Index by author
The Issue in Brief
Competing Demands or Clinical Inertia: The Case of Elevated Glycosylated Hemoglobin
Michael L. Parchman, MD, MPH , and colleagues
Background Medication plays a key role in controlling blood sugars in diabetes patients. This study examines two possible reasons why primary care doctors might not change the medication of diabetes patients whose blood sugar is not well controlled: "clinical inertia" (recognizing but not acting on a medical problem), and "competing demands" (the need to address several medical problems, patient concerns, and preventive health measures in the limited time of a doctor visit).
What This Study Found Primary care doctors address and prioritize many medical issues during patient visits. As the number of medical issues raised by a patient with high blood sugar goes up, the likelihood of a change in their medication goes down. Compared with other doctor visits, those in which diabetes medication is changed are longer, and the patient has fewer medical concerns but a higher blood sugar. Doctors spend the same amount of time discussing self-care measures with patients who have high blood sugars, regardless of whether they change the medication.
Implications
- The ability to treat multiple conditions is a strength of primary care. Because multiple conditions present competing demands, the patient and doctor must set goals and priorities during their visits.
- Studies using the term "clinical inertia" usually focus only on diabetes care and not the patients� other health care needs. As a result, approaches to diabetes care based on clinical inertia are likely to be ineffective.
- The concept of competing demands better describes the diabetes patient�s primary care visit than the concept of clinical inertia.
Alberta S. Kong, MD, MPH , and colleagues
Background This study looks at the relationship between acanthosis nigricans, a skin condition, and type 2 diabetes, the most common form of diabetes. More than 1,000 patients from 7-39 years old took part in the study.
What This Study Found Patients with acanthosis nigricans (AN) were almost twice as likely as other patients to have type 2 diabetes. Children and adults with a family history of type 2 diabetes had higher rates of AN than other patients. Identifying AN often led doctors and patients to discuss lifestyle changes that can lower the risk of diabetes.
Implications
- AN can be used to quickly identify patients with risks for type 2 diabetes.
- Diagnosing AN may help doctors identify patients who would benefit from lifestyle changes that can reduce the risk of diabetes.
Jesse C. Crosson, PhD , and colleagues
Background Electronic medical records (EMRs) can help medical practices manage complex information for patients with diseases such as diabetes. This study looks at the relationship between the use of an EMR and the quality of diabetes care in family medicine practices.
What This Study Found Practices that used electronic medical records were less likely to meet measures for diabetes quality of care than practices without EMRs. This finding might be due to differences in features of the EMR, the degree to which clinicians used the EMR, and resources available to support these efforts.
Implications
- Having an electronic medical record does not guarantee that quality of care will improve. More study is needed to determine how EMRs can help support quality of care for patients with chronic illnesses such as diabetes.
- Policy makers and primary care practice owners should consider how to maintain and improve quality both during and after the implementation of an EMR.
- EMR companies should be encouraged to develop products with easy-to-use features that support improved health care quality in primary care practices.
Sufficiently Important Difference for Common Cold: Severity Reduction
Bruce Barrett, MD, PhD , and colleagues
Background In this study, people with colds were interviewed about 4 cold treatments. They were asked about the amount of benefit they would want in exchange for the costs and possible side effects of the treatments. The study set out to determine the sufficiently important difference (SID) in these treatments, that is, the smallest benefit that a treatment would require in order to justify its costs and risks.
What This Study Found Of the 4 treatments, a $0.05 vitamin C pill with few or no side effects required the least benefit to justify treatment, followed by a $0.50 dose of an herbal extract with no side effects (other than bad taste), a $0.20 lozenge, which could taste bad and cause nausea, and finally a $2 prescription-only pill with unknown side effects. The study finds that, on average, people want the severity of a cold to be reduced by 25% to 57% to justify the costs and risks of cold treatments.
Implications
- This study sheds light on patients� health values, which play a role in medical decision making and the design of research studies.
- The authors suggest that the concept of sufficiently important difference be tested for other medical conditions.
Beth Barnet, MD , and colleagues
Background Adolescent mothers have high rates of repeat pregnancy, depression, and school dropout, and less chance of being financially independent in the future. This study evaluates a program for pregnant teenagers and teenage mothers in which trained home visitors provide parenting education, encouragement to use contraception and continue school, and connection to primary medical care.
What This Study Found The home-visiting program improved teenage mothers� attitudes and beliefs about parenting and helped them stay in school. It did not reduce repeat pregnancy or depression and did not provide coordination with primary care.
Implications
- Home visiting can provide important results for low-income adolescent mothers.
- Community-based home-visiting programs and primary care practices may achieve greater benefits if they work together to develop and test methods to coordinate care for high-risk adolescents.
Different Paths to High-Quality Care: Three Archetypes of Top-Performing Practice Sites
Chris Feifer, DrPH , and colleagues
Background This study looks at 9 medical practices that have been successful in improving the quality of medical care they deliver.
