The Issue in Brief

Comparing the Effects of White Coat Hypertension and Sustained Hypertension on Mortality in a UK Primary Care Setting

Martin G. Dawes , and colleagues

Background Blood pressure measurements are of major importance, but they can be unreliable. Some patients have normal blood pressure when measured over time through a process called ambulatory blood pressure monitoring but high blood pressure when measured in the doctor's office (referred to as white coat hypertension). This study examines death rates in patients with white coat hypertension and compares them with those whose blood pressure is high in both the clinic and through ambulatory blood pressure monitoring.

What This Study Found White coat hypertension carries significantly less risk of death than if the patient has high blood pressure in both the clinic and when measured by ambulatory blood pressure monitoring.

Implications

• The authors suggest the medical community consider whether to stop using office blood pressure measurements for routine screening and diagnosing high blood pressure.
• Research is needed to evaluate how much risk can be reduced in patients with white coat hypertension who are treated with blood pressure-lowering therapy.

Impact of Title VII Training Programs on Community Health Center Staffing and National Health Service Corps Participation

Diane R. Rittenhouse , and colleagues

Background There have been substantial cuts in the US Title VII (Section 747) program, which helps medical schools and residency programs produce doctors to work with underserved populations. This study examines whether obtaining medical training in programs with Title VII grants is related to later work in community health centers or the National Health Service Corps, both of which care for underserved populations.

What This Study Found There is a strong association between attending Title VII-funded medical training programs and both practice in community health centers and participation in the National Health Service Corps.

Implications

• Reductions in Title VII funding affect institutions that produce high numbers of doctors who participate in the National Health Service Corps and/or work at community health centers and ultimately harms efforts to improve access to medical care for the underserved.
• The findings of this study help inform efforts to adequately staff community health centers.

An Exploratory Study of Spiritual Care at the End of Life

Timothy P. Daaleman , and colleagues

Background Although spiritual care is an important element of end-of-life care, it is unclear how this care is viewed and delivered at the end of life. This study explores how health caregivers understand and view spiritual care for dying patients and their family members.

What This Study Found Clinicians consider spiritual care at the end of life as a series of interpersonal processes, rather than a set of defined roles. These processes include being present with the patient, awareness by patient and clinician of one another's humanity and perspectives, and cocreation by patients, family members, and clinicians of a wholistic care plan that maintains the patient's humanity and dignity in the face of death.

Implications

• These findings provide a conceptual framework for spiritual care at the end of life.
• Future research should focus on the appropriateness of this framework for enhancing spiritual care and the overall care of patients at the end of life.

Impact of Spiritual Symptoms and Their Interactions on Health Services and Life Satisfaction

David A. Katerndahl

Background Physical, psychological, and social factors all contribute to health. This study asks whether spiritual factors are related to health as well, looking not only at spiritual symptoms alone, but also at their interaction with physical, psychological, and social symptoms.

What This Study Found Spiritual symptoms (alone or in interaction with other factors) are related to seven of ten measurements of health used in this study. Life satisfaction is associated with both physical and spiritual symptoms.

Implications

• Spiritual symptoms, alone and in interaction with other factors, contribute to our understanding of health.
• This study confirms the complex relationship between spiritual, physical, psychological, and social symptoms of health.
• When attempting to understand why patients with poor quality of life use high levels of medical services, clinicians should inquire about spiritual issues.

Human Resource Staffing and Service Functions of Community Health Services Organizations in China

Jun Yang , and colleagues

Background The Chinese government is increasing its focus on providing community health services (CHS) to its population. This study reports on the development of staffing and service functions in the CHS organizations.

What This Study Found The delivery of basic clinical services and public health services is steadily increasing; however, more doctors and nurses are needed in CHS stations. Furthermore, 68% of doctors and 87% of nurses in CHS centers have low-level medical training, and 59% of CHS stations are open less than 12 hours per day. Health records are widely used, and both public health education and individual patient education have been widely adopted.

Implications

• Improvements are needed in training for doctors and nurses providing health services, including training in basic clinical services and management of noncommunicable chronic diseases.
• The authors call for increased governmental support for the development of CHS organizations.

Accuracy of Primary Care Clinicians in Screening for Diabetic Retinopathy Using Single-Image Retinal Photography

Tillman F. Farley , and colleagues

Background Early detection and treatment of diabetic retinopathy, an eye disease common in people with diabetes, can slow or prevent the development of blindness. Screening for diabetic retinopathy usually involves an ophthalmologist (eye specialist), but low-income patients may have limited access to such specialists. Researchers have tested a screening program in which primary care doctors are trained to read a single image taken with a retinal camera, a tool that can identify diabetic retinopathy. This study looks at the doctors' accuracy in reading the photographic images and correctly identifying patients needing referral to ophthalmologists.

