Index by author
The Issue in Brief
Myocardial Infarction Mortality in Rural and Urban Hospitals: Rethinking Measures of Quality of Care
Paul A. James, MD, and colleagues
Background Previous research suggests that rural hospitals give lower quality of care to patients with heart attack (myocardial infarction) than hospitals in urban areas. This study uses unique methods to examine whether patient characteristics (such as age and health) affect rates of death for heart attack patients in rural vs urban hospitals.
What This Study Found Death rates from heart attack were not higher in rural hospitals when patient characteristics were taken into account. Heart attack patients in urban and rural hospitals were significantly different from each other. Patients admitted to urban hospitals were younger and more likely to be male or black, whereas those admitted to rural hospitals were sicker and older than their urban counterparts.
Implications
- In-hospital death rates that do not consider the severity of patient illness may not accurately indicate quality of care of heart attack patients.
- These findings challenge the suggestion that heart attack patients receive worse care in rural hospitals compared to urban hospitals.
Patient Education on Prostate Cancer Screening and Involvement in Decision Making
Alex H. Krist, MD, MPH, and colleagues
Background National guidelines state that doctors should not screen men for prostate cancer without first discussing potential harms, benefits, and scientific uncertainties about the screening process. This study examines whether patients� review of prostate cancer information before a doctor visit increases the rate at which they share decisions about screening for the disease with their doctor.
What This Study Found Patients invited to review information about prostate cancer and screening were more informed and more involved in screening decisions than other patients. Paper- and Web-based materials were equally effective in educating patients and involving them in the decision process. Exposure to these materials, however, did not promote a process in which patients and doctors truly shared control of decision making.
Implications
- Men who reviewed educational materials were more knowledgeable about prostate cancer and less likely to be screened for it.
- Providing patients with prostate cancer information can increase their involvement in decision making.
How Physicians Approach Prostate Cancer Screening Before and After Losing a Lawsuit
Alex H. Krist, MD, MPH, and colleagues
Background In 1999, a family medicine resident and a patient shared decision-making about whether the patient would be screened for prostate cancer. The patient, who decided not to be screened, was later diagnosed with prostate cancer and successfully sued the practice. This study examines whether doctors at the practice changed their approach to shared decision-making for prostate cancer screening as a result of the lawsuit.
What This Study Found Doctors in the practice did not change their approach to involving patients in decision-making for prostate cancer screening before, during, or after becoming aware of the lawsuit.. They continued to spend time discussing issues related to prostate cancer screening and patients were equally well informed about it.
Implications
- This study casts doubt on the idea that doctors change their practice methods as a result of the threat or experience of a lawsuit.
Major Depression Symptoms in Primary Care and Psychiatric Care Settings: A Cross-Sectional Analysis
Bradley N. Gaynes, MD, MPH, and colleagues
Background Depressed patients are more likely to see a primary care doctor than a mental health specialist for diagnosis and treatment of depression. This study compares characteristics and conditions of depressed patients in primary care and psychiatric specialty care settings.
What This Study Found Patients with major depression in primary care and specialty care settings have similar symptoms and similar levels of depression. Risk factors for suicide are commonly seen in both settings, although they are more frequent in specialty care. In each setting, more than half of depressed patients had another psychiatric illness, in addition to depression.
Implications
- These findings challenge the suggestion that depressed patients in primary care settings are less depressed than those in specialty care settings.
- Research results based on similar patient populations may be applicable to both primary care and specialty care practices.
- The care of major depression increasingly falls on primary care doctors as better treatments become available and as community mental health clinics begin restricting treatment to patients with more
William C. Wadland, MD, MS, and colleagues
Background This study compares two methods of encouraging doctors to refer patients who smoke to a telephone quit line. The methods are comparative feedback (doctors receive information comparing their rates of referring patients to the quit line with those of other doctors, particularly with other doctors who refer at high rates) and postcards reminding them about quit line services. The quit line is a 24-hour service staffed by trained nurses who counsel callers in how to quit smoking and keep from starting again.
What This Study Found Doctors who receive comparative feedback refer patients to a smoking quit line at higher rates than doctors who receive a postcard reminder. The estimated number of referred smokers who quit was 66 in the feedback group and 36 in the postcard reminder group. The added cost to develop feedback information was about $65 per estimated patient who quits smoking.
Implications
- Comparative feedback on referrals to a smoking quit line had a modest effect on doctors.
