Table of Contents
The Issue in Brief
An Evaluation of a Quality Improvement Collaborative in Asthma Care: Does it Improve Processes and Outcomes of Care?
By Matthias Schonlau, PhD, and colleagues
Background The purpose of this study was to
examine the effectiveness of an asthma care program that involved collaboration
between health care organizations around the
What This Study Found A national collaborative asthma care program can significantly improve processes of care. Participating patients are more likely than other patients to attend educational sessions and are more satisfied with communications with their clinicians. They also use more written action plans, goal-setting, peak flow monitoring, and long-term controller medications. There was not an improvement in patients� quality of life or a decrease in hospitalizations for asthma.
Implications
� Other research has shown that improving care processes, attending educational sessions, goal-setting, and peak flow monitoring can improve the health of asthma patients.
Is There Time for Management of Patients with Chronic Diseases in Primary Care?
By Truls �stbye, MD, PhD, and colleagues
Background Many Americans are not receiving recommended health care services. This is of particular concern for patients with chronic illnesses, such as high blood pressure or diabetes, because chronic illnesses can be difficult to control. This study estimated the amount of time required to care for patients with chronic illnesses if national guidelines are followed.
What This Study Found An average primary care doctor needs at least 2,484 hours per year, or 10.6 hours per day, to provide care for 10 common chronic diseases. This is more time than primary care doctors have available for all patient care. Furthermore, it does not include the time needed to provide preventive care, acute care, and needed follow-up.
Implications
� The time requirements for health care guidelines are an obstacle to delivering care to patients with chronic diseases.
� Guideline developers should carefully consider the time required to follow recommendations.
� It might be helpful to write guidelines that include more than one condition, rather than multiple single guidelines.
Comorbidity and the Use of Primary Care and Specialist Care in the Elderly
By Barbara Starfield, MD, MPH, FRCGP
Background This study examined the relationships between comorbidity (having more than 1 medical condition at the same time) and use of medical services in patients aged 65 years and older. Specifically, the study looked at how often these patients visit primary care doctors and specialists.
What This Study Found Patients with more medical conditions have more visits to specialists. However, patients with any level of comorbidity have a high number of specialist visits, including visits for conditions that might normally be handled by the primary care doctor. The number of doctor visits for comorbid conditions is much higher than the number of visits for any individual condition in individual patients. Primary care doctors diagnose about one third of conditions in patients� with comorbidity.
Implications
� It is important to consider comorbidity in the care of elderly patients.
� The high number of visits to specialists, including for situations that might be better handled by a primary care physician, could contribute to higher medical costs without improving the health of elderly patients. Policy makers and health care organizations need to reevaluate the roles of specialists.
� Patients with multiple medical conditions might be helped by having a case manager to coordinate their care, rather than a disease manager who focuses on a single condition.�
� Primary care doctors have skills to care for patients with multiple conditions, including skills in prioritizing patient needs and managing complex medication effects. Their care of patients with comorbidity is strengthened when they clearly divide responsibilities with specialists and collaborate with other health professionals working in teams.
Prevalence of Multimorbidity Among Adults Seen in Family Practice
By Martin Fortin, MD, MSc, CMFC, and colleagues
Background When patients have multiple medical
conditions at the same time, it is referred to as multimorbidity or comorbidity.
There has been little research examining whether multimorbidity is common in
patients. The purpose of this study was to determine the rate of multimorbidity
in patients in the
What This Study Found Nine of 10 patients seeing family physicians have more than 1 chronic medical condition. Almost one half of patients had 5 or more chronic conditions. On average, older patients have more chronic conditions than younger patients.
Implications
� Among patients seeing family physicians, having more than 1 medical condition is the rule, rather than the exception.
� Guidelines for medical practice that are designed for patients with a single medical condition might not be suitable for patients with multiple conditions.
� Treatment plans need to consider the unique needs of patients with multiple conditions.
� Clinicians, educators, researchers, policy makers, and others should pay special attention to the impact of multimorbidity as they make decisions about medical care and the delivery of health care services.
Are Patients� Ratings of Their Physicians Related to Health Outcomes?
By Peter Franks, MD, and colleagues
Background Past research has suggested that a doctor�s style of interacting with the patient can influence a patient�s health. This study used detailed methods of analyzing data to reexamine the question of whether patient ratings of their doctors are related to patient ratings of changes in their own health.
What This Study Found A doctor�s style of interacting with patients is not related to reported changes in health. The results of past research might have been influenced by patient characteristics. For example, patients with similar characteristics might go to the same doctors. Also patients who tend to rate their doctors highly might also tend to report better health. By using different methods of analyzing data, this study was able to eliminate the influence of patient characteristics on the study results. The results then show that there is not a relationship between a doctor�s style and patient health.
Implications
� It is difficult to prove that a doctor�s style influences patient health.
� Past research has suggested that a doctor�s style which is centered around patient participation in care is best. This assumption may stand in the way of research into other beneficial ways of interacting with patients. �
Breast and Cervical Cancer Screening: Impact of Health Insurance Status, Ethnicity and Nativity of Latinas
By Michael A. Rodriguez, MD, MPH
Background Latinas in the
What This Study Found Foreign-born Latinas have higher rates of never being screened with a mammogram, a clinical breast exam, and a Pap smear, compared with U.S.-born Latinas and non-Latina whites. Among all ethnic and native groups studied, timely screening for breast cancer and cervical cancer is 11% to 48% lower for uninsured women. A greater proportion of foreign-born Latinas are uninsured compared with other groups studied, so they are at greater risk of not receiving timely cancer screening.
