninsured patients were most likely to include changes in medical management decisions, whereas visits by privately insured patients were least likely to include such changes.

Implications

• Primary care doctors consider their patients’ health insurance status when they make medical decisions during office visits.
• In this study, doctors considered insurance in almost one half of patient visits and changed their medical management in almost one quarter of visits.
• Additional research is needed to understand the effect of these changes on patient health and to help doctors and patients get the best quality of care within the limitations of the current health ins

Mandatory Reporting of Elder Abuse: Between a Rock and a Hard Place

Michael A. Rodriguez, MD, MPH, and colleagues

Background Although doctors are required by law to report elder abuse, they do so at low rates. In this study, researchers interviewed primary care doctors about their experiences and perspectives on required reporting of elder abuse. The goal of the study was to gain insights to help train medical professionals and students on elder abuse issues.

What This Study Found Doctors identified paradoxes, or contradictions, in the required reporting of elder abuse, including the following: (1) A strong bond between patient and doctor can create the trust needed for a patient to disclose abuse, which increases the likelihood that the abuse will be reported. Doctors who have a strong bond with a patient, however, may be hesitant to report abuse for fear that the patient will feel deceived and their relationship will be damaged. (2) A doctor may report abuse because of a desire to improve the patient’s quality of life by removing the elder from the abusive situation. But a doctor may be less likely to report elder abuse out of concern that it will decrease the patient’s quality of life in other ways (such as revenge or another negative response by the abuser). (3) Required reporting is a way to potentially help the patient and therefore increases the doctor’s control over the patient’s well-being . Because reporting is required, however, it also decreases the doctor’s ability to decide how to best help the patient.

Implications

• Although these paradoxes may be hidden or unconscious, they appear to influence doctors’ decisions about whether report elder abuse.
• There is a need to increase primary care doctors’ awareness about elder abuse and its reporting.
• There has been progress in training health care professionals about child abuse and intimate partner violence, but it is unclear to what extent the topic of elder abuse has been included in such tra
• There are mismatches between required reporting laws and the realities of primary care practice. Reducing these mismatches, as well as the paradoxes they create, could help increase reporting of elder

Excess Mortality Due to Medical Injury

Linda N. Meurer, MD, MPH, and colleagues

Background To improve safety, hospitals often rely on voluntary reporting of errors and near misses; however, many medical injuries occur during care that is appropriate. Identifying errors by focusing on patient health, rather than errors, can provide additional information about patient safety problems. This study uses such a model to identify medical injuries among patients discharged from Wisconsin hospitals and to estimate related deaths.

What This Study Found In 2002, 13.8% of patients in Wisconsin hospitals experienced a medical injury. Those who had a medical injury had a 48% higher risk of death. Medical injury and risk of in-hospital death were higher among older patients who had multiple medical conditions. Multiple medical conditions must be taken into account to avoid inflating estimates of in-hospital medical injuries.

Implications

• The number of deaths directly attributable to medical injury may not be as high as previously thought when the patient’s medical conditions are fully considered.
• Family physicians can help improve patient safety by assisting with hospitalization decisions, coordinating patients’ care, and managing their chronic illnesses.

Psychological Distress and Multimorbidity in Primary Care

Martin Fortin, MD, MSc, and colleagues

Background Psychological distress can increase the effects of illness and contribute to health problems. Even so, little is known about the relationship between psychological distress and multimorbidity (that is, having more than 1 chronic disease). This is a study of the relationship between psychological distress and multiple chronic diseases in family medicine patients. It looks at both the number of chronic diseases a patient has and the severity of the diseases.

What This Study Found Patients with multiple chronic diseases that are more severe had more psychological distress than patients with multiple chronic diseases that are less severe. The risk of psychological distress was almost 5 times higher in patients with the highest burden of disease. Psychological distress was not related to the number of chronic diseases a patient has.

Implications

• This is the first study to analyze the relationship between multimorbidity and psychological distress in a family practice setting, taking severity of illnesses into account.
• Psychological distress may be present in patients with multiple chronic diseases. Clinicians should consider this as they manage the care of these complex patients.

Associations Between Night Sweats and Other Sleep Disturbances: An OKPRN Study

James W. Mold, MD, MPH , and colleagues

Background Research has shown that night sweats are more common than previously thought. This study examines possible relationships between night sweats and sleep disorders.

What This Study Found Thirty-three percent of patients in this study experienced night sweats, with 16% reporting nighttime sweating severe enough to soak their bedclothes. Night sweats appear to be associated with a variety of sleep symptoms (daytime tiredness, waking up with a bitter taste in the mouth, legs jerking during sleep, and awakening with pain in the night), but it is not clear how they are associated. Sleep-related symptoms, such as waking often at night and daytime drowsiness, were also common among primary care patients.

Implications

• Night sweats are commonly experienced by adults who visit primary care doctors and are associated with a variety of sleep symptoms.
• Doctors should ask patients with night sweats about sleep problems.

Evidence of Nephropathy, Peripheral Neuropathy in Undiagnosed Diabetes

Richelle J. Koopman, MD, MS , and colleagues

Background Although early diagnosis of diabetes can help prevent health problems from the disease, there is evidence that some health problems may develop before diabetes is diagnosed. This is the first large-scale study of how often 2 conditions occur in adults with undiagnosed diabetes: nephropathy, a form of kidney damage from high blood sugar, and peripheral neuropathy, or nerve damage from high blood sugar.

