Table of Contents
The Issue in Brief
Daniel C. Vinson , and colleagues
Background High levels of alcohol use are often thought to be related to sleep problems, but this association has never been tested in the primary care setting. This study examined the relationship between heavy alcohol use and sleep problems among primary care patients.
What This Study Found While hazardous drinking and sleep problems were prevalent in this large cross-sectional national survey of primary care patients, researchers found no associations between drinking status and self-reported measures of insomnia, overall sleep quality, or restless legs syndrome symptoms. They did find, however, that self-reported use of alcohol for sleep was strongly associated with hazardous drinking.
Implications
- Physicians should consider asking about excessive alcohol use when patients report using alcohol for sleep.
Implications of Reassigning Patients for the Medical Home: A Case Study
Katie Coleman , and colleagues
Background As part of its pilot test of the patient centered medical home, the Group Health Cooperative reduced clinician panel size in order to strengthen the doctor-patient relationship. This required the reassignment of approximately one-quarter of the practice�s 8,000 patients to new clinicians. This study examined the effects of reassigning patients to new physicians.
What This Study Found Practice redesign initiatives aimed at improving the patient experience may have unanticipated consequences. In this study, researchers found that reassigned patients were less likely to use primary care services but equally likely to use expensive emergency department care as patients who were retained by their existing physicians. Even with the disruption, however, reassigned patients were no less satisfied with their care experience. Physicians in this demonstration project, when given the chance to retain patients in their panels, chose to retain � not drop � those patients who were older and sicker. Patients who were less connected with a physician were more likely to be reassigned.
Implications
- To ensure that practice redesign does not adversely affect relationships with younger, healthier patients, the researchers call for more to be done proactively to connect patients to their new physicians and practice teams after being reassigned.
Stephen M. Campbell , and colleagues
Background In the United Kingdom, major reforms in primary care policy and practice have been introduced in recent years, including financial incentives to improve clinical quality and provide more rapid access to care. This study set out to examine the impact of these changes on patients' experiences.
What This Study Found Although there was a modest improvement in access to care for patients with chronic illness, the changes had negative effects on continuity. Patients reported seeing their usual physician less often and gave lower ratings for care continuity and satisfaction. There were no significant changes in quality of care reported by patients before and after the introduction of the government Quality and Outcomes Framework program for communication, nursing care, coordination, and overall satisfaction. For patients with chronic disease, some aspects of urgent access improved significantly (ability to book an urgent appointment and the satisfaction with this experience); however, patients without a long-term condition did not experience this improvement. Patients in both groups reported seeing their usual physician less often and gave lower satisfaction ratings for continuity of care in 2007 compared with 2003.
Implications
- Efforts to increase access to primary care need to be balanced against the fundamental primary care principle of continuity.
- Current discussions of the patient-centered medical home in the United States should take into account that initiatives to enhance access to care may compromise continuity.
Vaccines Provided by Family Physicians
Doug Campos-Outcalt , and colleagues
Background This study documents the extent to which family physicians provide vaccinations, an important public health measure, as part of their routine services, as well as their participation in the publicly-funded Vaccines for Children (VFC) program.
What This Study Found Although many family medicine practices provide the most routinely recommended child, adolescent, and adult vaccines, smaller practices report difficulty offering a full array of vaccine products, instead referring patients outside the medical home. Eighty percent of respondents reported providing the most routinely recommended vaccines at their practice sites. A significant proportion, however, reported referring elsewhere for some vaccines (44% for children and adolescent vaccines and 54% for adult vaccines), with the most frequent referral location being a public health department. A higher proportion of solo and two-physician practices than larger practices reported referring patients. One-half of those who refer patients cited lack of adequate payment as the primary reason for referral outside the practice. One-half of respondents indicated they did not participate in the federally-funded VFC program, most often due to administrative requirements.
Implications
- Nonparticipation in VFC has implications for the family medicine practice's role as a medical home for children and adolescents.
- The authors suggest that, given the importance of family physicians in providing health care to children, especially in rural areas, the issue of VFC nonparticipation, the reasons for it, and how it affects other vaccine practices should be studied further.
Adolescent Primary Care Visit Patterns
James D. Nordin , and colleagues
Background The American Academy of Pediatrics and the American Medical Association recommend annual preventive services visits for all patients aged 11 to 21 years. Little is known, however, about how often adolescents actually visit a medical office or their reasons for visiting. This study set out to quantify the type and frequency of adolescent medical visits.
What This Study Found Less than 2 percent of those studied met the APA and AMA recommendations. One-third of teenagers with four or more years of continuous health plan enrollment had no preventive care visits from age 13 through 17 years, and another 40 percent had only one such visit, despite having insurance without a deductible or co-pay for preventive care. Nonpreventive care visits were more frequent in all age-groups, averaging about one per year at 11 years, climbing to about 1.5 per year at 17 years.
Implications
- Adolescent medical visits for nonpreventive care offer an opportunity to provide preventive care services. Systems should be set up to make that possible, even in busy practices with short clinician visits.
John Hickner , and colleagues
Background Event reporting, a safety improvement method in which workers report problems that may be solved by changing systems or policies, has been an effective tool in hospitals, but hasn't been tested in the primary care setting. This study evaluated an easy-to-use, Web-based office system for reporting medication errors (errors in prescribing, dispensing or using medications) and adverse drug events (injuries due to medication use).
