Table of Contents

The Issue in Brief

September-October 2004

Cumulative list of Issues In Brief

Prevalence and Predictors of Night Sweats, Day Sweats, and Hot Flashes in Older Primary Care Patients: An OKPRN Study
By James W. Mold, MD, MPH, and colleagues
Although patients often experience and have questions about night sweats, there has been little research on this condition. Many elderly people in particular experience night sweats, day sweats, or hot flashes. This study found that older people with these conditions are more likely to have other symptoms as well. People with night sweats are also likely to have fever, muscle cramps, numbness in the hands or feet, vision problems, and hearing loss. People with day sweats are likely to have fever, restless legs, lightheadedness, and diabetes. People with hot flashes are likely to have fever, bone pain, vision problems, and nervous spells. The presence of night sweats, days sweats, or hot flashes can provide important clues to other conditions that the patient might be experiencing.

Comfortably Engaging: Which Approach to Alcohol Screening Should We Use?
By Daniel C. Vinson, MD, MSPH, and colleagues
There are many tests available that doctors can use to help determine if a patient has a problem with alcohol. A test in which the doctor asks a single question about the patient�s alcohol use was compared with a 4-question test. Most patients, including those who indicated that they might have a problem with alcohol, were equally comfortable with either test. Among patients who might have a problem with alcohol, about one third reported thinking about or planning to change their drinking behavior.

How Many Problems Do Family Physicians Manage at Each Encounter? A WReN Study
By John W. Beasley, MD, and colleagues
During the course of a patient visit, family doctors address multiple problems and issues (such as illness, mental health, and prevention of disease). In this study, family doctors reported treating an average of more than 3 problems or issues per visit. On average, the bill for the visit reflected less than 2 problems or issues. In making medical decisions during the limited time of a medical visit, the primary care doctor must prioritize the patient�s medical needs and coordinate care of multiple conditions.

Seasonal Variation in Diagnoses and Visits to Family Physicians
By Wilson D. Pace, MD, and colleagues
Family doctors tend to treat the same types of illnesses and problems over time. Based on the season of the year, however, there is variation in the illnesses and problems that family doctors treat and in the ages of patients who visit them. In the winter, for example, family doctors treat more infectious conditions and have more visits by children than during other times of the year. An understanding of seasonal differences helps researchers study medical conditions that are frequently seen in primary care practice.

Evaluating Computer Capabilities in a Primary Care Practice-Based Research Network
By Adolfo J. Ariza, MD, and colleagues
Primary care research increasingly depends on the availability of computers in the offices of participating medical practices. A survey of a network of 40 pediatric practices found that they vary widely in the types of hardware and software they use, and in their ability to connect to the Internet. These differences must be taken into account in planning research activities.

Exploring Patient Reactions to Pen-Tablet Computers: A Report from CaReNet
By Deborah S. Main, MD, and colleagues
Patients who were asked to complete a survey in their primary care doctor�s office reported that they were comfortable using a pen-tablet computer to complete the survey. Most patients were open to the idea of using a pen-tablet computer and found it easy to use.

How and Why to Study the Practice Content of a Practice-Based Research Network
By Kevin A. Pearce, MD, MPH, and colleagues
Groups of primary care practices are joining together in practice-based research networks (PBRNs) to develop new knowledge about the primary care setting. One new PBRN studied the types of patients and medical conditions in its member practices. This will help the group conduct local research and determine whether their research findings apply to others. In addition, the study found that 70% of adult patients in the practices were either overweight or obese, and that doctors were more likely to counsel obese patients about diet or exercise compared to other patients.

Opportunities, Challenges, and Lessons of International Research in Practice-Based Research Networks: The Case of an International Study of Acute Otitis Media
By Larry A. Green, MD, and colleagues
A study of acute otitis media (middle ear infection) in children was undertaken in the Netherlands, the United Kingdom, and North America (the United States and Canada) in the mid-1990s. Participating countries used different approaches to treating this condition: antibiotics were rarely used in the Netherlands but were used for 5 to 7 days in the United Kingdom, and for 10 days in North America. In spite of these differences in treatment, patients recovered in about the same amount of time. The study contributed to current approaches that encourage limited use of antibiotics in treating middle ear infection. Researchers also learned important lessons about the challenges of conducting international practice-based research, including the need for administrative skill and strong, trusting relationships among researchers.

