The Issue in Brief

Ann Fam Med 5: 1.

Creating Demand for Prescription Drugs: A Content Analysis of Television Direct-to-Consumer Advertising

Dominick L. Frosch , and colleagues

Background Average American television viewers see as many as 16 hours of prescription drug advertisements per year. Arguments in favor of advertising prescription drugs on television state that they help educate people about health conditions and available treatments. This study analyzes the messages in television prescription drug ads to understand how they influence consumers and whether they meet their educational potential.

What This Study Found Television prescription drugs ads usually try to persuade viewers using reasons other than medical costs and benefits. Ads provide some factual claims and rational arguments, but they don’t usually describe the causes or risk factors for a condition, or whether the condition is common. Almost all ads use emotional appeals and show characters who have lost control over their social, emotional, or physical lives without the medication. Ads portray prescription drugs as medical breakthroughs and minimize the value of healthy lifestyle changes.

Implications

• Despite claims that ads serve an educational purpose, they provide limited information about the causes of a disease or who may be at risk.
• Because prescription drug ads are unclear about who might need or benefit from the products, they imply that people may be at risk for a wide range of health conditions that can be treated by prescription drugs.
• The ads have limited educational value and may oversell the benefits of drugs in ways that may conflict with promoting health.

Use of Chronic Care Model Elements is Associated With Higher Quality Care for Diabetes

Paul A. Nutting, MD, MSPH , and colleagues

Background The Chronic Care Model is a comprehensive approach to caring for people with chronic diseases. This report explores whether there is a relationship between certain elements of the Chronic Care Model and the care of diabetes patients. The study included 90 clinicians (doctors, nurse-practitioners, and physician's assistants) and 886 patients.

What This Study Found Clinicians’ use of certain elements of the chronic care model, such as systems of tracking and following up with diabetes patients, was related to lower hemoglobin A1c (a measure of overall diabetes control) and lower cholesterol levels in diabetes patients, two indicators of good diabetes management.

Implications

• There is growing evidence that elements of the Chronic Care Model improve the care of patients with chronic disease in primary care settings.
• Clinicians in small, independent primary care practices are able to incorporate aspects of the Chronic Care Model into their practice style, often without making major changes in their practice, and this is related to higher levels of diabetes care and better health of diabetes patients.
• Small primary care practices might consider more ambitious efforts to change the ways in which they care for patients with chronic illnesses.

Exploring and Validating Patient Concerns: Relation to Prescribing for Depression

Ronald M. Epstein, MD , and colleagues

Background There are inconsistencies in the prescription of antidepressants in the primary care office. Some patients with major depression do not receive medications while others with less clear symptoms do. This study set out to understand the relationship between the ways in which patients and doctors communicate and decisions to prescribe depression medications.

What This Study Found When doctors explore and confirm patient concerns--including patient symptoms, ideas, expectations, ability to function, and feelings¯they are more likely to prescribe antidepressants for patients who will likely benefit from them, and less likely to prescribe them for patients whose need for the medication is not clear.

Implications

• Exploring and validating patient concerns is linked to quality of care for depression.
• This is one of the first published studies to link doctors’ communication with appropriateness of prescribing medication.

Cost-Effectiveness Analysis of Treatment Options for Acute Otitis Media

Andrew S. Coco, MD, MS

Background In the United States, there are 13.6 million doctor visits per year for children with acute otitis media, or inflammation of the middle ear. In 1995, these visits cost an estimated $2.98 billion. This study compares the costs and effectiveness of 4 approaches to treating children with acute otitis media: (1) watchful waiting (waiting 72 hours to see whether symptoms settle before starting the patient on amoxicillin (an antibiotic)); (2) delayed prescription (parents return to the office for a prescription of amoxicillin if symptoms continue for 48-72 hours); (3) 5 days of amoxicillin treatment; and (4) 7 to 10 days of amoxicillin treatment.

What This Study Found Children with acute otitis media would receive the most benefit by taking routine amoxicillin for 7 to 10 days; however, this approach is costly. Delayed prescription is the least costly option and would have the added benefit of reducing resistance to antibiotics, which occurs with frequent antibiotic use.

Implications

• From an economic perspective, it is reasonable to treat acute otitis media with either an initial period of observation or routine amoxicillin.
• The effectiveness of antibiotics in reducing several hours of symptoms of acute otitis media comes at considerable financial cost.
• This study supports recent guidelines from the American Academy of Pediatrics and American Academy of Family Physicians, which offer the option of observing lower risk children with acute otitis media for 48 to 72 hours, providing relief of symptoms rather than antibiotic treatment.

