Index by author
The Issue in Brief
The Prevalence of Primary HIV Infection in Symptomatic Ambulatory Patients
By Andrew Coco, MD, MS, and colleagueBackground: Approximately 40,000 new cases of HIV infection are identified each year in the United States. Primary HIV infection refers to the early, flu-like symptoms associated with HIV disease. Diagnosis of primary HIV is an opportunity to help prevent the disease from being transmitted. This study set out to estimate how many patients visiting the doctor�s office, emergency department, or hospital clinic for fever, rash, or sore throat have primary HIV infection.
What This Study Found: Based on data from a large national survey, the study estimates that primary HIV infection would be found in 0.66 percent of patients complaining of fever, 0.56 percent of patients with rash, and 0.13 percent of patients with sore throat.
Implications
� This study is the first to estimate the rate of primary HIV infection.
� The study results can help policy makers develop national guidelines for HIV testing.
The Cost-Effectiveness of Expanded Testing for Primary HIV Infection
By Andrew Coco, MD, MSBackground: Primary HIV infection, which has flu-like symptoms, can be difficult to diagnose. This study looked at whether widespread testing for primary HIV infection would be cost-effective.
What This Study Found: In a group of 2 million hypothetical patients with fever, other viral symptoms, and at least one HIV risk factor, expanded testing would identify 17,054 cases and avoid infection in 435 sexual partners. Based on a cost-effectiveness analysis, expanded testing for primary HIV infection has a high probability of being cost-effective.
Implications
� The findings suggests that widespread testing for primary HIV infection in patients with fever or other viral symptoms could be cost-effective.
� The authors believe that large-scale testing would be similar to screening for diseases such as colon cancer and breast cancer in its cost-effectiveness, and could help reduce the rate of HIV in the United States.
'Coming Down the Line'- Patients' Understanding of Their Family History of Common Chronic Disease
By Fiona Walter, MA, MSc, FRCGP, and colleagueBackground: A patient�s family history is important in preventing chronic disease or detecting the disease early. This study explored how primary care patients understand and come to terms with their family history of cancer, heart disease, or diabetes. Thirty patients were interviewed.
What This Study Found: Once a person acknowledges that an illness runs in their family, the family history gains personal meaning, and the person develops a sense of being vulnerable to the disease, which they try to cope with or control. Patients� understanding of their risk of developing a common chronic disease is based not only on the number of relatives who had the disease, but also on the emotional impact of witnessing illness in the family and the nature of their relationship with the ill relative. Many patients have fatalistic attitudes about their risk of disease, particularly cancer, which they feel less able to control.
Implications
� Personal experiences of disease can contribute to a patient�s sense of vulnerability.
� Incorporating beliefs and experiences with family risk into discussions of chronic disease could improve patient understanding and help patients make informed decisions about healthy behaviors and screening tests.
Antibiotic Treatment and Survival of Nursing Home Patients with Lower Respiratory Tract Infection: A Cross-National Analysis
By Robin Kruse, PhD, and colleaguesBackground: Nursing home residents frequently develop lower respiratory tract infections (LRI), such as pneumonia and bronchitis; however, there is little research to support a specific method of treatment. This study assessed the effects of different antibiotic treatments on the survival of elderly nursing home residents with LRI in the United States and the Netherlands, where treatment approaches are quite different.
What This Study Found: Thirty-nine different antibiotics were used in the United States, compared with 15 in the Netherlands. Only 1 Dutch patient was hospitalized, compared with almost one third of U. patients. Use of intravenous antibiotics, multiple antibiotics, intravenous fluids, and feeding tubes were also relatively rare in the Netherlands compared with the United States. Although patients in the Netherlands were more severely ill, death rates did not differ between the two countries.
Implications
� More aggressive treatment did not show greater benefit for nursing home patients.
� This finding suggests that patients can receive simpler treatments that involve less discomfort.
Patient Centered Communication and Diagnostic Testing
By Ronald Epstein, MD, and colleaguesBackground: In patient-centered communication (PCC), doctors help patients feel understood by asking about their needs, perspectives, and expectations, and patients are involved in decisions about their care. PCC can improve health and patient trust, but little is known about whether it affects health care costs. This study looked at the relationship between PCC and expenditures for diagnostic testing.
What This Study Found: Doctors who use a patient-centered communication style tend to have lower diagnostic testing expenditures and longer patient visits.
Implications
� Encouraging PCC would not necessarily drive up health care costs.
