Index by author
The Issue in Brief
January/February 2013
How Long Does a Cough Last? Comparing Patients' Expectations With Data From a Systematic Review of the Literature
Mark H. Ebell, and colleagues
Background Acute cough illness is one of the most common reasons patients seek primary care treatment. Although it is usually caused by viruses and resolves itself without treatment, many patients seek care and request antibiotics. This study examines whether there is a mismatch between patient expectations of the duration of acute cough and the natural history of the condition. Such a mismatch could help explain why patients believe antibiotics are effective for this condition.
What This Study Found There is a large mismatch between patients' expectations of the duration of an acute cough and the actual duration. This study finds that the average duration of a cough is 17.8 days. In contrast, nearly 500 adults surveyed expect a cough to last an average of 7 to 9 days. If patients seek antibiotics after 5 to 6 days, and begin taking an antibiotic 7 days after the onset of symptoms, they may begin to feel better 3 or 4 days later, with the episode fully resolving 10 days later. Although this reflects the natural history of cough, it can reinforce the mistaken idea that the antibiotic worked. Those expecting a longer illness are more likely to be white and female and have self-reported asthma or lung disease. Those who believe antibiotics are always helpful for cough are more likely to be nonwhite, report some college education or less, and have previously taken antibiotics for acute cough.
Implications
- By emphasizing to patients the natural history and actual duration of acute cough, doctors can help prevent unnecessary antibiotic prescribing.
The Rise of Electronic Health Record Adoption Among Family Physicians
Imam M. Xierali, and colleagues
Background Electronic health records (EHRs) are generally expected to improve the quality of health care, lower health care costs, and provide patients with more involvement in their own health care. Achieving these benefits, however, depends on clinicians' use of the technology. This study estimates uptake of EHRs by US family physicians and other outpatient doctors, and looks at EHR adoption by state.
What This Study Found Adoption of electronic health records by family physicians has doubled since 2005, reaching 68 percent nationally in 2011. Family physicians are adopting electronic health records at a higher rate than other office-based physicians and are likely to exceed 80 percent penetration by 2013 if the current trend continues. State-level analysis, however, indicates significant variation in EHR adoption, from a low of 44 percent in North Carolina to a high of 88 percent in Hawaii, according to 1 of 2 data sets, and a low of 47 percent in North Dakota and a high of 95 percent in Utah, according to another. These findings point to important geographical gaps that may result from significant variation in states' commitment to adopting health information technology. States with higher EHR adoption among family physicians generally have higher EHR adoption for other office-based physicians, consistent with a state-level effect.
Implications
- The authors call for further research and policy making to address the significant variability between states.
Vascular Outcomes in Patients With Screen-Detected or Clinically Diagnosed Type 2 Diabetes: Diabscreen Study Follow-up
Erwin P. Klein Woolthuis, and colleagues
Background Does treatment of patients with type 2 diabetes detected through screening result in lower vascular event rates when compared with treatment of patients diagnosed by clinical symptoms? This study compares outcomes in family medicine patients with type 2 diabetes diagnosed through these 2 different methods.
What This Study Found Regardless of how type 2 diabetes is diagnosed --whether through clinical diagnosis based on signs and symptoms (eg, excessive thirst and/or urination, fatigue, infections, blurred vision) or using opportunistic targeted screening of high-risk patients (eg, family history of diabetes, history of cardiovascular disease, obesity, hypertension, high cholesterol) --the rate of iillness and death from cardiovascular disease over a 7-year period does not differ significantly. Among 565 patients with newly diagnosed type 2 diabetes, composite primary event rates during follow-up did not differ between the opportunistic targeted screening and clinical diagnosis groups. There are also no significant differences in the separate events rates of deaths from cardiovascular disease, nonfatal heart attacks, and nonfatal strokes.
Implications
- The authors call for future research to investigate the findings in a larger setting and with longer follow-up.
Intervention to Enhance Communication About Newly Prescribed Medications
Derjung M. Tarn, and colleagues
Background This study tests a program to improve doctor-patient communication about newly prescribed medications. In particular, the study looks at 5 elements of communication about medications (discussion of medication name, purpose, directions for use, duration of use, and side effects), as well as patients' ratings of communication about new prescriptions.
