Index by author
The Issue in Brief
Mack T. Ruffin, IV , and colleagues
Background A new online tool helps primary care practices collect and use family history to help prevent disease. This study looks at whether patients who receive a risk assessment and messages tailored to their family health history of six diseases are more likely to change their lifestyle behaviors or get health screening, compared with patients who receive a generic preventive health message.
What This Study Found Using a Web-based tool to screen for family history and tailor prevention messages to family risk improves some health behaviors. Preventive messages tailored to family risk for coronary heart disease, stroke, diabetes, and colorectal, breast, and ovarian cancers modestly increases fruit and vegetable consumption and physical activity. Specifically, intervention participants were 3 percent more likely to increase daily fruit and vegetable consumption from 5 or fewer servings a day to 5 or more servings a day and 4 percent more likely to increase physical activity to five to six times a week for 30 minutes or more compared with patients receiving a generic preventive health message. The untailored (generic) message increased the percentage of patients getting a cholesterol screening.
Implications
- Familial risk may be an important motivator of health behavior change.
- Additional research is needed to determine how to effectively implement family history assessment in primary care.
Impact of Electronic Health Record Clinical Decision Support on Diabetes Care: A Randomized Trial
Patrick J. O'Connor , and colleagues
Background This study tests a diabetes decision support tool embedded in an electronic health record. The tool offers doctors drug-specific treatment suggestions based on the patient�s current treatment, clinical goals, other medical conditions, and kidney and liver functions.
What This Study Found Compared with patients in the control group, patients in the intervention group had significantly better hemoglobin A1c values, better maintenance of systolic blood pressure control, and borderline better maintenance of diastolic blood pressure control. Participating doctors were highly satisfied with the intervention, and many continued using the technology after the study ended.
Implications
- The authors conclude that, in the coming era of genomic medicine and personalized chronic disease care, clinical support decision strategies like the one tested in this trial, capable of simultaneously standardizing and personalizing clinical care, will become essential to effective primary care.
James M. Gill , and colleagues
Background Electronic health records (EHRs) with clinical decision support hold promise for improving quality of care, but their impact on management of chronic conditions has been mixed. This study examined the impact of EHR-based clinical decision support on adherence to guidelines for reducing gastrointestinal complications in primary care patients taking nonsteroidal anti-inflammatory drugs (NSAIDs).
What This Study Found Among 5,234 patients, the EHR intervention had a significant effect on discontinuing the traditional NSAID or co-prescribing a gastroprotective medication, but the absolute difference was only 3 percent, with just 25 percent of patients in the intervention group receiving guideline-concordant care. Analzying the impact of the intervention on the care of patients with different risk factors, researchers found a significant impact for only one subgroup of patients � those on low-dose aspirin. Even for this group, however, the impact was relatively small, with less than a 5 percent difference between intervention and control patients. For patients in other high-risk groups, the differences were not statistically significant.
Implications
- These findings add to the growing literature about the complexity of EHR-based clinical decision support for improving quality of care.
- EHRs, even when coupled with robust clinical decision support, might not result in large improvements in quality of care. To fulfill the promise of improving quality of care, EHRs must be implemented in a manner that fits into the clinical work flow of primary care offices.
Eit Frits van der Velde , and colleagues
Background The Wells clinical prediction rule for assessment of patients with suspected deep vein thrombosis is widely used, especially in secondary care settings. Recently, a new clinical decision rule for primary care patients has been proposed. This study compares the two rules on their ability to safely rule out a diagnosis of deep vein thrombosis among primary care patients and reduce the number of referrals for negative findings on leg ultrasound tests.
What This Study Found Both clinical decision rules, when used in combination with a point-of-care D-dimer blood test, are effective and can spare almost half of patients an unnecessary referral for ultrasound. This study of 1,002 patients with possible deep vein thrombosis found a venous thromboembolic event occurred during follow-up in 7 patients with a low score and a negative blood test, both with the Wells rule and primary care rule. Direct medical costs per patient were about the same using both rules. Using the Wells rule, 447 patients (45 percent) would not need referral for further testing compared with 495 (49 percent) when using the primary care rule.
Implications
- The authors suggest that the primary care rule, which prevents slightly more unnecessary ultrasound procedures than the Wells rule, is somewhat more convenient for both patients and physicians.
M. Diane McKee , and colleagues
Background Adolescents with privacy concerns are less likely to talk openly with a clinician about important health issues. Many youth, however, do not have time alone with clinicians during medical visits. This study explores clinicians� perspectives on delivering confidential services to adolescent patients.
What This Study Found Interviews with 18 primary care clinicians in urban health centers elicited clinician perspectives on the challenges of providing confidential services to adolescents. Despite competing time demands, clinicians reported a commitment to offering time alone during preventive visits, and to infrequently offering time alone during other types of visits depending on the chief complaint and parent-child dynamics. Clinicians cited time constraints as a major barrier to offering time alone more frequently, and they perceived parents were receptive to time alone. Many clinicians noted feeling conflicted about providing confidential services to adolescents with serious health threats and regard their role as facilitating adolescent-parent communication to optimize health outcomes.
Implications
- The authors call for the development of office systems to enhance the consistency of the delivery of confidential services to adolescents.
Comparison Between US Preventive Services Task Force Recommendations and Medicare Coverage
Lenard I. Lesser , and colleagues
Background A 2008 law allows Medicare to pay for medical services rated A or B by the US Preventives Services Task Force (USPSTF), a government-authorized and -sponsored independent panel of experts in primary care and prevention. This study compares preventive medical services offered by Medicare with those recommended by the USPSTF.
