The Complexity of and Opportunity for Screening in Primary Care

This issue features articles on the early detection of disease and risk factors.

Four of these articles¹,^–4 and an editorial⁵ showcase colorectal cancer screening. Three of these studies evaluate the role of primary care in colorectal cancer early detection. A study using nationally representative data¹ shows that colorectal cancer screening rates are associated with having a personal clinician, as well as with social factors. In contrast, Jimbo and colleagues² find that primary care physician decisions are a major factor in patients not undergoing complete evaluation for a positive fecal occult blood screening test. To further complicate the picture of the role of primary care physicians in colorectal cancer screening, Wilkins conducts a meta-analysis of 12 studies of colonoscopy by primary care physicians, finding quality parameters similar to those in studies of specialists.⁴

The fourth colorectal cancer screening study, featured as this issue’s Annals Journal Club selection, is a clinical trial of a pragmatic intervention that links fecal occult blood testing to influenza immunization clinics. The dramatic effect shows that, when properly configured, complementary services can represent competing opportunities⁶ rather than competing demands.⁷

Several other studies in this issue address screening for other conditions. Jeppesen and colleagues find complementary value in several different brief screens for health literacy.⁸ Gjerdingen et al⁹ find that the optimal strategy for identifying women with postpartum depression may be a 2-stage screening procedure that involves using a 2-item initial screen, followed by a 9-item instrument for those whose screening test was positive. Rhodes et al,¹⁰ screening for intimate partner violence among men seen in an urban emergency department, find the highest rate of mental health symptoms occur among men who disclose both victimization and perpetration. This finding shows that the simplistic label of victim or perpetrator masks a more complex problem. A clinical policy guideline based on a systematic review¹¹ finds strong evidence for screening patients for depression after myocardial infarction and moderate to strong evidence for treatment.

A population-based study of children with asthma finds greater prescribing variability in younger children.¹²

Patient requests for specific new prescriptions are found in 3.5% of patient visits to clinicians in a practice-based research network.¹³ Although physicians reported that the requested medication was not their first choice for treatment, in 62% of these instances, the medication was prescribed 53% of the times it was requested. Despite this finding, clinicians reported a negative impact from these requests, stimulated by direct-to-consumer advertising, in only 10% of visits.

An essay by Buetow uses the art concept of negative space to help us see patients and situations (and sometimes ourselves) in relief, separated from preconception and focused on the moment.¹⁴

Please share your insights on these articles and your experience with the important topics they bring up by joining the Annals online discussion at http://www.AnnFamMed.org.

• © 2009 Annals of Family Medicine, Inc.