Table of Contents
The Issue in Brief
Ian M. Bennett , and colleagues
Background This study of older adults looks at the relationship between preventive health services, health disparities (gaps in the quality of health and health care between different groups), and health literacy (the ability to use health information to make health decisions).
What This Study Found Among older adults, health literacy contributes to racial/ethnic and education-related disparities in self-rated health status and receipt of influenza vaccination. Education-related disparities are also associated with receipt of mammography and dental care.
Implications
- Health disparities in older adults might be reduced by efforts to improve their health literacy and lower the reading level of print materials aimed at them. Further research of these approaches is needed.
Cumulative Incidence of False-Positive Results in Repeated, Multimodal Cancer Screening
Jennifer Miller Croswell , and colleagues
Background Although cancer screening tests play an important role in early detection of the disease, they can produce false-positive results (incorrect results that mistakenly identify cancer). This study examines the costs, in resources and human terms, of false-positive test results over time.
What This Study Found A large study that screened for cancers of the prostate, lung, colon and ovary found that the risk of a false-positive result increases with the number of screening tests. Specifically, by the fourth test, the risk of having at least one false-positive is about 37 percent for men and 26 percent for women. By the 14th test, the risk is approximately 60 percent for men and 49 percent for women. The risk of undergoing an invasive diagnostic procedure because of false-positive results is about 17 percent for men and 12 percent for women after four tests and 29 percent for men and 22 percent for women after 14 screening tests.
Implications
- This study provides a clearer picture of the burdens and risks associated with multiple cancer screening programs.
- Physicians and patients should discuss the likelihood of false-positive results in cancer screening, and they should examine the balance of risks and benefits in deciding on a patient's best course of action.
Patient Error: A Preliminary Taxonomy
Stephen Buetow , and colleagues
Background Most research of medical errors focuses on clinicians and systems. This study proposes a method to account for patients' role in medical errors.
What This Study Found Researchers have developed a three-level system which includes 70 possible types of errors patients might make, alone or with others. Two main groups are action errors, which result from patient behavior, and mental errors, or errors in thought processes.
Implications
- This classification system is the first that describes how patients can influence medical errors. Further research, using a variety of methods, is needed to understand more about patient contributions to errors.
- Errors are often not created by patients, clinicians, or systems alone, but rather through interactions between these groups. Future work on medical errors should recognize this interdependence.
Detecting Somatoform Disorders in Primary Care With the PHQ-15
Hiske van Ravesteijn , and colleagues
Background Up to one-half of all primary care patients with physical symptoms have symptoms that cannot be medically explained. This study tests a new instrument that screens patients for somatoform disorders (medically unexplained symptoms). It tests the instrument among patients at high risk for somatoform disorders, that is, patients who visit the doctor frequently, and those with mental health problems or unexplained symptoms.
What This Study Found The PHQ-15 is a valid and moderately reliable instrument for recognizing somatoform disorders in high-risk primary care patients.
Implications
- Medically unexplained symptoms are a complex problem. The PHQ-15 can help clinicians identify patients at high risk for somatoform disorders.
Felicity Goodyear-Smith , and colleagues
Background The CHAT is a simple tool to help identify risky health behaviors, such as inactivity and drug use, and mental health issues, such as depression, stress, or anger problems. For each of these issues, patients are asked whether they would like help with the problem. This study evaluates the benefit of asking patients whether they would like help.
What This Study Found Asking patients whether they would like help with the issues on the CHAT reduces false-positive results; people who have a positive CHAT question score and indicate they would like help with the issue are very likely to have the condition being assessed. Using the help question reduces the amount of time doctors spend during patient visits determining which patients require immediate help with particular issues.
Implications
- The CHAT's help question allows patients with multiple conditions to prioritize issues they want to address, indicates their readiness to change, and promotes self-determination. It helps clinicians decide which topics to pursue with patients.
Combining Web-Based and Mail Surveys Improves Response Rates: A PBRN Study From PRIME Net
Philip J. Kroth , and colleagues
Background Electronic communications offer new methods of conducting survey research. This study looks at whether individuals who do not respond to an electronic survey form will respond when offered the opportunity to complete the paper version of the survey instrument.
What This Study Found Paper is still an important element of survey research in practice-based research networks (PBRNs). In this survey of primary care physicians in PBRNs, 24% of responses were received on paper despite multiple requests to complete the Web-based version of the survey.
Implications
- Including options for responding on paper as well as via the Web may improve response rates in survey research among primary care PBRN physicians.
- Although Web-based surveys offer potential cost savings compared with paper, the differences may not be as significant as expected when Internet technology costs are taken into account.
Reconceptualizing the Experience of Surrogate Decision Making: Reports vs Genuine Decisions
Laurence B. McCullough , and colleagues
Background When patients are no longer able to make decisions about their life-sustaining treatment, family members or legal representatives must serve as surrogate decision makers. Their decisions are based on substituted judgment (the patient's values and preferences) or, if such values aren't known, they are based on what is in the patient's best interest. In this article, the authors reexamine this decision-making model to better reflect the experience of making surrogate decisions.
What This Study Found The authors propose that the current model of surrogate decision making be replaced by a new model. The new model distinguishes between making decisions for the patient, which is necessary when patient preferences are not known, and making reports on the patient's behalf when preferences are known. Making reports carries less stress and anguish than actual surrogate decision making.
Implications
- The concept of surrogate decision making should be used only when actual decision making is needed. Clinicians should help patients distinguish between making reports and making decisions.
Paul A. Nutting , and colleagues
Background The Patient Centered Medical Home (PCMH) is an approach to providing comprehensive primary care based on partnerships between patients and clinicians. This special report from the evaluation team of the National Demonstration Project (NDP) offers early lessons and recommendations for transforming practices to PCMHs.
What This Study Found Early lessons from the NDP include the following: (1) becoming a PCMH requires transformation; (2) incorporating new technology for the PCMH is difficult and time consuming; (3) transformation to a PCMH requires personal transformation of physicians; (4) "change fatigue" is a serious concern; (5) transformation to a PCMH is a developmental process; and (6) transformation is a local process. The authors also provide recommendations for policy makers and practices.
Implications
- The PCMH is an important opportunity to restore a healthy foundation for primary care and better health for the United States.
- The PCMH requires adequate funding, negotiation of hidden agendas, caution against industrial-like schemes and language, a local focus, and respect for variability.
David Loxterkamp
Background Change is a gradual process that takes place within trusting relationships. The work of Michael Balint, William Miller, and Stephen Rollnick offers a framework for understanding change. By working with patients, primary care physicians can serve as companions and guides to the change process, for both patients and communities, and can learn to understand their own capacity for change.
David Loxterkamp
Background Ownership reflects our values, influences our choices, and encourages stability. It is critical to the practice of medicine. We must ensure that the business of medicine has human relationships at its core and that we retain the sense of commitment and empowerment that are a part of ownership.
Doctors' Work: Eulogy for My Vocation
David Loxterkamp
Background When a family physician no longer sees his work as a vocation, it becomes an opportunity to view his work differently. An encounter with a patient helps him realize that his life's work is simply to be present for his patients, offering conversation, connection, and the opportunity to come alive.
David Loxterkamp
Background Aged patients often have major physical and emotional challenges, and caring for them is a daunting task. "Slow medicine," which focuses on kindness and preservation of function, provides a framework for the care of older patients. The author shares his own experience as a member of the Old Duffers' Club, in which self-support, conversation, and friendship serve patients and physician alike.