Describing Primary Care Encounters: The Primary Care Network Survey and the National Ambulatory Medical Care Survey

Helen J. Binns, MD,MPH , and colleagues

Background Practice-based research networks (PBRNs) are groups of practices that join together to conduct research and quality improvement activities. Many primary care PBRNs, however, do not have accurate, up-to-date data describing their members and patients, information that is necessary for conducting studies. Twenty PBRNs administered the Primary Care Network Survey to collect data about clinicians and patient visits, while testing the survey for use by other PBRNs.

What This Study Found Clinicians who took the survey included doctors (89%), doctors in residency training (4%), advanced practice nurses/nurse-practitioners (5%), and physician’s assistants (2%). Most (53%) specialize in pediatrics, 34% in family medicine, and 9% in internal medicine. Compared with the National Ambulatory Medical Care Survey, these participants had more visits for preventive care and had more children, members of minority racial groups, and low-income individuals in their practices.

Implications

• The Primary Care Network Survey is the first systematic effort to catalog health care delivery in primary care offices by a large, diverse group of PBRN members.
• These results help describe delivery of health care services in primary care offices and may offer a more in-depth view of particular aspects of primary care. The results are also important for examining research questions in PBRNs.

Validation of a 4-Item Score Predicting Hip Fracture and Mortality Risk Among Elderly Women

Daniel M. Albertsson , and colleagues

Background The aim of this study was to develop and test a practical tool to assess the risk of hip fracture and death in elderly women.

What This Study Found The Fracture and Mortality Index uses simple yes/no questions about 4 risk factors for hip fracture: old age, low weight, previously broken bones, and using arms to rise from a sitting position. This tool predicts hip fractures as well as more complex scoring systems. Among 1,248 women participating in the survey, most (63%) had 0 or 1 risk factor, which suggests a very low risk of hip fracture and death within 2 years. The risk of hip fracture was more than 7 times higher for the 37% of women with at least 2 risk factors.

Implications

• The Fracture and Mortality Index is a simple, practical tool for routine use in primary care.

Current Diagnosis of Venous Thromboembolism in Primary Care: A Clinical Practice Guideline from the American Academy of Family Physicians and the American College of Physicians

Amir Qaseem , and colleagues

Background Venous thromboembolism refers to two related conditions: deep venous thrombosis (a blood clot that can form, most often in the "deep veins" in the legs, thighs, or pelvis) and pulmonary embolism (which occurs if part or all of the blood clot in the deep vein breaks off and blocks an artery in the lung). There are an estimated 600,000 cases of venous thromboembolism in the United States each year. This guideline presents recommendations to help primary care doctors diagnose deep venous thrombosis and pulmonary embolism.

Review of the Evidence on Diagnosis of Deep Venous Thrombosis and Pulmonary Embolism

Jodi Segal , and colleagues

Background Venous thromboembolism refers to two related conditions: deep venous thrombosis (a blood clot that can form, most often in the deep veins in the legs, thighs, or pelvis) and pulmonary embolism (which occurs if part or all of the blood clot in a deep vein breaks off and blocks an artery in the lung). Practical methods of diagnosing venous thromboembolism are important so that the condition can be treated early. This systematic review summarizes the evidence about the effectiveness of techniques for diagnosing deep venous thrombosis and pulmonary embolism.

Management of Venous Thromboembolism: A Clinical Practice Guideline From the American College of Physicians and the American Academy of Family Physicians

Vincenza Snow , and colleagues

Background Venous thromboembolism is a common condition, referring to deep venous thrombosis (a blood clot that can form, most often in the deep veins in the legs, thighs, or pelvis) and pulmonary embolism (which occurs if part or all of the blood clot in a deep vein breaks off and blocks an artery in the lung). Treating deep venous thrombosis at an early stage can help avoid further complications, such as pulmonary embolism. This guideline on treating venous thromboembolism is intended for clinicians caring for patients with a diagnosis of deep venous thrombosis or pulmonary embolism.

A Headache at the End of the Day

Howard Brody, MD, PhD

Background In this essay, a child's headache provides a window into the relationship between the parents and the sources of their worries about the child's health. It highlights the many concerns that doctors must keep in mind and the challenge of addressing these threads and understanding their interactions during relatively short office visits.