Table of Contents

The Issue in Brief

Predicting Prognosis and Effect of Antibiotic Treatment in Rhinosinusitis

By An De Sutter, MD PhD, and colleagues

Background Rhinosinusitis (or sinusitis) is an infection or inflammation of membranes inside the nose and face. Although antibiotics are not generally effective in treating this condition, they are effective in treating a bacterial type of sinusitis that affects a minority of patients. The goal of this study is to search for clues to help identify sinusitis patients who might benefit from antibiotics.

What This Study Found Signs and symptoms of sinusitis and abnormal sinus x-ray findings do not help predict the course of the illness or whether the patient will benefit from antibiotics.

Implications

• This study contributes to a better understanding of the natural course of the "cold."
• There is no evidence that signs or symptoms of rhinosinusitis indicate a need for antibiotic treatment. Sinus x-rays have no added value in treating rhinosinusitis patients.
• The authors suggest that the best policy for patients who might have rhinosinusitis (and who do not have signs of complications or severe infection, such as high fever and serious pain) is to wait for natural recovery.

Are Sore Throat Patients Who Hope For Antibiotics Actually Asking For Pain Relief?

By Mieke van Driel, MD, MSc, and colleagues

Background Doctors often prescribe antibiotics for patients with sore throats, even though evidence shows that antibiotics may not be effective in such cases. Doctors are more likely to prescribe an antibiotic if they believe the patient expects it. This study examines what sore throat patients consider important when they visit their family doctor.

What This Study Found Pain relief is an important concern of patients visiting their family doctor about a sore throat. Patients who hope to receive an antibiotic prescription are more concerned about pain relief than patients who are not interested in antibiotics.

Implications

• Patients' desire for an antibiotic may be based on the mistaken view that it is the best treatment for pain relief.
• Addressing patients' expectations and needs for managing pain may help doctors treat sore throats without prescribing antibiotics. Additional research is needed to explore this possibility.

What General Practitioners Find Satisfying in Their Work: Implications for Health Care System Reform

By Karen Fairhurst, PhD, MRCGP, and colleague

Background It is increasingly common to evaluate medical practice according to patients' views of quality and clinicians' ability to meet standards of clinical and organizational quality established by a variety of groups. This kind of approach does not usually consider doctors' values, beliefs, and expectations about patient care or the context in which a visit to the doctor takes place. This study of general practitioners in Scotland explores what is meaningful to them in their work.

What This Study Found General practitioners' satisfaction with patient visits is related to developing and maintaining relationships, rather than to technical aspects of diagnosis and treatment. In their most satisfying visits, they achieve successful results by using interpersonal aspects of care, especially knowing the patient. They view success in terms of restoring the person, not in terms of prevention, treatment, or cure of a disease. Doctors' satisfaction with their work is also influenced by their sense of self as a doctor and the way in which they relate to and accept discussions about what determines good medical practice.

Implications

• Health care systems tend to focus on technical and measurable aspects of care. This may result in a model of medical practice in which purpose and meaning are not consistent with doctors' experiences of their work, and could harm professional morale.
• Health care reform should ensure that work conditions do not prevent the development of meaningful relationships between doctors and patients.

All in the Family: Headaches and Abdominal Pain as Indicators for Consultation Patterns in Families

By Mieke Cardol, PhD, and colleagues

Background This study explores patterns of doctor visits within families. In particular, it looks at whether families have patterns of visits for minor conditions, such as headache or abdominal pain.

What This Study Found Families have shared patterns of doctor visits for headaches and abdominal pain. This clustering of symptoms is most common in mothers and children, particularly daughters.

Implications

• Understanding patients' family context can help primary care doctors better diagnose and care for them. It may also help patients identify and act on patterns of seeking care that are not useful.
• The decision to visit the family doctor for headache or abdominal pain is influenced by behavior in one's family.

Discovery of Breast Cancers Within 1 Year of a Normal Screening Mammogram: How Are They Found?

By Patricia A. Carney, PhD, and colleagues

Background There has been little research into how breast cancer is discovered when it is not picked up on a mammogram or when it appears between mammograms. This study looks at how breast cancer is discovered within 1 year of a normal mammogram.

What This Study Found Of the 143 women in this study, approximately one half decided to visit to the doctor when they had 1 or more breast concerns, especially when they found a lump and had a personal or family history of breast cancer. Seventeen percent of the breast cancers were found by women's primary care doctors, and the rest were picked up on a follow-up mammogram. Most women in the study were cared for by the doctor who referred them for the mammogram that identified the cancer.

Implications

• No screening test, including mammograms, picks up all cancers.
• Women at highest risk for breast cancer should be monitored by their primary care doctor and strongly encouraged to visit the doctor at the first sign of a lump.
• Women, especially those with a personal or family history of breast cancer, should report breast symptoms to the doctor, even if they have had a recent negative mammogram.
• An ongoing relationship with a primary care doctor is important in helping to detect breast cancer between mammograms.

Perspectives on Confidential Care for Adolescent Girls

By M. Diane McKee, MD, MS, and colleagues

Background Adolescent girls who live in poor urban areas are at much higher risk for health problems related to sexual activity than girls in other areas, yet they don't often seek confidential reproductive health care on their own. This study looked at the role that mothers play in encouraging appropriate and timely gynecologic care for adolescent girls.

What This Study Found Mothers want to protect their daughters against early sexual activity, pregnancy, and sexually transmitted infection, and believe they will be responsible for dealing with the results of such problems. Many mothers believe that a daughter's private visit to the doctor would promote risky behavior and challenge the mother-daughter bond. Mothers are willing to help their daughters receive gynecologic care, but only after the girls become sexually active. Mothers' awareness of sexual activity is low, and girls in this study worked hard to keep their sexual status private.