What This Study Found A program to improve patient education and counseling about new medications by targeting physician communication appears to be effective. On average, doctors who participate in the program address more than 1 of 5 additional elements of basic information compared with control group physicians; they also have more discussions than control group doctors about all 5 major elements emphasized by the intervention. Furthermore, the intervention result in patients reporting better communication about medication information.
Implications
- When doctors introduce a new medication, it sets the stage for whether and how patients will initiate use of the medication. The authors call for future research testing the clinical impact of the intervention.
Life Disruptions for Midlife and Older Adults With High Out-of-Pocket Health Expenditures
David Grande, and colleagues
Background American families are spending a growing amount of their personal income on health, leading them to make financial trade-offs. Little is known about the choices families make and how they make them. This study investigates the social, medical, financial, and sometimes legal disruptions from high out-of-pocket health expenses, referred to here as "life disruptions."
What This Study Found Among 33 insured patients seeking philanthropic financial assistance, all of whom face major chronic illnesses and most of whom are covered by Medicare, there is considerable anxiety, major debt problems, and disruptions of medical care because of high levels of cost sharing. Participants describe various borrowing strategies (such as credit cards), legal problems (such as debt collections), and threats to their household budgets (such as food and housing). Although participants understand their health benefits, they describe considerable anxiety about changes to those benefits that could easily disrupt carefully managed household budgets. Specifically, benefits that have large variation in financial liability from month to month (such as large deductibles or coverage gaps) impose considerable financial challenges.
Implications
- The authors urge policy makers to consider the consequences of high cost sharing for families facing strained household budgets. Continuity of benefits and month-to-month stability of financial liability are important considerations that may be undervalued in policy discussions.
Clinicians' Implicit Ethnic/Racial Bias and Perceptions of Care Among Black and Latino Patients
Irene V. Blair, and colleagues
Background Bias can be explicit or implicit. Explicit bias is overt and freely expressed; implicit bias may not be consciously acknowledged and operates in more subtle ways. Clinicians are unlikely to directly express ethnic/racial bias yet may still deliver care that is influenced by unrecognized bias. In this study, patients evaluate the degree to which their clinicians are patient-centered during their interactions. Researchers then examine those evaluations in terms of patients' ethnicity/race and the clinicians' implicit and explicit ethnic or racial bias.
What This Study Found Clinicians with higher levels of implicit ethnic or racial bias are rated less favorably by black patients than are clinicians with lower levels of implicit bias. Surveys of nearly 3,000 patients found black patients rated clinicians who had greater implicit bias against blacks lower in patient-centered care than they did clinicians with little or no such implicit bias. Latino patients' ratings were not correlated to clinicians' implicit bias, though they tended to give clinicians lower ratings overall than did other groups.
Implications
- Clinicians' implicit bias may jeopardize their clinical relationships with black patients, which could have negative effects on other care processes, including adherence to medical advice.
- The authors conclude these findings support the Institute of Medicine's suggestion that clinician bias may contribute to health disparities. They note that implicit bias is malleable, and they encourage interventions that may help render bias less implicit and unconscious, thereby fostering real reflection, analysis, and change.
Clinician Suspicion of an Alcohol Problem: An Observational Study From the AAFP National Research Network
Daniel C. Vinson, and colleagues
Background In clinical practice, detection of alcohol problems often relies on clinicians' suspicion instead of use of a screening instrument. This study assesses the sensitivity, specificity, and predictive values of clinician suspicion compared with screen-detected alcohol problems.
What This Study Found In this study, primary care clinicians missed most (more than 70 percent) of patients with an alcohol problem when they relied on clinical suspicion instead of using a screening instrument. In a sample of 1,699 patients, 171 patients (10 percent) screened positive for hazardous drinking and 64 patients (4 percent) screened positive for harmful drinking using validated screening instruments. Clinicians suspected either hazardous or harmful drinking in only 81 of those patients (5 percent). Conversely, when clinicians suspected a patient had an alcohol problem, they were correct 98 percent of the time.