What This Study Found Of the 15 USPSTF recommended interventions for adults aged 65 years and older, Medicare reimburses fully for only 1 service. For most preventive services (60 percent), Medicare reimburses fully for the service or test, but only partially for the coordination of obtaining that service. For 4 services (27 percent), Medicare reimburses clinicians partially for both the preventive coordination and the actual service. For 1 service, Medicare reimburses fully for the coordination and assessment but not for the test/service itself. Further, instead of providing payment to clinicians for recommended preventive services, Medicare pays clinicians to provide 7 services that are not recommended, potentially increasing harm to patients as well as medical costs.
Implications
- Medicare coverage for preventive services needs to be reassessed, with special focus on preventive coordination.
- Current Medicare coverage will likely promote both inadequate and excessive delivery of preventive services. The new health care reform law, however, has the potential to improve the provision of preventive services to Medicare beneficiaries.
- The authors call for Medicare to align itself with the USPSTF recommendations and usher in an era of improved quality of care through effective prevention.
Knowledge and Use of Ethnomedical Treatments for Asthma Among Puerto Ricans in an Urban Community
Luis E. Zayas , and colleagues
Background Many Hispanics use or are aware of ethnomedical therapies (treatments based on cultural beliefs and practices). This study examined the use of ethnomedicine among Puerto Ricans with asthma living in the United States.
What This Study Found Based on interviews with 30 Puerto Rican Americans, researchers developed a typology of asthma remedies rooted in patients� cultural beliefs and practices. The remedies identified during the interviews were predominantly behavioral strategies rather than ingested or topical therapies. Moreover, patients reported greater use and perceived efficacy of the behavioral strategies, which included lifestyle changes, air exposure, mind/body exercises, and religious or spiritual practices.
Implications
- The authors conclude that clinicians should ask Puerto Rican patients about their use of ethnomedical therapies for asthma to better understand their health beliefs and try to integrate these therapies into patients� treatment plans.
Methods to Achieve High Interrater Reliability in Data Collection From Primary Care Medical Records
Clare Liddy , and colleagues
Background Patient chart audits are often the only way to collect required data for research. There is little guidance, however, about methods to assess inter-rater reliability, the degree of agreement when a measurement is repeated under identical conditions by different raters. This study describes a 4-part data collection quality monitoring procedure and the process to measure data inter-rater reliability.
What This Study Found The 4-part data quality monitoring procedure included standardized protocols and forms, extensive training, continuous monitoring of inter-rater reliability, and a quality improvement feedback mechanism. There was excellent agreement between chart abstractors in this study, and no charts needed to be reabstracted, thus supporting the effectiveness of this training and data collection approach.
Implications
- These findings offer a guide and benchmark for other medical chart review studies in primary care.
Card Studies For Observational Research in Practice
John M. Westfall , and colleagues
Background The card study is a method for gathering data about primary care clinicians, patients, and their care. It is a type of brief survey completed by clinicians as they see patients. This article describes the research questions a card study can address, types of card studies, resources required, issues of human subjects protection and implementation, and future considerations for card study research.
What This Study Found Card studies can be designed to study specific conditions or care (clinicians complete a card when they encounter patients who meet inclusion criteria) and to determine trends and prevalence of conditions (clinicians complete a card on all patients seen during a period). Data can be collected from both clinicians and patients and linked.
Implications
- Card studies remain a robust research tool for primary care practice-based research networks because they are inexpensive, flexible, standardized, customizable, and easy to develop and use.
A Systematic Review of Clinical Decision Rules for the Diagnosis of Influenza
Mark H. Ebell , and colleagues
Background Clinical decision rules to accurately identify patients at low, moderate, or high risk of influenza could help doctors determine appropriate treatment and avoid unnecessary tests. The goal of this analysis of previous research is to identify and evaluate the accuracy and validity of existing clinical decision rules for the diagnosis of influenza.
What This Study Found This systematic review of 12 articles regarding clinical decision rules for the diagnosis of influenza found that, although influenza is a common cause of illness and death, studies about diagnosing this infection are largely small, use varied inclusion criteria and reference standards, and do not report their results in a way that would be helpful to clinicians. No study prospectively evaluated a clinical score or multivariate model for diagnosing influenza. Rather, the studies validated only simple clinical heuristics, such as �fever and cough� and �fever, cough, and acute onset,� and even then, the sensitivity and specificity varied considerably, and it was not possible to calculate summary measures of accuracy for these rules.
Implications
- Future research is needed to validate multivariate models for the diagnosis of influenza, as well as point scores that are easier for clinicians to use at the point of care.
Health Care Reform and Equity: Promise, Pitfalls, and Prescriptions
Kevin Fiscella
Background The United States has made little progress toward greater equity in health care quality. This essay describes the potential promise, pitfalls, and prescriptions in recent health care reforms that could jump-start progress toward more equitable health care.
What This Study Found Recent reforms, particularly the Patient Protection and Affordable Care Act of 2010, offer a historic opportunity to make inroads in addressing health care disparities. Six key health care reform provisions are relevant to promoting equity: improved access, strengthening primary care, enhanced information technology, new payment models, a national quality strategy, and improved disparity monitoring.
Implications
- Health care reforms offer an unprecedented opportunity to create a more equitable, patient-responsive health care system.
- The creations of a more equitable and responsive health system will require effective implementation, improved alignment of resources with patient needs, and most importantly, revitalization of primary care. It may also depend in part on the ability of primary care clinicians to seize these opportunities and champion systems of care responsive to the needs of all patients.