Rapid Assessment of Agents of Biological Terrorism: Defining the Primary Care Differential Diagnosis of Inhalational Anthrax using Electronic Communication in a Practice-Based Research Network
By Jonathan L. Temte, MD, PhD, and colleague
In cases of bioterrorism, primary care doctors need to diagnose diseases that are rare and that may resemble other, more common diseases. Practice-based research networks (PBRNs) are groups of primary care practices that join together to conduct research in the medical office setting. PBRNs in which the doctors can be contacted by e-mail are well-suited to identify and deal with bioterrorism. They can play an important role in gathering data quickly and providing early detection of bioterrorism.

The Primary Care Differential Diagnosis of Inhalational Anthrax
By Jonathan L. Temte, MD, PhD, and colleague
Inhalational anthrax is a very rare infectious disease that resembles many other common diseases, such as influenza, pneumonia, and acute bronchitis. Because of this resemblance, patients are likely to go to their primary care doctors when anthrax symptoms arise. The resemblance to other diseases also makes inhalational anthrax difficult to diagnose. Primary care doctors have a key role to play in recognizing and responding to bioterrorism events, such as inhalational anthrax, and should be included in educational efforts for such events.

Interpersonal Continuity of Care and Patient Satisfaction: A Critical Review
By John W. Saultz, MD, and colleague
Patients who have a long-term, trusting relationship with their doctor are more likely than other patients to be satisfied with the doctor. There is not yet evidence to answer questions about �cause and effect,� however. For example, we do not know whether long-term, trusting relationships cause patients to be satisfied, whether being satisfied causes patients to establish long-term relationships, or whether the relationship and level of satisfaction influence each other. More research and new ways of studying this topic are needed to learn more about these connections.

Patient-Physician Shared Experiences and Value Patients Place on Continuity of Care
By Arch G. Mainous, III, PhD, and colleagues
Patients are more likely to value an ongoing relationship with their family doctor when they feel that they have been through a lot with the doctor or when they have seen the same doctor over time. Patients place the highest value on an ongoing relationship with the doctor when both factors are present�they have seen the same doctor over time and feel that they have been through a lot together.

The Doctor-Patient Relationship and Compliance With Medication: a Primary Care Investigation
By Ngaire Kerse, MD, and colleagues
Patients who feel that the doctor understands them and their health problems, and who agree with the doctor about their treatment, are more likely than other patients to take their medications as prescribed. Efforts to make sure that patients and doctors understand each other and reach agreement could have important health benefits.

Patients' Needs for Contact With Their GP at the Time of Hospital Admission and Other Life Events. A Quantitative and Qualitative Exploration
By Henk Schers, MD, MSc, and colleagues
Patients in the Netherlands want to have contact with their general practitioner (GP) when they experience a major life event (such as a birth or death) or when they are admitted to the hospital for a life-threatening condition. Following a birth or death, patients feel that contact with the GP provides emotional support and demonstrates the doctor�s commitment to them. During a hospitalization, patients feel that their doctor can provide emotional support or advice. Most patients expect the doctor to initiate such contact.

Should Years of Schooling Be Used to Guide Treatment of Coronary Risk Factors?
By Kevin Fiscella, MD, MPH, and colleague
Patients who have not finished high school have a higher risk of dying of coronary heart disease than those with more schooling. The risk is as strong as other risks such as high cholesterol and smoking. This finding can help medical professionals identify and provide early treatment for people who may be at risk of heart disease.

Brief Physician Advice for High-Risk Drinking Among Young Adults
By Paul M. Grossberg, MD, and colleagues
Each year, more than 20,000 people between the ages of 15 and 34 years die from alcohol-related causes. High-risk drinking among 18- to 30-year-olds is reduced when they receive brief counseling about alcohol use from their primary care doctor. Brief alcohol counseling also leads to a decrease in the number of motor vehicle crashes, arrests for substance or liquor violations, and emergency room visits.