Implications
- These findings, the authors conclude, support the routine use of a screening tool to supplement clinicians' suspicions about alcohol problems.
Clinical Intuition in Family Medicine: More Than First Impressions
Olga Kostopoulou, and colleagues
Background Clinical intuition is sometimes viewed as the mark of an expert and other times as mere guesswork. This study examines intuition as experienced by physicians and identifies the cognitive processes active in medical decision making.
What This Study Found Although the medical literature discusses clinical intuition as first impressions or the first thing that comes to a physician's mind, this is only a part of what most family physicians understand by the term "intuition." Based on in-depth interviews with 18 family physicians analyzing 24 different patient cases in which the physicians believed they experienced an intuition, 3 types of decision processes emerged: gut feelings, recognitions, and insights. In all cases examined, participants experienced conflict between their intuition and a decision they perceived to be more rational or between their intuition and their expectations about what other physicians would do.
Implications
- The outcomes of clinical intuition can be negative or positive.
- The authors suggest that, until we know more about the circumstances under which intuitive processes produce accurate judgments, physicians should not be directed to avoid intuition.
Primary Care Physicians' Use of an Informed Decision-Making Process for Prostate Cancer Screening
Robert J. Volk, and colleagues
Background Although most primary care physicians screen for prostate cancer, little is known about their use of advance discussions of the risks and benefits of screening, a key component of an informed decision-making process. This study examines the use of prescreening discussions about the potential benefits and harms of prostate cancer screening and explores the role of physicians' beliefs about the efficacy of prostate cancer screening.
What This Study Found There is considerable variability in primary care physicians' approaches to engaging patients in advance discussions about prostate cancer screening. Much of the variability in styles can be attributed to physicians' personal beliefs about prostate cancer screening, some of which may be amenable to change. Compared with physicians who order screening without discussion (24 percent), physicians who discuss harms and benefits with patients and then let them decide (48 percent) are more likely to believe that scientific evidence does not support screening, that patients should be told about the lack of evidence, and that patients have a right to know the limitations of screening. They are also less likely to endorse the belief that there is no need to educate patients because they want to be screened. In this study, physicians who discussed the harms and benefits and recommended the test more often expressed concerns about the legal risk associated with not screening compared with physicians who discuss and let the patient decide.
Implications
- The authors call for the use of patient decision aids and efforts to educate physicians about the shared decision-making process, including countering the false beliefs that perpetuate routine screening.
Physician Assistants in Primary Care: Trends and Characteristics
Bettie Coplan, and colleagues
Background There has been a recent decline in the percentage of physician assistants (PAs) choosing careers in primary care. This study examines the demographics associated with an increased likelihood of primary care practice among PAs in hopes that such knowledge may aid efforts to increase that number.
What This Study Found The demographic characteristics associated with an increased likelihood of primary care practice are similar to those of medical students who choose primary care specialties. Specifically, female, Hispanic, and older PAs are more likely to work in primary care practice.
Implications
- Workforce policy measures aimed at increasing the number of primary care physicians, such as loan repayment, improved levels of reimbursement for primary care physicians, and expansion of Title VII Section 747 of the Public Health Service Act, might also successfully increase the percentage of primary care PAs.
Enhancing the Primary Care Team to Provide Redesigned Care: The Roles of Practice Facilitators and Care Managers
Erin Fries Taylor, and colleagues
Background Policy makers are focusing on redesigning primary care in the United States to achieve better patient experience, improved health, and reduced costs. This report examines the distinct and complementary roles of 2 potential members of the primary care team in redesign and practice improvement processes: practice facilitators, also known as practice coaches or quality improvement coaches, and care managers.
What This Study Found Practice facilitators play a vital systems-level role in coordinating practice quality improvement and redesign efforts, helping build capacity for activities that improve quality and safety and the implementation of evidence-based practices. Care managers, on the other hand, do the critical work of coordinating patient care and helping patients navigate the system, improving access and communicating across the care team.
Implications
- These 2 members of the primary care team work in a complementary fashion to help primary care practices deliver coordinated, accessible, comprehensive, and patient-centered care.