Table of Contents
The Issue in Brief
Ann Fam Med 8: 290.
The Issue in Brief
Randomized Trial of a Program to Increase Staff Influenza Vaccination in Primary Care Clinics
Zvi Howard Abramson , and colleagues
Background Health care workers are a high-priority group for receiving influenza vaccinations because of their proximity to patients, but they have low immunization rates. This study looks at the effects of a promotional and educational program on raising influenza vaccination rates among primary care clinic staff. The program included an educational session, e-mail reminders, literature distribution, and personal reminders from a key staff member.
What This Study Found The program produced a substantial increase in influenza vaccinations among health care workers. Staff immunization rates doubled in clinics that received the program, compared to other clinics. It was successful among both individuals who had been immunized the previous season and those who had not.
Implications
- The program's success may be the result of raising the issue of immunization repeatedly and using a variety of educational and promotional methods.
- This simple program can easily be replicated in other primary care offices, and could lead to a substantial increase in influenza immunization rates.
Chyke A. Doubeni , and colleagues
Background In 2001, Medicare began providing reimbursement for screening colonoscopies for those at average risk of colorectal cancer, as defined by national guidelines. This study examines whether the expanded benefits reduced disparities associated with colorectal cancer screening.
What This Study Found Despite expanded coverage, Medicare enrollees who did not have supplemental insurance or a usual place of health care had disproportionally lower rates of colorectal cancer screening. During the 6-year study period, the gap in colorectal cancer testing grew between those without a usual source of health care and those who received usual care from a primary care physician.
Implications
- Expanding health insurance benefits without additional targeted efforts to improve utilization of appropriate health care services will not eliminate disparities.
- These findings reinforce the important role of primary care and the potential role of a patient-centered medical home in the delivery of colorectal cancer screening services.
Physician Satisfaction With Chronic Care Processes: A Cluster-Randomized Trial of Guided Care.
Jill A. Marsteller , and colleagues
Background In Guided Care, a primary care practice team (including a registered nurse, 2 to 5 doctors, and office staff) provide enhanced care for chronically ill older patients. This study examined the effects of Guided Care on doctors' experiences and satisfaction with specific processes of caring for chronically ill older patients.
What This Study Found Guided Care physicians are significantly more satisfied than other doctors with their patient/family communication and their knowledge of their patients� clinical conditions. Guided Care did not have significant effects on doctors� satisfaction with management of chronic care, knowledge of patients� personal circumstances, or on their ratings of the practice�s care coordination activities.
Implications
- Guided Care can address chronically ill older adults� needs and improve doctors� satisfaction with some processes of care and knowledge of their patients. This may be particularly important as the number of primary care doctors decreases and the number of older adults continues to grow.
Gradual Electronic Health Record Implementation: New Insights on Physician and Patient Adaptation
Renee R. Shield , and colleagues
Background Although there is considerable interest in implementation of electronic health records (EHRs), there is limited information about how doctors, staff, and patients adapt to the implementation process. This study examines the effects of EHR implementation on a medical practice, particularly on doctor-patient communication and behaviors and patients� responses.
What This Study Found During the implementation of an electronic health record, strong patient trust in the doctor-patient relationship was maintained and work flow improved. The role of the computer and the choice of where in the room it was placed had a significant effect on the doctor-patient interaction.
Implications
- Gradual implementation of an electronic health record may help support the development of beneficial adaptations by doctors and staff, while maintaining positive patient-doctor relationships and fostering the sharing of medical information.
Elena V. Kuklina , and colleagues
Background Young adults receive cholesterol screening at low rates in the United States. This study examined the national prevalence of risk factors for coronary heart disease (CHD) and compliance with cholesterol screening guidelines among young adults.
What This Study Found Approximately two-thirds of all young adults have one or more risk factors for CHD, yet less than 50 percent are screened for high cholesterol levels. About 59 percent of young adults had CHD or CHD equivalents, or one or more risk factors (high blood pressure, smoking, family history or obesity). The prevalence of high cholesterol increased with the number of CHD risk factors, yet there was no significant difference in screening for cholesterol among those with one, two, or more risk factors for CHD compared with those with no risk factors. High cholesterol levels were observed in 65 percent of young adults with CHD or CHD equivalents, 26 percent of young adults with two or more risk factors, 12 percent of young adults with one risk factor, and 7 percent with no risk factors.
Implications
- The authors call for clinical and public health programs to improve risk assessment and management of cardiovascular disease in young adults.