- The additional cost of providing feedback information is small considering the effectiveness of the feedback method and the long-term health benefits of stopping smoking.
Research Productivity Among Recipients of AAFP Foundation Grants
Martin C. Mahoney, MD, PhD, and colleagues
Background The Joint Grant Awards Program (JGAP) of the American Academy of Family Physicians Foundation and the American Academy of Family Physicians supports small-scale research projects. A survey of JGAP recipients from 1990 to 2000 was conducted to evaluate their research productivity.
What This Study Found Sixty-nine JGAP recipients reported 91 publications and 129 presentations based on JGAP-supported research. After awarded their JGAP grants, recipients received a total of 26 grants ($9.6 million total costs). Funded applicants had more publications during the 5 years before and after their JGAP submissions than applicants who did not receive JGAP awards.
Implications
- JGAP projects have generated a large body of publications and presentations, and additional grant activity.
- JGAP plays an important role in supporting the early career development of family medicine researchers.
Treating Opioid Addiction with Buprenorphine-Naloxone in Community-Based Primary Care Settings
Ira L. Mintzer, MD, and colleagues
Background Buprenorphine is a medication that has been approved for treating patients who are addicted to opioids, a group of drugs that include heroin and some prescription pain relievers. Doctors who receive special certification can provide buprenorphine treatment in their office. This study examines the effectiveness and practicality of buprenorphine treatment in two primary care offices.
What This Study Found Opioid-addicted patients can be safely treated in primary care offices. In this study, 54% of patients were sober at 6 months, which is similar to success rates in more specialized drug treatment centers.
Implications
- Opioid-addicted patients can be safely and effectively treated in primary care offices with limited on-site resources.
- The authors call for more buprenorphine treatment outside of specialized treatment centers, and they encourage other primary care doctors to consider providing such treatment.
Ratings of Physician Communication by Real and Standardized Patients
Kevin Fiscella, MD, MPH, and colleagues
Background This study examines the strengths and limitations of two methods of rating doctors� communication skills. The two methods are ratings by real patients and ratings by standardized patients (people who are trained to portray specific patient cases in predetermined ways).
What This Study Found Trained standardized patients, who visit a doctor unannounced, provide a more objective (though much narrower) assessment of doctors� communication skills than do real patients. Ratings of doctors� communication by standardized patients have better psychometric (statistical and psychological) properties than ratings by real patients. Ratings by real patients and standardized patients provide different information.
Implications
- Real and standardized patients rate doctors� communication styles differently.
- Differences in ratings by standardized and real patients may be due to differences in their relationship with the doctor (that is, an ongoing relationship for the real patient vs a one-time visit fo
- Both standardized and real patients provide useful information for understanding the clinician-patient relationship.
Clinical Concerns About Clinical Performance Measurement
Rachel M. Werner, MD, PhD, and colleague
Background Performance measurement, in which clinical performance is measured against preset standards, is a part of current efforts to improve health care quality. Although performance measurement can help practices meet preset guidelines, many doctors are concerned that it is a barrier to delivering good care, therefore reducing some aspects of health care quality. In particular, they are concerned that doctors become overly focused on meeting performance measures rather than on the needs of individual patients. The authors offer ways to improve performance measurement and call for quality improvement efforts that focus on patients.
Jazz and the 'Art' of Medicine: Improvisation in the Medical Encounter
Paul Haidet, MD, MPH
Background Improvisation is an important aspect of patient-doctor communication. It is also an important feature of jazz music performance. This essay uses examples from jazz to illustrate principles of improvisation in communicating with patients. These principles include giving patients space to say what they want to say, developing a unique communication style, and accommodating the communication styles of others. Jazz improvisation can inform efforts to research and teach these aspects of communication in the medical setting.
Caring for a Surge of Hurricane Katrina Evacuees in Primary Care Clinics
Thomas D. Edwards, DO, and colleagues
Background Approximately 4,500 victims of Hurricane Katrina were evacuated to Tarrant County, Texas, over a 5-day period. A local health network, with a strong family medicine component, took primary responsibility for 3,700 evacuees and provided medical care to 1,664 (44%) of them during a 2-week period. They prevented the emergency department and hospital from being overwhelmed by using a triage system located away from the emergency department. Most patients with health care needs were referred to a primary care clinic. The authors share lessons learned to help in planning for future disasters.