Table of Contents
The Issue in Brief
Michael S. Klinkman , and colleagues
Background Primary care practices increasingly provide care management programs for depressed patients, but little is known about whether such efforts are effective over time. This study evaluated the ongoing effectiveness of a low-intensity, tailored management program for chronically depressed patients in the primary care setting.
What This Study Found This program to support primary care clinicians� management of patients with depression was feasible and highly effective over time. It resulted in sustained improvement in core clinical outcomes, including improved remission rates and reduced-function days for a period of 18 months. The program was acceptable to patients, with most patients remaining active in the program for at least 6 months.
Implications
- A low-intensity, tailored care management program can lead to sustainable improvement in depression care for chronically depressed patients in real-world primary care practices.
- The study results support a shift in depression care management from a focus on short-term results for patients entering a new treatment episode to longer-term results for patients receiving enhanced primary care treatment over time.
Longitudinal Adherence With Fecal Occult Blood Test Screening in Community Practice
Joshua J. Fenton , and colleagues
Background Screening with fecal occult blood testing (FOBT) reduces colorectal cancer mortality, but its effectiveness may diminish if patients do not get repeated screenings. This study assessed subsequent screening among patients who previously received a fecal occult blood test.
What This Study Found Nearly one-half of patients who initiated FOBT screening on a 2-year basis did not receive colorectal screening in the following 2-year observation period.
Implications
- Programs to promote regular screening may be necessary to achieve high effectiveness in fecal occult blood testing.
Effect of Drug Sample Removal on Prescribing in a Family Practice Clinic
Daniel M. Hartung , and colleagues
Background Pharmaceutical marketing practices and potential financial conflicts of interest between doctors and the pharmaceutical industry have raised a number of ethical concerns. This study evaluated the effect of a rural family practice�s policy prohibiting prescription drug samples and visits from pharmaceutical representatives.
What This Study Found There were modest reductions in brand name drug use in several classes of drugs after the prohibition of prescription drug samples and visits by pharmaceutical representatives. Levels of brand name drug use did not change significantly after the policy was implemented, but branded drugs prescribed for respiratory disease declined significantly (by 11.34 percent) compared with those prescribed by a control group. Prescriptions of promoted cholesterol-lowering drugs and antidepressants were reduced by approximately 9.98 percent and 11.34 percent, respectively. The average cost per prescription for lipid-lowering drugs was significantly reduced by $0.70 per prescription per month. Overall, however, average prescription drug costs increased by $5.18 immediately after policy implementation.
Implications
- The authors suggest that clinics considering similar restrictions should evaluate both the positive and negative roles samples and industry representatives play on patient care.
Michael L. Parchman , and colleagues
Background Participatory decision making, in which patients actively participate in the medical visit, is associated with better outcomes in patients with chronic illnesses. This study of patients with type 2 diabetes aimed to shed light on the pathway between a clinician's participatory decision-making style, patient participation in the visit, and taking medication as prescribed.
What This Study Found Diabetes patients who reported a higher level of participatory decision making were more likely to actively participate in the medical visit. Active participation in the visit was associated with taking medications as prescribed, and taking medications as prescribed was associated with improved control of hemoglobin A1C levels and LDL cholesterol levels (but not blood pressure).
Implications
- Actively involving patients in decision making about their care requires adequate visit time and resources. This will require a fundamental restructuring and transformation of many primary care settings.
Quality of Care for Chronic Diseases in a British Cohort of Long-Term Cancer Survivors
Nada F. Khan , and colleagues
Background Research from the United States has shown that long-term cancer survivors with other chronic diseases may receive poorer care for those diseases compared with the general population. This study set out to establish the quality of care for chronic diseases in cancer survivors in the United Kingdom.
What This Study Found Chronic disease is well managed in British primary care � most cancer survivors who are not at the end of life receive the same level of care as noncancer patients. Analysis of records on 21,366 adult cancer patients reveals that, in British primary care, history of cancer is not associated with poorer management of hypertension, diabetes, cerebrovascular disease, or coronary artery disease.
Implications
- This difference in quality of care between the United States and United Kingdom may be the result of differences in health care delivery. Specifically, the introduction of incentives for chronic disease monitoring, universal health care, and a clear role for primary care in the UK may help ensure appropriate comprehensive care for adult cancer survivors.
Bijal A. Balasubramanian , and colleagues
Background Changes in practice organization can contribute to improvements in health care processes and patient outcomes, but making practice-level change is complex. A study using facilitated practice improvement teams (called reflective adaptive process RAP teams) to enhance communication and decision making to improve adherence to multiple clinical guidelines failed to show significant clinical improvements. This study aimed to better understand the team-based collaborative change management strategies used and types of issues addressed by participants.
What This Study Found Although primary care practices can successfully engage in facilitated team meetings (18 of 25 practices successfully convened improvement teams despite a history of not meeting regularly), they may choose not to spend the time focusing on guideline adherence. In this study, not a single practice focused on improving adherence to specific chronic disease guidelines during the meetings. Instead, when given a choice, RAP team members focused on patient care and practice improvement issues related to communication, access to care, and access to information, brainstorming solutions, and implementing changes to address these issues.