Implications
� Foreign-born Latinas might benefit from tailored public health efforts to improve the use of cancer screening services.
� Programs that are culturally and
linguistically appropriate and that take into account whether participants are
foreign-born or
� Lack of health insurance is a significant obstacle that needs to be addressed to improve use of cancer screening services for all uninsured women.
Tamoxifen for Breast Cancer Chemoprevention: low Uptake By High-Risk Women After Evaluation of a Breast Lump
By Rebecca Taylor, MD, MsC and Kenneth Taguchi, MD, MDCM
Background Tamoxifen, a drug used to treat breast cancer, has also been shown to help prevent breast cancer in women at high risk for the disease. However, it has potentially serious side effects. The purpose of this study was to determine whether women are taking tamoxifen to prevent breast cancer and to understand the reasons for their decisions.
What This Study Found The study included 89 women who were identified as being at high risk for breast cancer. The women were told about tamoxifen and encouraged to discuss the issue with their family physician. Of the 89 women in the study, only 1 decided to take tamoxifen for preventive purposes. Forty-eight women discussed tamoxifen with their family physician. In 3 cases, the family physician advised taking tamoxifen. In 8 cases, the family physician made no recommendation. In 37 cases, the family physician advised against taking tamoxifen. The most common reasons why women didn�t take tamoxifen were fear of serious side effects, the perception that they were at low risk for breast cancer, and the lack of recommendation by their doctor.
Implications
� Women at high risk for breast cancer as well as family physicians appear to be concerned about the potential side effects of taking Tamoxifen for breast cancer prevention.
� A family physician�s opinion is a key factor in the decision to not use Tamoxifen.
� Women who are at high risk for breast cancer need information to help weigh the risks and benefits of using Tamoxifen for preventive purposes.
Patients' Advice to Physicians about Intervening in Family Conflict
By Sandra K. Burge, PhD, and colleagues
Background Thirty-four to 46% of adult women who are patients in primary care practices have experienced family violence. Most doctors believe it is important to identify and manage family violence, but rates of screening for it are low. This study examined patients� views of how doctors screen for and handle family violence and conflict among their patients.
What This Study Found Most patients, including those who commit violence or have been victims of violence, believe that doctors should ask patients about family violence and that doctors can be helpful. Patients recommend that doctors ask about family violence, listen to their patients� stories, and provide information and referrals.
Implications
� Patients recommend that family physicians ask about family violence, listen to patients� stories, and provide information.
� Because little is known about whether such actions are effective in reducing family violence, further research is needed.
The Meaning of Healing: Transcending Suffering
By Thomas R. Egnew, EdD, LCSW
Background Medicine is a healing profession but until now, the profession has not defined �healing.� The purpose of this study was to develop a definition of healing based on interviews of leading figures in medicine and holistic health.
What This Study Found Healing can be defined as �the personal experience of the transcendence of suffering.� Wholeness, narrative (the patient�s life story), and spirituality are a part of healing.
Implications
� Suffering can cause the person experiencing it to feel separate from herself/himself and from society. By sharing suffering, doctors and patients can create meaning and reduce the sufferer�s feeling of separation.
� Doctors can be better healers by recognizing, diagnosing, minimizing, relieving, and helping patients go beyond suffering.
Screening for Gonorrhea: Recommendation Statement
By the
Background Women with gonorrhea infection can
develop serious medical conditions. Men are more likely than women to have
symptoms of gonorrhea that are diagnosed and treated. The U.S. Preventive Services Task Force
(
What This Statement Recommends The USPSTF recommends that clinicians screen
all sexually active women, including those who are pregnant, for gonorrhea
infection if they are at increased risk (that is, if they are young or have
other risk factors). The
Implications
� Rates of gonorrhea have been decreasing each year since 1999. However, only 8 states had gonorrhea rates below a target of 19 cases per 100,000 people.
� Rates of gonorrhea vary widely among regions of the country. Clinicians may wish to consult with their local health departments to obtain information more relevant to their specific communities and practices.
COGME's 16th Report to Congress: Too Many Physicians Could Be Worse than Wasted
By Robert L. Phillips, MD, MSPH, and colleagues
Background The most recent report of the Council on Graduate Medical Education (COGME) warns of a small shortage of doctors in the next 10 to15 years and recommends that more medical students and residents be trained.
What This Essay Suggests COGME based its recommendations on how doctors work now, rather than how they will be working in the future. The recommendations don�t account for the ways in which growing numbers of nurse practitioners and physician assistants will affect health care in the future. An excess of doctors might not improve the health of the public and risks using resources that would otherwise go to education and the health of the nation.
Implications
� There is growing interest in developing better health care teams. Therefore, estimates of numbers of doctors needed in the future should take into account other members of the health care team.
� COGME should offer a vision of what types of medical services should be provided in the future and how the physician workforce will take part in delivering them.
The Irreverent Nature of Evidence
By Zachary Flake, MD
Background In recent years, medical professionals have relied more heavily on evidence and information from other sources, rather than personal experience, when making clinical decisions.
What This Essay Explores The author explores the value of evidence vs experience as the foundation for medical judgment.
Implications
� Family physicians can learn from both evidence and experience.
� Evidence can provide important information, while experience and personal interactions with patients are important to the human side of medicine.