Table of Contents
The Issue in Brief
July-August 2004
Cumulative list of Issues In Brief
A
Going To Scale: Re-Engineering Systems for Primary Care Treatment of Depression
By Allen J. Dietrich, MD, and colleagues
One hundred eighty clinicians in 60 medical practices nationwide are evaluating a new system for treating depression. The
system provides collaboration and interaction between the patient, the patient's primary care physician, a care manager, and
a psychiatrist. The primary care physician diagnoses the depression, initiates treatment, and provides follow-up care, the
psychiatrist oversees treatment, and the care manager provides telephone support and facilitates communication.
A Randomized Controlled Trial to Increase Cancer Screening Among Attendees of Community Health Centers
By Richard C. Roetzheim, MD, MSPH, and colleagues
Racial and ethnic minorities, low-income persons, and those who are uninsured or insured by Medicaid are more likely to have
poor cancer outcomes. This may be due, in part, to lower use of screening tests. The "Cancer Screening Office Systems" program--a
low-cost, non-computerized program--increased the use of screening tests in primary care practices serving these groups.
The program focused on 3 cancer screening tests: mammograms, Pap smears, and fecal occult blood tests (a test for digestive
system problems including colon cancer). As part of the program, patients completed a checklist about when they last received
cancer- screening tests. The medical office used a series of stickers on medical records to show whether cancer-screening
tests were due, ordered, or completed. In addition, office staff members were assigned specific roles in carrying out the
program.
Primary Care Providers Evaluate Integrated and Referral Models of Behavioral Health Care for Older Adults: Results from a
Multisite Effectiveness Trial (PRISM-E)
By Joseph J. Gallo, MD, MPH, and colleagues
A recent study compared 2 approaches for treating older adults for depression and other mental health problems. In one approach
(called "integrated care"), a mental health or substance abuse specialist was located in the same practice as the patient's
primary care doctor. In the other approach (called "referral care"), patients were referred to a separate mental health or
substance abuse clinic, with transportation and case management provided. Most primary care doctors in the study preferred
the integrated care approach. They felt it led to better communication between doctors and mental health specialists, was
more convenient for patients, and that patients were less stigmatized.
Preventing Errors in Clinical Practice: A Call for Self-awareness
Francesc Borrell-Carri�, MD, and colleague
Teaching doctors to develop their insight and self-awareness could help reduce medical errors. Specific skills to reduce
errors include learning to rethink medical situations (that is, being open to a new understanding of the patient's condition(s)
and what the doctor should do in response) and learning techniques so that difficult or tense medical visits are not ended
too soon.
A String of Mistakes: The Importance of Cascade Analysis in Describing, Counting, and Preventing Medical Errors
By Steven H. Woolf, MD, MPH, and colleagues
Studying medical errors as a chain of events can shed light on the underlying causes of the errors. Using this approach,
the authors found that, in primary care offices in 6 different countries, 2 of 3 chains of medical errors were set in motion
by errors in communication. This suggests that communication issues should be considered in programs to reduce medical errors.
Event Reporting to a Primary Care Patient Safety Reporting System: A Report from the ASIPS Collaborative
By Douglas H. Fernald, MA, and colleagues
A system has been developed to collect and manage reports of harm or potential harm to patients in primary care practices.
The system offers medical and non-medical personnel the opportunity to submit reports by telephone, paper, or online. Reports
can be confidential, in which the reporter's name and phone number are collected, or anonymous. Among 475 participants in
33 medical practices, 66% used the confidential form. The most frequently reported errors involved communication problems
and problems with diagnostic tests and medications.
Patient Reports of Preventable Problems and Harms in Primary Health Care
By Anton J. Kuzel, MD, MHPE, and colleagues
Thirty-eight patients were interviewed about problems they experienced in the primary care office setting. Most of the problems
they identified related to difficulties in their relationships with doctors or others in the medical office (for example,
many felt that they were treated with disrespect or insensitivity), or problems in getting access to the doctor or the office
(such as delays in getting appointments or long waiting times). Patients described more psychological and emotional harms
than physical harms.
Use and Appropriateness of Lyme Disease Serologic Testing
By Alan H. Ramsey, MD, MPH&TM, and colleagues
Each year, approximately 2.8 million tests are done in the United States to detect Lyme disease, a bacterial infection spread
by ticks. Early testing based on a tick bite or potential exposure to ticks is often not effective or accurate. A recent study
found that 20% of Lyme disease tests were appropriate and at least 27% were not appropriate. In more than one half of the
inappropriate tests, the patient did not show symptoms of the disease. Most inappropriate tests were initiated by physicians.
Almost 40% of the tests requested by patients were inappropriate.
Screening for Syphilis Infection: Recommendation Statement
By the U.S. Preventive Services Task Force
The U.S. Preventive Services Task Force examined research on syphilis conducted from 1994 to 2003. Based on this evidence,
the Task Force recommends that pregnant women and people who are at higher risk for syphilis infection receive screening tests
for the disease. People at higher risk for syphilis include men who have sex with men and engage in high-risk sexual behavior,
commercial sex workers, persons who exchange sex for drugs, and those in adult correctional facilities. The U.S. Preventive
Services Task Force recommends against routine screening of people who are not at increased risk for syphilis infection and
do not show symptoms of the disease.
Discussing Spirituality with Patients: A Rational and Ethical Approach
By Gary McCord, MA
Most patients want doctors to ask about their spiritual beliefs in at least some circumstances; however, openness to such
questions depends on the situation. Discussion of spirituality is most welcome in cases of serious or life-threatening illness
or following the death of a loved one. Patients are interested in discussing spirituality so that their doctors can better
understand them and their decisions, and provide compassion, hope and advice.
Subclinical Hypothyroidism and the Risk of Hypercholesterolemia
By William J. Hueston, MD, and colleague
Hypothyroidism is a condition in which there is too little thyroid hormone circulating in the body. People with subclinical
hypothyroidism have normal levels of thyroid hormone in circulation, but their thyroid-stimulating hormone is a little too
high. Although hypothyroidism may lead to increased cholesterol levels, subclinical hypothyroidism does not lead to increased
levels of cholesterol or triglycerides.
The Visit before the Morning After: Barriers to Preprescribing Emergency Contraception
By Alison Karasz, PhD, and colleagues
In an inner-city health center, physicians and women patients expressed mixed feelings about emergency contraception (also
known as the "morning-after" pill). Most women patients felt that emergency contraception could help them in their lives;
however, they also had medical and moral concerns about its use. They were divided in their beliefs about whether physicians
should provide advance prescriptions for emergency contraception. Most physicians had positive attitudes about emergency contraception,
but few routinely talked with their patients about it. Some physicians and patients were concerned that providing advance
prescriptions for emergency contraception would encourage women to use it repeatedly.