Implications
- The authors call for additional strategies to engage practice leaders, particularly physicians, and to target issues related to guideline adherence.
Ethics of Health Research in Communities: Perspectives From the Southwestern United States
Robert L. Williams , and colleagues
Background Increasingly, research is conducted in communities and involves community members in the research process. Are existing research protections adequate for this type of research? This study assessed the views of people living in ethnic minority communities in the Southwestern United States about health research.
What This Study Found Human research protections established over the last 60 years to protect individuals during the research process are not adequate to safeguard communities, according to focus groups with Hispanic and Native American community members in New Mexico. Although participants recognized the value of health research, many also identified adverse social (labeling, stigmatization, and discrimination) and economic (job losses, increased insurance rates, loss of income) effects of research in their communities. Participants also emphasized no or ineffective return of information about research results to the communities.
Implications
- According to the authors, these findings support the addition of a fourth principle (requiring respect for communities) to the Belmont Report, which provides the ethical foundation for all current human research. They assert that the issues raised also call for more broadly applying the three principles of the Belmont Report (respect for persons, beneficence, and justice) to communities as well as individuals.
- The authors also conclude that researchers should adopt additional approaches to community-based research by engaging communities as active partners throughout the research process, focusing on community priorities, and taking extra precautions to assure individual and community privacy. Furthermore, plans for disseminating meaningful results to communities should be part of the research design.
Continuity and Trust in Primary Care: A Qualitative Study Informed by Game Theory
Mary Dixon-Woods , and colleagues
Background The relationship between continuity of care and patient trust in primary care is not fully understood. This study uses game theory, developed by mathematicians in the 1920s to specify how players will act and what outcomes will result in particular games, as a lens to understand more about patients� trust in general practitioners.
What This Study Found Interviews with 20 patients in the United Kingdom suggest that game theory provides a theoretical basis for understanding the relationship between continuity of care and the development of patient trust. Patients are often willing to draw on institutional trust, derived from expectations of medicine as an institution and doctors as professionals, to engage with unfamiliar doctors. This trust provides a starting point and can be reinforced or undermined by cues to trustworthiness picked up from interpersonal aspects of the patient-physician encounter. Consistent with game theory, repeated positive interactions with the same doctor, however, can allow patients to develop more secure expectations based on a history of other interactions and anticipation of future interactions. This provides a context that makes it possible for trust to build and become secure.
Implications
- Patients do not see doctors as interchangeable, and the move toward organizing services around single encounters between patients and often unfamiliar physicians may disrupt the development of secure trust. According to the authors, this is important because trust, which, apart from its intrinsic value, is associated with health outcomes such as patient satisfaction, adherence to treatment, and perceived effectiveness of care.
Including Socioeconomic Status in Coronary Heart Disease Risk Estimation
Peter Franks , and colleagues
Background There is a growing socioeconomic disparity in coronary heart disease. This study explored alternative approaches to assessing risk based on socioeconomic status (SES) (using the patient's place of residence) and derived an approach to incorporating SES risk into treatment guidelines.
What This Study Found Adding two measures of socioeconomic status into coronary heart disease risk estimation, the authors contend, can reduce the biases inherent in the widely used Framingham risk score, which currently results in undertreatment of patients of lower socioeconomic status. Modifying the score to include a geographic area-based measure of income (using block group US Census data) and individual education level eliminated the significant socioeconomic bias observed using the Framingham risk score alone. The revised approach suggests more aggressive cholesterol treatment thresholds for those with low socioeconomic status--thresholds of 10 percent and 20 percent should be lowered to 6 percent and 13 percent for low SES persons.
Implications
- The authors assert the proposed modifications should be easy for clinicians to accommodate.
Capability and Clinical Success
Robert L. Ferrer , and colleagues
Background Better outcomes for chronic diseases are hard to achieve because success depends on factors outside the control of the health care system, including patients� ability to mange their health behaviors and chronic diseases. Social and environmental factors influence patients' self-management of chronic diseases, but there is not yet a systematic clinical response to these barriers. The �capability� framework, defined as the real opportunity to achieve a desired lifestyle, offers an approach for addressing social determinants in practice, as well as planning and evaluating community responses to chronic illness.
What This Study Found Because it focuses attention on the conditions that constrain opportunity and how opportunity emerges from the interaction between personal resources and social environment, the capability framework has the potential to expand the informational basis for making clinical assessments, illuminating areas where patients� knowledge and motivation may be constrained by difficult circumstances. By focusing on external and internal supports, the capability framework can potentially augment the effectiveness of self-management and empowerment strategies. It may also help to more efficiently manage health behaviors and chronic disease by prospectively identifying patients who are at high risk of failing to change key behaviors.
Implications
Losing Touch in the Era of Superbugs?
Leif R. Hass
Background A physician reflects on how his own drug-resistant staphylococcus infection affected his work in the hospital, and how his subsequent decision to wear gloves during patient encounters created a barrier, not only to infection, but also between himself and his patients. He reflects on the value of touch as a communication tool in the doctor-patient relationship, especially as a means of bridging large socioeconomic and cultural gaps. The implications of contact precautions must be considered as clinicians reflect on balancing patient-centered care with infection control, the author concludes.