Age-Related Disparities in Cancer Screening: Analysis of 2001 Behavioral Risk Factor Surveillance System Data
Anthony F. Jerant, MD, and colleagues
An examination of 3 cancer-screening tests shows that such tests may be underused or overused based on age. Abnormal growths in the colon that can develop into cancer (called adenomatous polyps) are most likely to develop between 55 and 65 years of age. Screening for colorectal cancer, however, is relatively low among 50-year olds and increases with age, reaching its peak among 70- to 74-year-olds. Prostate-specific antigen (PSA) screening for prostate cancer also increases with age, from 50 years old through ages 75 to 79 years, despite the unproved benefit of PSA screening, particularly among men who are 70 years old and older. The rate of screening for breast cancer using mammograms is highest among women 55 to 59 years old and declines after that. Although some guidelines for mammograms do not include women aged 70 years and older, other recommendations suggest that mammograms should be discussed with all women who are expected to live 5 years or more, regardless of age. More research is needed on how age effects cancer screening.

Changing Prescribing Patterns and Increasing Prescription Expenditures in Medicaid
By Kenneth S. Fink, MD, MGA, MPH, and colleague
Spending on prescription drugs is increasing at high rates in the United States as a whole, and at even higher rates in state Medicaid programs. In the North Carolina Medicaid program in the years 1998-2000, the major cause of the increase in drug costs was a rise in the number of prescriptions for new and more expensive medications. There is an important role for many newer and more expensive drugs, but that role must be made more clear. To help control rising spending on prescription drugs, the costs and benefits of possible treatments must be considered.

Impact of an Evidence-Based Computerized Decision Support System on Primary Care Prescription Costs
By S. Troy McMullin, PharmD*
Doctors often learn about a new drug from information provided by the pharmaceutical company that makes the drug. Computer systems have been developed to help doctors select prescriptions based on scientific evidence. These systems also provide the doctor with information about the effectiveness, safety, and costs of drugs; new research findings; and prewritten prescriptions. Spending on drugs dropped among doctors using such a system, while spending on drugs increased among doctors not using the system. *Conflicts of interest: Authors McMullin and Longergan are salaried employees of WELLINX (St. Louis, Mo), owner of the computerized decision support system used by the intervention group. Co-author Dr. Thomas D. Doerr, MD, is one of the founders of WELLINX and has an ownership interest in the company.

The Spirituality Index of Well-Being: A New Instrument for Health-Related Quality-of-Life Research
By Timothy P. Daaleman, DO, and colleague
There is growing interest in the connection between religion, spirituality, and health. A tool for measuring the effect of spirituality on a patient�s well-being has been developed. It may be especially useful in studying quality of life related to health in patients with chronic illness, older people, and those needing end-of-life care.

Adapting Psychosocial Intervention Research to Urban Primary Care Environments: A Case Example
By Luis H. Zayas, PhD, and colleagues
Research in primary care doctors� offices can provide important new knowledge that helps meet patients� health care needs; however, it can be challenging to conduct such research. In a study of pregnancy-related depression in community health centers, researchers learned that they must have the flexibility to meet the needs of different people involved in the study (such as patients, medical professionals, and health center administrators) and must be able to adapt to changes within the practice and circumstances that arise in the lives of participating patients.

Towards a New Understanding of Provider Continuity
By Stephen A. Buetow, PhD
The ongoing relationship between patient and doctor is often referred to as �provider continuity.� In many cases, however, a patient receives care not only from a doctor, but also from family members, friends, and neighbors. These caregivers often come with the patient to the doctor�s office and may be responsible for speaking for the patient or making decisions about the patient�s care. As a result, health care professionals and researchers should consider not only the ongoing relationship between the patient and doctor, but also the ongoing involvement of other �providers� of care.

Linking Ruth to her Past
By Renate G. Justin, MD
A family doctor shares the story of her 30-year relationship with a patient and the strong ties they formed. The doctor was taught that keeping emotionally distant from patients was part of providing good medical care. This relationship, however, taught her that closeness, rather than distance, can be more healing because it recognizes the humanity that physicians and patients share.