� PCC is important not only for its potential contribution to lowering diagnostic testing expenditure; it is also important for its positive effects on patients and their health.
Delivery of Clinical Preventive Services in Family Medicine Offices
By Benjamin F. Crabtree, PhD, and colleaguesBackground: Although doctors believe that preventing disease is important, they deliver clinical preventive services at low rates. Clinicians and practices have many demands on their time and resources, and little is known about how they incorporate and deliver preventive services among their many priorities. The goal of this research was to better understand the organizational features of primary care practice that help explain how and why practices deliver clinical preventive services. The study of Midwestern family medicine practices used medical records, observation of outpatient visits, and patient exit cards to calculate rates at which practices deliver preventive services.
What This Study Found: Practices develop individualized approaches for delivering preventive services, such as counseling to stop smoking, cholesterol screening, and immunizations, with no one approach being successful across practices. Delivery of preventive services is often crowded out by care of acute and chronic illnesses. Preventive services delivery rates are influenced by the economic concerns of the practice and whether the practice has a doctor who champions prevention and makes it a priority.
Implications
� Medical practices are diverse, so efforts at applying standardized processes for implementing preventive services are likely to fail.
� The variability of practices, their patients, and their communities need to be taken into account in developing efforts to increase the delivery of preventive services.
Rochester Participatory Decision-Making Scale (RPAD): Reliability and Validity
By Cleveland G. Shields, PhD, and colleaguesBackground: Doctors have been encouraged to adopt a more participatory style, in which patients are directly involved in decisions about their medical treatment. Measuring participatory decision making in research has been difficult. The purpose of this study was to develop a reliable and valid way to measure the doctors� behavior in encouraging participatory decision making.
What This Study Found: The Rochester Participatory Decision-Making Scale (RPAD) was developed based on data from a study of doctor-patient communication involving 100 primary care doctors. RPAD assesses the ways in which doctors encourage patients to participate in decision-making.
Implications
� RPAD offers promise as a reliable, valid, and easy-to-use measure of participatory decision-making.
Social Network Analysis as an Analytic Tool for Interaction Patterns in Primary Care Practices
By John Scott, MD, PhD, and colleaguesBackground: Social Network Analysis (SNA) is a way of measuring personal relationships. It analyzes patterns of interaction among people in different kinds of networks. This study examined whether SNA can be used to characterize and compare communication patterns in primary care practices.
What This Study Found: Although decision-making patterns were very different in the study�s two example practices, the SNA allowed comparison between several aspects of those differences. Because SNA differentiates individuals only by their pattern of interaction, it is not a good tool for measuring how individual differences affect the functioning of an organization.
Implications
� SNA is a useful tool for analyzing the complex systems represented by primary care practices. SNA could be useful in designing programs to promote organizational change in primary care practices.
Efficacy and Tolerability of Tricyclic antidepressants and SSRIs Compared With Placebo For Treatment of Depression in Primary Care:A Meta-Analysis
By Bruce Arroll, MBChB, PhD, and colleaguesBackground: Most patients with clinical depression are seen in a primary care setting. Yet most studies examining the effectiveness of antidepressant medications are done with patients who see a psychiatric specialist and whose depression may have a different cause and disease course. This study examined existing evidence about the effectiveness of antidepressants for treating depression, as compared to placebos, among primary care patients.
What This Study Found: Two types of antidepressants--tricyclic antidepressants, which work by increasing levels of the mood chemicals serotonin and norepinephrine in the brain, and selective serotonin reuptake inhibitors, which work by increasing the amount of serotonin�are significantly more effective than placebo in primary care settings. In addition, the relatively low doses of tricyclic antidepressants sometimes used in primary care may be effective.
Implications
� Prescribing antidepressants in primary care is more effective than prescribing a placebo.
Metformin as Treatment for Overweight and Obese Adults: A Systematic Review
By Kara M. Levri, MD, MPH, and colleaguesBackground: Metformin is a drug used to treat diabetes in people who are overweight or obese. It is also commonly used to treat women with polycystic ovary syndrome (PCOS), a condition that causes infertility. This study looked at existing evidence to determine whether metformin is an effective treatment for overweight or obese adults who do not have diabetes or PCOS.
What This Study Found: There is not sufficient evidence to support the use of metformin to treat overweight or obese adults without diabetes or polycystic ovary syndrome.
Implications
� The authors recommend against using metformin as a treatment for overweight or obesity in nondiabetic patients or patients without PCOS.