Implications

• Lack of trust in doctors and a mother's role as protector can be barriers to reproductive health care for adolescent girls.
• New approaches are needed to help prepare mothers and daughters for the adolescent's transition to independent health care. Doctors could try setting aside a portion of visits as confidential when girls are in early adolescence as a way to encourage this transition.
• Doctors need to build skills to communicate about confidential care, while respecting the mothers' role as champion of her family's health care and protector of her adolescent's well being.

Conceptual Models of Treatment in Depressed Hispanic Patients

By Alison Karasz, PhD, and colleagues

Background There has been little study of how primary care patients view depression and its treatment. This study investigates how depressed Hispanic patients view primary care treatments for depression. In particular, it focuses on their views of the benefits and effectiveness of such treatments.

What This Study Found Most patients think their primary care doctor could be helpful in treating their depression. Three quarters believe that medication could be helpful or are not sure, and many patients are optimistic about the benefits of counseling. Patients who are currently being treated for depression are likely to view it as effective. Conversation is seen as a benefit of being treated by a primary care doctor for depression.

Implications

• Guidelines for depression treatment emphasize diagnosis and technical care. In contrast, this study finds that participants view "supportive talk" with the doctor as an effective treatment for depression.
• Little is know about the effectiveness of doctors' conversations with depressed patients or the content of such conversations. These are important topics for future study.
• Patients' views of the effectiveness of depression treatments may help shape their decisions about initiating and continuing treatment.

Improving Influenza Vaccination of High-Risk Inner-City Children Over 2 Intervention Years

By Richard K. Zimmerman, MD, and colleagues

Background Rates of influenza (flu) vaccination among children with high-risk conditions, such as asthma, are low. This study set out to determine whether selecting from a menu of specially designed strategies (such as flu vaccines on a walk-in basis or reminder e-mails for clinicians) would help inner-city health centers raise vaccination rates among high-risk children.

What This Study Found Over a 2-year period, a menu of tailored strategies results in a modest rise in flu vaccination rates for high-risk children aged 2 to 17 years. When offered a menu of options, inner-city health centers use a variety of strategies based on their specific needs and their office and patient cultures.

Implications

• In this study, immunization rates were lower in adolescents. Strategies particularly targeted to older children, such as after-school immunization clinics or providing flu vaccination when asthma medications are refilled, may be helpful.
• Immunization rates may be further improved by refining the strategies offered and focusing on the culture of individual medical practices.

Impact of the 2004 Influenza Vaccine Shortage on Repeat Immunization Rates

By Charles P. Schade, MD, MPH, and colleague

Background In 2004, there was a severe shortage of influenza (flu) vaccine in the United States. As a result, it was recommended that doctors give flu vaccinations only to people in high-risk groups. This study examines Medicare data in West Virginia to determine how doctors and patients were affected by the shortage of flu vaccines.

What This Study Found In 2004, total Medicare claims for flu vaccinations in West Virginia dropped by more than 50%, from more than 92,000 in 2003 to approximately 44,000 in 2004. Some patients received vaccines from sources other than their regular doctors, most often from a mass immunizer (an organization such as a public health clinic or pharmacy that offers vaccinations to large numbers of people). The number of Medicare beneficiaries receiving a flu vaccine fell by about 8% in 2004 compared with previous years. The percentage of Medicare recipients who received flu vaccine from the same clinician as the year before fell from 54% in 2002-2003 to 3% in 2003-2004.

Implications

• The 2004 vaccine shortage severely affected the ability of doctors to provide flu immunizations, an important preventive health service, to their patients.
• The shortage also appeared to disrupt the ongoing relationship between patients and doctors.
• Those who did not receive immunizations were most likely people who lacked transportation or were too ill to locate a different source of flu vaccine.

Measuring Continuity of Care In Diabetes Mellitus: An Experience-Based Measure

By Martin C. Gulliford, FRCP, and colleagues

Background An ongoing relationship between patient and doctor is important in managing diabetes, since diabetes care requires close cooperation between the patient and the health care team. Some diabetic patients, however, do not receive care on a regular basis. There are few methods available for measuring the ongoing relationship between patients and medical professionals (often called "continuity of care"). This study aimed to develop and test a questionnaire to measure continuity of care in patients with type 2 diabetes.

What This Study Found A questionnaire was developed, based on patient interviews, to measure diabetes patients' experience of continuity of care. It was tested in a survey of 193 diabetes patients in London, England. This study shows that the tool is a reliable and valid measure of experienced continuity of care.

Implications

• The questionnaire may be used in family practice settings and by other specialists, and can be completed by the patient or presented in an interview format.
• The questionnaire can increase understanding of factors that improve or harm patients' experiences of continuity of care.
• Because it is short, acceptable to patients, and can be used in different care settings, the questionnaire can be used to routinely monitor quality of care.

BiDil: Assessing a Race-Based Pharmaceutical

By Howard Brody, MD, PhD, and colleague

Background BiDil is the first drug approved by the FDA and marketed for a single racial-ethnic group, African Americans, in the treatment of congestive heart failure. This essay explores background issues to help prepare family physicians to counsel patients about this controversial drug. Issues include the following: (1) The scientific research leading to BiDil's approval tested the drug only in African Americans, apparently for commercial reasons, so the drug's effectiveness in other populations is not known. (2) Race can be an important factor in considering risk of certain diseases and health care disparities in American medicine; however, we should not assume that differences in the occurrence of diseases among racial or ethnic groups are due to genetic differences. BiDil is an example of how the contribution of social and cultural factors in the causes of a disease may be overlooked because of an assumption of a "racial" and genetic difference. (3) BiDil is a profit-making venture. Doctors could consider prescribing lower-cost generic options.