What This Study Found The practices in this study, which are successful in improving quality of care, can be described by 3 models or archetypes. The Technophile archetype describes practices that quickly adopt and consistently use an electronic medical record and its tools, such as automated guides to help clinicians and staff perform and document routine tasks. Each of these practices has a doctor who is committed to finding new ways to use the electronic medical record. Practices in the Motivated Team archetype look for new ways to use existing resources to improve quality. They involve the entire practice by sharing information, holding practice meetings, involving and motivating staff, and setting aside time for improvement efforts. Practices in the Care Enterprise archetype select clinical areas that they want to improve and design systems to do so, involving staff if needed. They take a customer-service approach to provide care that meets the needs of patients and doctors and is consistent with recommended guidelines.
Implications
- No single approach creates success in improving quality of care. Practices in this study use many common strategies, with different approaches for organizing their practice change efforts.
- Practices that succeeded in improving quality in this study had someone in the practice who was a "champion" for the improvement effort.
- Medical practices do not have to start out with a focus on technology to improve quality.
A National Survey of Primary Care Practice-Based Research Networks
William M. Tierney, MD , and colleagues
Background Practice-based research networks (PBRNs) are groups of medical practices that take part in research projects. Their research is set in the doctor�s office and examines questions about primary health care. This study surveyed PBRNs in the United States to learn more about them.
What This Study Found The survey included 86 PBRNs representing 4 primary care specialties (family medicine, pediatrics, general internal medicine, and family nurse-practitioners), 1,871 medical practices, almost 13,000 doctors, and more than 14 million patients. Three-quarters of the PBRNs are affiliated with a university. Most PBRNs in the study get research ideas from their members and from outside researchers. Eight-five PBRNs focus their clinical research on diabetes, risk of cardiovascular disease, mental health, and preventing illness and disease. PBRNs serve a diverse patient population and most have difficulty getting funding.
Implications
- PBRNs are gaining momentum and recognition both nationally and internationally, and are increasingly involved in clinical and public health issues.
- To meet their full potential, PBRNs need to continue to grow and mature.
- Effective communication is needed between funding agencies, researchers, PBRN administrators, and PBRN participants. PBRNs must be aware of the research interests and needs of funding agencies, and funding agencies should use PBRNs to explore questions about high-quality, cost-effective primary care.
- PBRNs should also collaborate and share experiences among themselves.
Improving Medical Practice: A Conceptual Framework
Leif I. Solberg, MD
Background Systems of delivering health care need to be improved in order to improve American medicine. This article provides a simple framework for changing medical practice. The framework is based on existing information about quality improvement as well as the author�s extensive experience in this area.
What This Study Found To improve care, health care organizations or systems must address 3 main factors: priority (the desire and commitment of the organization to change), change process capability (factors that help an organization change, such as strong, effective leadership and communication skills), and care process content (specific changes in patient care activities). Change also depends on removing or minimizing barriers to change and encouraging elements that help change to happen.
Implications
- This simple framework can be a guide for individuals and organizations that would like to change the way they delivery medical care.
- It can also be helpful in developing or testing specific programs and recruiting medical practices to take part in change efforts.
Disease Management: Panacea, Another False Hope, or Something in Between?
John P. Geyman, MD
In the United States 125 million Americans have one or more chronic diseases, such as diabetes, asthma, or high blood pressure. Health care organizations use disease management programs to help patients manage these conditions. There are two major types of disease management programs. One type, used by some managed care organizations, involves the patient�s primary care doctor, who looks at the patient�s total health care needs, and uses such tools as electronic disease registries, consultations with disease experts, and patient education on how to manage the condition. The second type of program is sold commercially and intended to help health care organizations reduce costs. Commercial programs focus on providing patient education and helping patients manage their conditions through telephone calls, mailings, and the Internet, with little interaction with the patient�s primary care doctor. The first type of program, based on primary care, has shown promise in improving quality of care, but may not save costs. The second type of program, which is commercial and for-profit, has not yet proved to save money or improve care of chronic illness over time.The Impotence of Being Important - Reflections on Leadership
Ian Douglas Couper, BA, MBBCH, MFamMed
Leaders are most effective when they delegate responsibilities to others, work as part of a team, review their own performance, remain open to learning from others, and aren�t too self-important.Toward an Ecosystemic Approach to Chronic Care Design and Practice in Primary Care
Hassan Soubhi, MD. PhD
This essay offers a new framework for thinking about care of chronically ill patients. It describes chronic care as what patients, family members, and health professionals do to achieve specific health results within the opportunities and limitations of the illness. In this framework, there is not a standardized approach to care of chronic illnesses. Instead, chronic care is a group response that adapts as the illness changes over time. Health professionals would develop new ways to recognize, value, and manage the group response to illness; new ways to document and learn from the changing nature of illness experiences; and new ways to build openness, trust, and group involvement to encourage learning and help participants respond to the changing illness process.