What This Study Found A Web-based system for reporting medication errors and adverse drug events appears to be feasible in the medical office setting. There was little difficulty and minimal time demand on the part of study participants. During the course of the 10-week field test, participants identified errors nearly equally distributed throughout the medication management spectrum in four major categories: ordering, dispensing, receiving, and documenting. At least 43 percent of participants reported one or more medication event during the study period, a high participation rate for event reporting. The most frequent contributors to medication errors and adverse drug events were communication problems (41 percent) and knowledge deficits (22 percent). Many participants indicated the reporting process positively affected the safety culture of their practices by increasing awareness of medication errors and adverse drug events and prompting changes in office routines for managing medications; however, 36 percent of participants also felt the event reporting increased the fear of repercussion in the practice. Participants identified time pressure as the main barrier to reporting.
Implications
- It is feasible to deploy a Web-based medication event reporting system that clinicians and staff can understand and use in busy primary care practices.
- A culture of safety has not yet taken hold in all primary care practices; some study participants feared possible reprisal from reporting errors. This must change before event reporting can be a catalyst for improvement in ambulatory care.
Mich�le Aubin , and colleagues
Background Cancer patients often experience fragmented care, as they consult a variety of health professionals in multiple settings. This study of 395 patients with lung cancer in the province of Quebec, Canada, describes the expected and actual roles of family physicians during different phases of cancer care and follow-up.
What This Study Found Fewer than one-half of patients reported a high degree of family physician involvement in most aspects of cancer care throughout the cancer care trajectory. A majority of patients (more than 90 percent) identified the oncology team or oncologists as mainly responsible for their cancer care, except in the advanced/terminal phase, where a majority (70 percent) attributed this role to their family physician. Immediately following diagnosis, only 15 percent of patients perceived a shared care pattern between their family physician and oncologists, but this proportion increased with cancer progression. Most patients would have liked their family physician to be more involved in all aspects of cancer care.
Implications
- The authors call for better communication and collaboration between family physicians and the oncology team to facilitate shared care in cancer follow-up.
Guidelines for the Primary Care of Lesbian, Gay, and Bisexual People: A Systematic Review
Ruth P. McNair , and colleagues
Background This study reviewed existing research to determine whether current guidelines for the primary care of lesbian, gay, and bisexual (LGB) people meet appropriate standards of rigor in their development and provide consistently practical guidance for primary care clinicians.
What This Study Found A systematic review of studies in the United States, Canada, United Kingdom, Australia, Ireland, and New Zealand identified only 11 existing guidelines for the primary care of lesbian, gay, and bisexual people worthy of full appraisal. None of the guidelines met appropriate standards of quality and developmental rigor as measured by the Appraisal of Guidelines for Research and Evaluation instrument, and only two were specifically designed for primary care. Researchers did find, however, that currently available guidelines are philosophically and practically consistent and provide a degree of evidence-based clinical and systems support to primary care clinicians.
Implications
- The authors conclude that there is a need for evidence-based LGB guidelines that are more rigorously developed, disseminated, and evaluated specifically for the primary care setting.
Efficacy and Harms of the Hypoglycemic Agent Pramlintide in Diabetes Mellitus
Susan L. Norris , and colleagues
Background This study examined existing evidence about the efficacy, effectiveness, and harms of pramlintide, a new drug that complements insulin for maintaining glycemic and weight control in adults and children with type 1 or type 2 diabetes.
What This Study Found The study found that pramlintide was modestly effective. It improved glycated hemoglobin levels by 0.2 to 0.4 percent compared with placebo in both type 1 and type 2 diabetes populations, except when type 1 was managed with intensive insulin treatment, for which there was no significant difference between groups. Weight loss was observed with pramlintide in both type 1 and type 2 diabetes, whereas placebo-treated patients tended to gain weight. There was little evidence to suggest that pramlintide is significantly better than placebo at reducing fasting plasma glucose levels, postprandial glucose levels, or total insulin dose. Moreover, pramlintide-treated patients experienced more frequent nausea and severe hypoglycemia compared with patients treated with placebo.
Implications
- The authors conclude that although improvements in glycated hemoglobin levels were small, incremental improvements from the addition of pramlintide may ultimately contribute to long-term glycemic control and cardiovascular health when combined with other means of improving glycemic control.
- Further studies are needed to evaluate the long-term health outcomes and adverse events associated with pramlintide to determine whether the benefits outweigh risks.
Thomas Bodenheimer
Background A primary care physician reflects on how his experience with a chronic foot injury taught him important lessons about living with a chronic condition: people with chronic conditions may blame themselves, may feel guilty that other people have to help them, often have depression that may be worse than the chronic condition itself, and may lose confidence in their capacity to do anything useful in life. He concludes these feelings need to be elicited and addressed when physicians provide care to people with chronic conditions.
Learning Through Vulnerability: A Mentor-Mentee Experience
Kohar Jones , and colleagues
Background In an essay drawn from their work journals, a family medicine resident and visiting clinical mentor chronicle their experiences together in an Advanced Clinical Mentoring program that included direct observation and feedback sessions. The authors describe how they developed personally and professionally as they revealed thoughts and emotions during teaching interactions.
Snapshots of Haiti: A Physician�s Relief Work in a Country in Crisis
Robert C. McKersie
Background A family physician shares his experience as a relief worker after the January 2010 earthquake in Haiti. Reflecting on his week-long stay, including the physical and emotional toll, and the challenge of giving adequate and meaningful health care in a country that is broken, the author concludes that humans are able to accomplish immense good when we work together for a common purpose.