Table of Contents

The Issue in Brief

Randomized Controlled Trials: Do They Have External Validity for Patients With Multiple Comorbidities?

Martin Fortin, MD, MSc, CMFC , and colleagues

Background Randomized controlled trials, or RCTs (studies in which research participants are randomly selected to receive different treatments or approaches) are often used to help develop guidelines for treating medical conditions. Many RCTs may be of limited usefulness, however, because they exclude participants with multiple medical conditions (comorbidities), or they do not assess the effect of the treatment/approach on more than one medical condition. This report looks at the rate of multiple medical conditions among patients who were eligible to participate in RCTs studying treatment of hypertension (high blood pressure).

What This Study Found Eighty-nine to 100% of patients eligible for 5 RCTs of hypertension treatment had more than 1 chronic medical condition. The RCTs, however, did not fully report how many patients with multiple conditions were included or excluded.

Implications

• Excluding participants with multiple medical conditions from randomized controlled trials makes it more difficult to apply the results to a wide variety of patients.
• Randomized controlled trials should report whether participants with multiple conditions were included or excluded.
• If research results are going to be applied in medical practice, studies must focus on the realities of the types of patients who need care.

Transforming Medical Care: Case Study of an Exemplar Small Medical Group

Leif I. Solberg, MD , and colleagues

Background Many studies have focused on ways in which large medical groups and health care systems address the challenges of delivering health care. Fewer studies have shed light on health care delivery in smaller medical groups, in which most doctors work. This case study aims to learn more about the culture and organization of a small medical group that provides its patients with high levels of chronic disease management and preventive medical care.

What This Study Found The authors identify 12 attributes of this practice that appear to be associated with good quality of care. These include a strong focus on patients, capable leaders who successfully involve the entire staff, strong support for the physician-patient relationship, a team approach to care, openness to/systems for making change, and pride and joy in their work.

Implications

• The attributes identified in the study show a path to achieving excellent quality in several aspects of medical care.
• Identifying high-performing medical practices and understanding how they are different from other practices can provide insights into excellent medical care.

The Effect of Primary Health Care Orientation on Chronic Care Management

Julie A. Schmittdiel , and colleagues

Background Chronic illness is a major health crisis in the United States, and evidence suggests there is a great need to improve the quality of chronic illness care. One way to improve chronic illness care may be to emphasize comprehensive, coordinated primary care. This study examines whether medical practices and groups that are oriented toward providing primary care also demonstrate features of the Chronic Care Model, a widely-recognized model that identifies elements of health care that encourage effective care of chronic illnesses.

What This Study Found Medical practices and groups that have 6 core features of primary care, representing comprehensive health service delivery and a commitment to overall patient health, also have more features of the Chronic Care Model.

Implications

• These findings support the need for patients to have a primary care ��home�� to strengthen management of chronic care illness.
• Efforts by policy makers and payers to increase medical organizations� focus on primary care may improve chronic illness care.

Physicians, Patients, and the Electronic Health Record: an Ethnographic Analysis

William Ventres, MD, MA , and colleagues

Background The electronic health record (EHR), a secure computer-based resource that includes the patient�s medical information, is often viewed as a vital tool for medical practices in the 21st century.This study explores whether and how EHRs affect patients� visits to the doctor.

What This Study Found Use of an EHR by doctors in the examination room influences the patient visit. This study identified 14 factors that shape how EHRs are perceived and used in medical practice, including spatial factors (ways in which the physical presence and location of the EHR influences interactions between doctors and patients), relational factors (how patients� and doctors� perceptions of the EHR affect its use), educational factors (the need to help doctors learn to use the EHR and to help patients understand it), and structural factors (institutional and technological forces that influence how doctors perceive their use of an EHR).

Implications

• The EHR is not just a computerized version of a paper medical record. Rather, it has an identity that can influence medical care.
• Medical practices need to consider the ways in which EHRs influence the relationship between patients and doctors.

Nasal Carriage of Staphylococcus Aureus and Methicillin-Resistant Staphylococcus Aureus in the United States, 2001-2002

Arch G. Mainous III, PhD , and colleagues

Background Staphylococcus aureus is a common cause of invasive infection, often found in hospitals and other institutional settings. A drug-resistant strain called methicillin-resistant S aureus (MRSA) has been increasingly found outside the hospital setting. This study estimates the prevalence of S aureus and MRSA in the general population of the United States.

What This Study Found An estimated 86.9 million people, or nearly one-third of the US population, carry S aureus. More than 2.2 million people, or less than 1 percent of the population, carry MRSA. Teens and males are more likely than other groups to carry S. aureus. When elderly patients carry S aureus, they are more likely than younger people to carry MRSA.

Implications

• Avoiding overuse of antibiotics is important to slow the spread of resistant organisms, such as MRSA.
• Clinicians should take infection control procedures that are effective against S aureus, particularly when treating teen and male patients.
• Elderly patients with suspected staphylococcus infections may need antibiotic coverage against resistant strains.
• The authors advise clinicians making therapeutic decisions to monitor bacterial carriage rates and resistance patterns for their own hospitals and cities, in addition to the patterns identified in thi

Services Provided by Family Physicians for Patients with Occupational Injuries and Illnesses

Allard E. Dembe , and colleagues

Background Many family physicians provide care for patients with occupational illnesses and injuries, but little is known about the services they provide or how they compare with services provided by other types of physicians. This study aims to learn more about the care family physicians provide for patients with work-related disorders.