What This Study Found Among adults older than 40 years with undiagnosed diabetes, almost 25% had signs of nephropathy; more than 21% had signs of peripheral neuropathy.

Implications

• Undiagnosed diabetes is a serious public health concern.
• Health professionals may need to reconsider current approaches for detecting diabetes. Most current approaches wait for medical signs and symptoms, and by then it may be too late to prevent some hea
• The authors call for more aggressive diabetes testing based on patients’ risk for the disease. They also call on insurers to provide reimbursement for such tests.

Discussing Prostate-Specific Antigen Tests With a Physician by US Men

Stephanie L. McFall, PhD

Background Medical professionals disagree about whether the PSA (prostate-specific antigen) test is a helpful tool in screening men for prostate cancer, and whether prostate cancer screening should be recommended for men older than 50 years. It is recommended that doctors inform men about the benefits and risks of prostate cancer screening, so that they can make their own informed decisions. This study looks at whether men who receive a PSA test discuss the test with their doctors in advance, as well as other factors that might be related to such discussions.

What This Study Found About 60% of men who received a PSA test discussed the pros and cons of the test with their doctors in advance. Discussions were more likely to occur with African American men, with men who had an established source of medical care, and when the doctor suggested the test.

Implications

• These findings suggest that doctors are aware that African American men are at greater risk of prostate cancer and are addressing prostate cancer screening in their office visits.
• Topics for future study include the effect of the medical practice setting and the patient-doctor relationship on the discussion of prostate cancer screening, and methods for getting patients actively

NIH Funding in Family Medicine: An Analysis of 2003 Awards

Howard K. Rabinowitz, MD, and colleagues

Background The National Institutes of Health (NIH) is an important source of funding for research, but it has not been a major source of research funding in family medicine. This study set out to learn more about NIH funding awarded to family medicine departments.

What This Study Found In 2003, 149 NIH awards, totaling $60,085,000, were granted to 45 family medicine departments. Approximately 2 of 3 awards and funds went to principal investigators who were not full-time family medicine faculty in family medicine departments, or were not working in core family medicine areas. Nationally, only 17 R01 awards (research project grants based on the mission of the NIH) went to family physicians. The authors identified 4 models to increase NIH funding. (1) Family medicine faculty in core areas can develop their own research focus and obtain NIH funding. (2) Junior researchers in core family medicine areas can obtain K (career development) awards. (3) Family medicine faculty can work in their own departments as well as in noncore areas of the university that offer research infrastructures. (4) Family medicine departments can incorporate faculty or other university components not usually part of their departments.

Implications

• There is a critical need to increase capacity for conducting research in family medicine.
• Some family medicine research is funded through important sources other than the NIH. These sources should be recognized when medical schools measure research accomplishments.
• Family medicine has the potential to make unique and important contributions to many NIH research priorities.

Creating Innovative Research Designs: The 10-Year Methodological Think Tank Case Study

David Katerndahl, MD, MA, and colleagues

Background A Methodological Think Tank has been held annually since 1994. A group of 3 to 4 research methodologists with diverse expertise work as a team, discussing a research question selected in advance. They explore the content area with the study investigator and help identify a desirable methodology for the study.

What This Study Found The Methodological Think Tank has been successful in developing innovative designs to answer important questions that are not easily addressed with conventional research designs. The 7 most recent think tanks produced research designs that received grant funding, including 1 K award (a National Institutes of Health career development award) and 4 R01 grants (research project grants based on the mission of the NIH). Participants attributed much of their success to participation in the Methodological Think Tank.

Implications

• The Think Tank process—a short-term collaboration involving researchers with diverse methodological expertise—can help bring about progress on complex research questions.
• Researchers and academic departments could use this process locally to develop innovative research designs.

General Medicine Practitioners Need to be Aware of the Theories on Which Our Work Depends

Paul Thomas, FRCGP, MD

Background When general practitioners and family physicians listen, reflect, and diagnose, they use 3 different theories of knowledge: postpositivism (which views the world as orderly and predictable), critical theory (which believes that truth exists, but may be hidden by other truths), and constructivism (which believes that there is no single truth but that people create truth and share meanings). Each of these theories is necessary because each highlights different aspects of the complex and changing world; together they help make sense of everyday experience. These theories serve as lenses and as guides to action. Understanding them can help clinicians learn, practice, and conduct research.

Family Medicine's Identity: Being Generalists in a Specialist Culture?

Howard F. Stein, PhD

Background This essay describes the relationship between family medicine’s struggle for identity and the dominant American culture within which that struggle occurs. The author argues that family medicine’s history may be best characterized by core conflicts rather than by core values. These include conflicts between the generalist nature of family medicine and the family physician’s identity as a specialist, and between the desire to be a part of mainstream American biomedical culture and a part of the medical counterculture. The author suggests that family medicine avoid new bandwagons and slogans that promise to solve its identity problems, and that clinicians adopt a reflective approach to their practice and to the future of the discipline.

Si, Doctora

Lucy M. Candib, MD

Background When a patient says “yes” to a doctor, it does not necessarily mean that they agree or that they will do what the doctor recommends. In this essay, the author describes how her understanding of “yes” changed when a friend from Ecuador was learning English. “Yes” may sometimes be a marker, used to keep the speaker talking when the listener does not fully understand. When patients say “yes,” it can have multiple possible meanings and can be a cue for the physician to probe more deeply.