Health Information Seeking, Receipt, and Use in Diabetes Self-Management
Daniel R. Longo , and colleagues
Background Self-management is one of the keys to diabetes care, yet little is known about patient preferences for sources of health information, the extent to which patients seek information directly, or whether they receive information passively through various media sources. This study set out to identify how individuals with diabetes seek and use health care information.
What This Study Found Diabetes patients make decisions about disease self-management based on their current needs. They seek out information and receive it passively. Some of this information comes from diverse sources not traditionally viewed as providing health information, including the Internet, television, newspapers, and friends.
Implications
- The researchers propose a more dynamic model of health-seeking behavior that reflects its nonlinear nature and the interplay of both active information seeking and passive receipt of information.
A Method for Estimating Relative Complexity of Ambulatory Care
David A. Katerndahl , and colleagues
Background Primary care physicians have long been fighting for a system of compensation that recognizes the complexity of the primary care visit. The current system does not account for several important aspects of primary care, including interactions between multiple "agents" (patient, family, friends, physician, office staff) and the patient's multiple, less-defined illnesses; less-specific diagnostic tests; and variable patient behavior. This article demonstrates a method for calculating the relative complexity of office visits in the primary care setting. The method estimates complexity based on the amount of care provided weighted by its diversity and variability.
What This Study Found Analyzing data from the 2000 National Ambulatory Medical Care Survey using this method, researchers found that when adjusted for duration of visit, family medicine has a greater complexity density per hour (167) than either cardiology (125) or psychiatry (31).
Implications
- The complexity of medical care has important implications for health policy.
Validation of PHQ-2 and PHQ-9 to Screen for Major Depression in the Primary Care Population
Bruce Arroll , and colleagues
Background The goal of this study was to validate the 2- and 9-question Patient Health Questionnaires, which have been recommended for depression screening in primary care.
What This Study Found The sensitivity and specificity of the PHQ-2 for diagnosing major depression were 86 percent and 78 percent, respectively, with a score of two or higher, and 61 percent and 92 percent with a score of three or higher. For the longer PHQ-9, the sensitivity and specificity were 74 percent and 91 percent, respectively, with a score of 10 or higher. For the PHQ-2, a score of two or higher detected more cases of depression than a score of three or higher. A PHQ-9 score of 10 or higher appeared to detect more depressed patients than the originally described PHQ-9 scoring for major depression.
Implications
- The PHQ-2 can be a useful and time-saving tool for primary care physicians in screening for depression.
- The authors call for a reevaluation of the original PHQ-9 criteria for major depression, as the simple additive score of 10 or higher identified more depressed patients than the original and more onerous method for scoring the questionnaire.
Professional Medical Organizations and Commercial Conflicts of Interest: Ethical Issues
Howard Brody
Background This essay addresses the recent controversy over the American Academy of Family Physicians (AAFP) accepting a large corporate donation from The Coca-Cola Company to fund patient education materials on obesity prevention. The author argues that accepting funds from commercial sources that seek to influence physician organization behavior in a direction that could run counter to the public health constitutes a conflict of interest. He asserts that many of the defenses offered by AAFP leadership are rationalizations rather than sound ethical counterarguments. Medical organizations, as the public face of medicine and as formulator of codes of ethics for their physician members, have special obligations to adhere to high ethical standards.
Lori Heim
Background In response to an editorial by Howard Brody, M.D., Ph.D., Lori Heim, M.D., F.A.A.F.P., President of the American Academy of Family Physicians (AAFP), counters that the AAFP�s new consumer alliance agreement with The Coca-Cola Company illustrates the AAFP�s adherence to its ethical foundation, demonstrates the AAFP�s commitment to serving physicians and the public, and maintains the trust Americans put in their family physicians and the organization that represents them. She contends that throughout the development of the program, the AAFP consistently addresses possible conflicts of interest openly and directly, sharing with its members and the public exactly what measures it takes to ensure that no unethical conduct or breach of trust will occur. The AAFP saw a public health and education need that was both unmet and undermined by the barrage of marketing messages and confusing information and acted to fill that need by developing unbiased educational materials to help patients make good nutrition decisions. In so doing, she concludes, the AAFP hewed to its high ethical standards, its core values, and its mission in the decisions made and the actions that followed.
A Public Celebration of a Personal Doctor
William R. Phillips , and colleagues
In this essay, two family doctors share the experience of seeing a community celebrate the life of their doctor. The stories shared by community members provided powerful testimony to the value that personal doctoring offers to patients, families, communities, and to the future. The authors call for innovations - such as health care reform, health care system change, and practice redesign - to empower personal doctoring.