What This Study Found Family physicians account for approximately 3 times as many visits each year for injured workers when compared with occupational medicine specialists. Patients receive more comprehensive care when they see their family physician for occupational injuries. During these visits, patients are more likely to have their blood pressure taken, receive diagnostic and screening services, and have prescription drugs prescribed or administered, compared with patients seeing other types of physicians.

Implications

• Family physicians often use visits for work-related conditions as opportunities to assess the patient��s overall health and provide other needed care.
• A family medicine approach offers added value to occupational illness care.
• These findings may be useful for establishing benchmarks to help family physicians assess the extent and type of services currently provided for work-related conditions.

A Practice-Sponsored Web Site to Help Patients Pursue Healthy Behaviors: An ACORN Study

Stephen H. Woolf, MD, MPH , and colleagues

Background One challenge medical professionals face in helping patients adopt healthy behaviors, such as exercise and stopping smoking, is connecting them with high-quality information. This study looked at whether patients were more likely to pursue healthy behaviors if they were referred to a Web site with health information and resources that were tailored to their specific needs.

What This Study Found An interactive Web site can be an effective tool to encourage patients to pursue healthy behaviors. Medical practices face challenges, however, in fostering use of such a Web site: although patients in this study expressed interest in the site, only a small percentage actually visited it.

Implications

• Web sites can help practices extend educational outreach beyond the time and place of the patient visit.
• Convenient access to the most appropriate information may help empower patients.
• An interactive Web site may be most effective as part of a set of tools designed to promote health behavior change.

Triage and Diagnosis of Chest Pain in Rural Hospitals.Implementation of the ACI-TIPIin the High Plains Research Network

John M. Westfall, MD, MPH , and colleagues

Background Ischemia, a condition in which the heart does not receive enough blood, and a possible cause of heart attack, can be difficult to diagnose. The Acute Cardiac Ischemia Time-Insensitive Predictive Instrument (ACI-TIPI) is designed to help diagnose acute ischemia in patients with chest pain and to help clinicians decide whether a hospital admission is needed by printing the patient's probability of acute cardiac ischemia on their electrocardiogram. The ACI-TIPI has been tested in urban and suburban settings. This study tested the impact of ACI-TIPI in rural emergency departments.

What This Study Found Among patients with chest pain at emergency departments in 10 rural hospitals, the use of ACI-TIPI did not have a significant impact on accuracy of diagnosis or triage (that is, decisions by emergency department staff to admit, transfer or discharge the patient).The average diagnostic accuracy was similar regardless of whether ACI-TIPI was used (86.8% ACI-TIPI off vs 89.0% ACI-TIPI on).

Implications

• Rural doctors in this study provided appropriate diagnosis and triage of patients with chest pain.
• Conducting this type of study in more rural hospitals may provide a broader base of information on the effect of ACI-TIPI in rural settings.

The Postpartum Health of Employed Mothers Five Weeks after Childbirth

Patricia M. McGovern , and colleagues

Background Most employed new mothers return to work within 1 to 3 months of giving birth. This study reports symptoms experienced by new mothers 5 weeks after birth and examines factors that influence their health.

What This Study Found Five weeks after giving birth, women still experience symptoms related to childbirth, particularly women whose infants were delivered by cesarean section or who breastfeed. Symptoms include fatigue, never or rarely feeling refreshed after waking in the morning, breast discomfort, and a decreased desire for sex. Women whose infants were delivered by cesarean section had significantly worse physical health than women who gave birth vaginally.

Implications

• With many new mothers returning to work soon after childbirth, there is a need to reexamine and broaden the definition of postpartum health, particularly for employed women.
• In examining new mothers, doctors should assess fatigue, as well as other physical and mental symptoms, including those related to breastfeeding.
• There is a need for ongoing support for new mothers and for ongoing rest and recovery beyond the traditional period that is common in the United States.

Helping Them: Our Role in Recovery from Opiod Dependence

David A. Loxterkamp

With the crisis of opioid addiction in the United States growing at a rapid pace, a family doctor reflects on his experience in treating addicts with buprenorphine, an office-based treatment for opioid dependence. The author acknowledges that opioid addiction is no longer limited to inner-city neighborhoods; it has infiltrated the mill towns and fishing villages of his home state of Maine. In this essay, he recounts his experience in treating addicted patients and the challenges, frustrations, and satisfactions of establishing and running a treatment program.

Facilitating Collaboration Among Academic Generalist Disciplines: a Call to Action

Jean S. Kutner, MD, MSPH , and colleagues

This essay calls for active collaboration among generalist disciplines. The authors assert that a lack of collaboration between the academic generalist disciplines�pediatrics, internal medicine, and family medicine�that form the source of the primary care physician workforce may be hampering each discipline�s efforts and futures because they are competing with each other for patients, trainees, and resources. Interspecialty collaboration, they suggest, is likely to lead to a greater focus on the critical role of primary care in the changing health care system to meet patient and population needs, rather than focusing on meeting the needs of physicians. Other advantages to collaboration include enhanced opportunities for trainees, more meaningful primary care research, powerful advocacy and improved patient care.