Table of Contents
The Issue in Brief
David Rabago, MD , and colleagues
Background Sinusitis is an infection or inflammation of the mucous membranes inside the nose and sinuses. In 1996, this common condition accounted for approximately 26.7 million office and emergency visits in the United States. This study examined patients' attitudes toward and experiences with hypertonic saline nasal irrigation (HSNI), a treatment that removes potentially allergen- and irritant-containing mucus by flushing the nasal cavity.
What This Study Found Twenty-eight patients who had participated in a research study that showed HSNI to be an effective treatment were interviewed. In this study, the authors identified 4 themes: (1) use of HSNI empowers those who use it by improving their ability to control sinus symptoms and treatment; (2) HSNI produces rapid and long-term improvement in the quality of life of patients with sinusitis; (3) there are barriers to use of HSNI, including fear, discomfort, time, and mild side effects; and (4) training and at-home use helps overcome these barriers.
Implications
- Doctors can confidently and safely prescribe this method to patients with chronic sinus symptoms.
- Patients may be more likely to use HSNI if they are educated and coached in its use.
Marsha N. Wittink MD, MBE, and colleagues
Background Communication between patients and doctors can influence patients� health and their willingness to follow treatment recommendations. In this study, the authors set out to understand how older adult patients with depression view their relationship with their primary care doctor and whether that relationship influences the ways they communicate about depression.
What This Study Found Participants� views of interactions with their doctors included the following themes: (1) �My doctor just picked it up.� Some patients feel that their doctor can �pick up on� aspects of their mood without needing to elicit them directly from the patient. (2) �I�m a good patient.� These patients feel that the doctor doesn�t view them as depressed, perhaps because they think of depression as a moral failing or because they want to avoid complaining or burdening the doctor. (3) �They just check out your heart and things.� In this case, patients do not bring up emotional issues because they may believe their doctor will not be interested. (4) �They�ll just send you to a psychiatrist.� Patients who expressed this opinion feel that the doctor would send them to a mental health specialist, rather than directly addressing any emotional issues.
Implications
- Patients� expectations and experiences with depression may have an impact on what they are willing to tell the doctor.
- The give-and-take between patients and doctors is dynamic, a �dance� of sorts that influences doctors� ability to recognize depression and negotiate a treatment plan.
- Doctors may, knowingly or unknowingly, signal to patients how they will address emotional problems. This influences how patients perceive their interactions with doctors about emotional problems.
Care Quality and Implementation of the Chronic Care Model: A Quantitative Study
Leif I. Solberg, MD , and colleagues
Background A new approach is needed to improve the care of people with chronic diseases. The Chronic Care Model (description below) is
widely accepted as a method for providing better care for chronically ill people. This study is one of the first to assess
the efforts of a large medical group in implementing the Chronic Care Model (CCM). In particular, the study examined whether
implementation of the CCM was associated with quality of care for patients with 3 common chronic conditions: diabetes, heart
disease and depression.
(Description: From: http://www.improvingchroniccare.org/change/model/components.html:
�The Chronic Care Model identifies the essential elements of a health care system that encourage high-quality chronic disease
care. These elements are the community, the health system, self-management support, delivery system design, decision support
and clinical information systems. Evidence-based change concepts under each element, in combination, foster productive interactions
between informed patients who take an active part in their care and providers with resources and expertise. The model can
be applied to a variety of chronic illnesses, health care settings and target populations. The bottom line is healthier patients,
more satisfied providers, and cost savings.�)
What This Study Found During a 2-year period, the medical group improved its implementation of most elements of the CCM and its quality of care for patients with diabetes and heart disease. (There was little improvement in quality of care for patients with depression). However, there does not appear to be a relationship between implementation of the CCM and quality improvements for people with these conditions.
Implications
- Demonstrating a relationship between implementation of the CCM and improvements in quality measures for 3 chronic diseases may require larger changes, more participating clinics, changes in other CCM elements, or more sensitive measurement tools.
- Additional research is needed to help identify which interventions and care changes matter the most and how they are best implemented.
Challenges of Change: Implementing the Chronic Care Model
Mary C. Hroscikoski, MD , and colleagues
Background Improving health care for people with chronic medical conditions is a major concern in the U.S. The Chronic Care Model (description
below) suggests that care of the chronically ill should include prepared teams in the medical practice interacting with informed,
involved patients. Although the Chronic Care Model (CCM) provides a well-developed framework for improving chronic medical
care, there are no specific steps available to guide medical groups wanting to implement it. The purpose of this study is
to examine and learn from the experience of a large medical group that implemented the CCM.
(Description: From: http://www.improvingchroniccare.org/change/model/components.html:
�The Chronic Care Model identifies the essential elements of a health care system that encourage high-quality chronic disease
care. These elements are the community, the health system, self-management support, delivery system design, decision support
and clinical information systems. Evidence-based change concepts under each element, in combination, foster productive interactions
between informed patients who take an active part in their care and providers with resources and expertise. The model can
be applied to a variety of chronic illnesses, health care settings and target populations. The bottom line is healthier patients,
more satisfied providers, and cost savings.�)
What This Study Found This medical group�s effort to transform its approach to care by implementing the CCM concepts appears to have produced some changes, in particular partial changes in the structure, roles, and function of medical teams and the introduction of an electronic medical record. Medical practices implementing the CCM should select care processes that have been well worked out in similar settings, or before tackling implementation, they should devote time to careful design and pilot testing. The CCM may be best suited as a backdrop for understanding the relationships and roles of specific care changes that are needed, rather than as a blueprint or training model for change.