What This Study Found Primary care doctors trained to read single images from a retinal camera have acceptable accuracy in screening for diabetic retinopathy. They screened 1,040 diabetic patients at a low-income health center. One hundred thirteen (10.9%) were found to have diabetic retinopathy, 46 severe enough to need referral to an ophthalmologist. Participating doctors missed diabetic retinopathy in 8.7% of the patients who had it (4 out of 46), but discovered it in 41 others. Of the 344 patients the ophthalmologist believed needed referral, primary care doctors failed to refer 35 (10.2%), usually because the doctor failed to recognize an inadequate photograph or abnormalities other than diabetic retinopathy.

Implications

• Using single-image retinal photography in primary care offices, with primary care doctors reading the images, may be a cost-effective way to help reduce vision loss in diabetes patients who have limited access to ophthalmologists.
• Further training may be needed to help primary care doctors recognize other common eye problems.

An Intervention for Treating Alcohol Dependence: Relating Elements of Medical Management to Patient Outcomes With Implications for Primary Care

Denise B. Ernst , and colleagues

Background This study examines factors in the relationship between patient, clinician, and treatment results in a program to treat alcohol dependence. The program, conducted in sites affiliated with academic alcohol research programs, has found that patients who receive the drug naltrexone plus a Medical Management approach significantly reduce their drinking. (In the Medical Management approach, patients work with a clinician to learn about alcohol dependence, develop treatment and follow-up plans, and monitor their progress).

What This Study Found Patients who attend more visits reduce their drinking and have better clinical results. Patients' positive views of the relationship with their clinician, as well as their satisfaction with treatment, predict more days of abstinence from alcohol during treatment. In this study, participating clinicians were generally warm and informative, provided direction, and followed and completed the study plan. They help improve patient results if they show confidence in the treatment and are flexible in delivering it.

Implications

• This approach to alcohol treatment may be suitable for the primary care setting.
• Using effective medications and managing alcohol dependence in primary care could make treatment more available and lower the stigma related to asking for and receiving treatment for alcohol problems.

The Hearing-Dependent Daily Activities Scale to Evaluate Impact of Hearing Loss in Older People

Jesús López-Torres Hidalgo , and colleagues

Background Up to 25% of persons between the ages of 65 and 75 years have undiagnosed hearing loss. This article describes the design and testing of the HDDA (Hearing-Dependent Daily Activities) Scale. The scale identifies the impact of hearing loss on daily life in older persons by measuring their ability to carry out hearing-dependent activities.

What This Study Found The HDDA Scale is a useful tool for detecting hearing loss in older people, a condition which frequently goes unnoticed during routine medical check-ups.

Implications

• Early detection of hearing loss can reduce its impact on the functioning and social behavior of older people.
• Only 20% of primary care doctors use a screening tool to identify hearing disorders. The HDDA Scale can help fill the need for an easy-to-use tool in clinical practice.

The 3 H and BMSEST Models for Spirituality in Multicultural Whole-Person Medicine

Gowri Anandarajah

Background There is growing interest in both whole-person care (which addresses the patient's body, mind, and spirit) and the role of spirituality in patient care. However, there are few comprehensive models of spirituality tailored to daily patient care needs. This article provides a theoretical framework, aimed at clinicians, educators and researchers, addressing how spirituality fits into whole-person health care.

What This Study Found Two models provide a basis for approaching spirituality in whole-person medicine. The 3 H model of spirituality (head, heart, hands) offers a multidimensional definition of spirituality, which can be applied across cultures and belief systems, with a common vocabulary. The BMSEST (body, mind, Spirit, environment, social, transcendent) models provide a framework for the role of spirituality in the larger health care context, useful for patient care, education, and research.

Implications

• Given the complexities of the human condition, the future study of whole-person care will require research methods and approaches from many disciplines, including science, social science, and the humanities.
• Although challenging, there are many opportunities to find common ground between different world views and ways to provide cure, relief, and comfort to patients.

Optimizing Practice Through Research: A New Perspective To Solve an Old Problem

Thomas E. Kottke , and colleagues

Background In this essay, the authors propose 5 principles to help improve patient outcomes through research: (1) the needs of patients and populations determine the research agenda; (2) the research agenda addresses contextual and implementation issues; (3) the research agenda determines research methodologies; (4) researchers and clinicians collaborate to define the research agenda, allocate resources and implement findings; and (5) the level of funding for implementation research is equal to the task.

'Be Gentle and Sincere About It': A Story About Community-Based Primary Care Research

Andrew L. Sussman , and colleagues

Background There is growing recognition of the importance of including the voices of community members in practice-based research. In this essay, a community focus group reminds a researcher of the value of listening, trust, and stories, using a traditional medicinal plant as a powerful cultural metaphor.