Implications
- The team changes in this study were small and varied, but they may represent a first step in creating a new foundation for transformed care.
- Changing traditional care patterns is very difficult, requiring enormous attention and focus with clear specifications, strong leadership, and attention to many details at both local and central levels of an organization.
Andrew L. Sussman , and colleagues
Background Counseling patients about preventing disease and staying healthy is an important part of primary care, but clinicians provide this type of counseling at low rates. In this study, researchers looked at factors that influence clinicians� decisions to provide preventive health counseling. In particular, they focused on counseling patients for obesity.
What This Study Found The decision to provide preventive counseling for obesity is influenced by complex factors in 2 categories: (1) Factors that are fairly stable and unchanging, such as the clinician�s personal values, definitions of success, and the availability of community resources. These factors �set the stage� for the patient visit. (2) Factors that are more dynamic and changing, such as the patient�s agenda for the visit, how receptive the patient is to the proposed counseling, and the presence of special opportunities (�teachable moments�) for counseling. These factors vary with each patient visit.
Implications
- Efforts to increase rates of preventive counseling need to focus on the complexity of the primary care visit, rather than on a few isolated elements of the visit.
- Clinicians actively manage time during the brief patient visit to maximize the benefits to the patient. Efforts to increase rates of preventive counseling should consider the many competing demands faced by clinicians and patients during the course of a visit.
Ian Bennett, MD, PhD, and colleagues
Background The ability to read is an important part of the ability to understand medical information and make health decisions. This study explored whether low reading levels are an obstacle to getting prenatal care (medical care for pregnancy).
What This Study Found Interviews with 202 low-income African American women found that communication with clinicians, not reading level, is the most important factor in whether women get adequate care during pregnancy. An open flow of information between patient and doctor promotes prenatal care, while unsuccessful communication makes women less likely to come to prenatal care visits. Clear communication requires the ability to break down information into understandable pieces.
Implications
- Clinicians who care for pregnant women should work to communicate clearly, including breaking information down into smaller, understandable pieces. This specific skill should be taught in efforts to improve clinicians� communication skills.
- Further research is needed to determine whether a focus on this approach will improve rates of prenatal care.
Tim A. Ahles, PhD, and colleagues
Background Pain is common among primary care patients and is difficult to manage. This study tested a program in which patients received information tailored to their pain problems. Patients with pain and psychosocial problems (such as emotional problems or substance abuse) received telephone coaching from a nurse who taught them skills in problem-solving and pain management. Doctors received feedback about their patients' problems and concerns.
What This Study Found For patients with pain and psychosocial problems, telephone-based assistance can reduce pain, improve psychosocial problems, and improve physical functioning.
Implications
- Tailored information for patients with pain, combined with feedback to physicians and telephone nurse support of pain self-management, appears to be effective. Further study is needed to determine the most cost-effective method for sharing information and providing support in such a program.
Syndromic Surveillance for Emerging Infections in Office Practice Using Billing Data
Philip D. Sloane, MD, MPH, and colleagues
Background Syndromic surveillance is the monitoring of health data to identify possible outbreaks of diseases associated with bioterrorism or pandemic illness. Since patients often visit their primary care doctors when they first become sick, primary care practices could provide timely information, yet there has been little research on syndromic surveillance in primary care settings. This study tested whether it is practical to conduct syndromic surveillance in a primary care office using billing data.
What This Study Found This 1-year study of a primary care practice finds that it is practical to convert billing data into daily summaries of diagnosis codes, which can be used for rapid surveillance of disease patterns in a community. These systems can be easily implemented at a low cost and with minimal effort.
Implications
- Further development of syndromic surveillance systems should include primary care offices.
- This type of surveillance could be used to detect bioterrorism attacks and emerging infections, especially those that are not lethal and resemble common infections.
- Rapid conversion of primary care practices to electronic medical records opens up the possibility of new, potentially low-cost systems for early detection of emerging infectious diseases.
Adults' Lack of a Usual Source of Care: A Matter of Preference?
Anthony J. Viera, MD, and colleagues
Background People with a usual source of care (a regular doctor or a regular place where they get their health care) receive more preventive health services and have better control of chronic medical conditions. Yet in 2001, an estimated 52 million Americans did not have a usual source of care. This study set out to learn more about people who don�t have a usual source of care.
What This Study Found The most common reason people gave for lacking a usual source of care was that they were seldom or never sick. Only 10.2% of people said that cost was the reason. Overall, 72% of the estimated 42.7 million adults without a usual source of care in 2000 apparently had little or no preference for one, and a minority (28%) appeared to prefer to have one if they could.
Implications
- It is commonly assumed that removing such barriers as cost and lack of transportation should be the goal in ensuring that people have a usual source of care. The results of this study suggest that it might be more important to teach people the value of having a usual source of care, or to develop systems that allow people to experience a usual care source.
Home Care: A Key to the Future of Family Medicine?
Steven H. Landers, MD, MPH
Background In this essay, a family physician reflects on his experience in making house calls and how it is satisfying for both patients and clinicians. He concludes that house calls to patients may be a key to the future of family medicine, rather than a thing of the past.