Table of Contents
The Issue in Brief
National Evidence on the Use of Shared Decision Making in Prostate-Specific Antigen Screening
Paul K. J Han , and colleagues
Background The prostate-specific antigen (PSA) test, which screens for prostate cancer, has limited accuracy, and there is conflicting evidence for its effectiveness in reducing mortality. Because of the nature of prostate cancer, PSA screening can lead to overdiagnosis and unnecessary evaluation and treatment. Professional organizations therefore recommend that clinicians inform patients about the pros, cons, and uncertainties of PSA screening, and that screening decisions be based on patient preferences. This study examines the prevalence of shared decision making in both PSA screening and nonscreening, as well as patient characteristics associated with shared decision making.
What This Study Found Most US men report little shared decision making in PSA screening, and the absence of shared decision making is more prevalent in men who are not screened. Nearly two-thirds of men report no past physician-patient discussion of advantages, disadvantages, or scientific uncertainty of PSA screening (no shared decision making); 28 percent report discussion of 1 to 2 elements (partial shared decision making); and 8 percent report discussion of 3 elements (full shared decision making). Forty-four percent of participants report no PSA screening, 28 percent report less than annual screening, and 25 percent report nearly annual screening. The extent of shared decision making is associated with black race, Hispanic ethnicity, higher education, health insurance, and physician recommendation. Screening intensity is associated with older age, higher education, usual source of medical care, and physician recommendation, as well as with partial shared decision making.
Implications
- These findings, the authors assert, justify a broader policy debate about PSA screening. Much of the debate has focused on the absence of shared decision making in PSA screening and the potential harm of undesired and unnecessary treatment. This study suggests the more prevalent problem is the absence of shared decision making in nonscreening--the harm of which is the failure to allow individuals to decide for themselves whether screening is beneficial.
Bo Feng , and colleagues
Background This study is part of a randomized controlled trial to educate physicians using an interactive Web-based module on prostate cancer screening. The current analysis explores how physicians approach discussions of risk and uncertainty around prostate cancer screening.
What This Study Found A Web-based educational intervention appears to improve shared decision making, encourage neutrality in recommendations, and reduce prostate-specific antigen (PSA) test ordering. Based on visits with 118 participating primary care physicians in which trained actors (standardized patients) prompt physicians to address prostate cancer screening, intervention physicians show more shared decision making behaviors and were more likely to mention the option of no screening, to encourage patients to consider different screening options, and to seek input from others.
Implications
- The authors suggest that interventions such as this may help influence physicians' behaviors in addressing controversial medical topics with public health implications and help decrease utilization of tests with uncertain value.
Michael S. Wilkes , and colleagues
Background Because of controversies surrouding prostate cancer screening, most expert groups recommend shared decision making between patient and doctor. This study tests whether educating primary care physicians and "activating" their patients has a synergistic effect on (1) perceived shared decision making, (2) rates of prostate cancer screening discussion, and (3) final physician prostate cancer screening recommendations.
What This Study Found Pairing a brief 20- to 30-minute Web-based educational intervention for physicians with a companion intervention for patients about counseling for prostate cancer screening appears to improve shared decision making rates and influence physicians' attitudes about screening. Prostate cancer screening discussion rates are higher among patients who receive the combination of physician education and patient activation compared with physician education alone or usual education. Standardized patients (actors trained to simulate real patient cases and later report on the encounter) also report that physicians seeing patients who receive the combined intervention are more likely to be neutral in their final recommendations about whether the patient should obtain a prostate-specific antigen blood test This shift in physicians' attitudes from a pro-screening bias to neutral counseling persists 3 months after the intervention. There is no difference in patients' ratings of shared decision making between the groups.
Implications
- Coupling physician education with patient activation, the authors conclude, has the potential to encourage shared decision making around issues of medical uncertainty, such as prostate cancer screening, and improve the appropriate utilization of medical services.
Allen J. Dietrich , and colleagues
Background Health plans are uniquely positioned to deliver outreach to their members. This study explores whether telephone outreach delivered by Medicaid managed care organization staff can increase colorectal cancer screening (CRC) among publicly insured urban women.
What This Study Found A previously proven telephone outreach intervention delivered by research-based staff to increase CRC screening can be successfully translated to the health plan arena. In this study, staff of a Medicaid managed care organization increases CRC screening rates by one-third to nearly double among publicly insured urban women. The study, involving 2,240 women overdue for screening and insured by 1 of 3 New York City Medicaid managed care organizations, finds intervention women are significantly more likely than usual care women to become up-to-date on CRC screening. Increases vary from 1 percent to 14 percent across participating organizations, with the overall increase driven by increases at one particular Medicaid managed care organization.
Implications
- Medicaid managed care organizations, key players in the delivery of health care to publicly insured and underserved populations, can successfully implement interventions to increase CRC screening, reducing health care disparities among a difficult to reach population.
Steven M. Ornstein , and colleagues
Background Delivery of recommended preventive health services is an important for public health, but it is unclear whether patients with chronic illnesses are more or less likely to receive such services. This study explores the issue in a large national practice-based research network.
What This Study Found Among 667,379 adult patients from 148 primary care practices across the United States, there are strong positive associations between receiving clinical preventive services and the presence of chronic illnesses. The associations persist regardless of the number of chronic illnesses.
Implications
- These findings are in contrast to commonly expressed concerns that increasing patient complexity impedes the delivery of preventive services because of competing demands.
- The authors suggest that primary care practices, using tools like electronic health records, can overcome competing demands and effectively deliver preventive services to the growing number of patients with multiple chronic illnesses.
Care From Family Physicians Reported by Pregnant Women in the United States
Patricia Fontaine , and colleagues
Background Women receive medical care from many types of clinicians during pregnancy, including family physicians, obstetrician-gynecologists, midwives, other specialists, and midlevel clinicians. It is not known, however, how many pregnant women have family doctors. This analysis of nationally representative data from 2000 to 2009 describes the proportion of family physicians providing medical care of any sort to pregnant women in the United States and examines trends over time and by geographic region.
What This Study Found Approximately one-third of pregnant women report having seen or talked to a family physician for medical care during the prior year, a percentage that has remained stable over the past decade. A substantial and steady proportion of pregnant women (36 percent) receive some care from family physicians, with most reporting receiving care from multiple types of clinicians, including family physicians, obstetrician-gynecologists, midwives, nurse practitioners, and physician assistants. There are regional differences in trends in family physician care, with pregnant women in the North Central United States increasingly reporting care from family physicians and women in the South reporting a decline.
Implications
- Because most pregnant women report care from multiple clinicians, care coordination is important for this patient population.
Impact of Individual and Team Features on Patient Safety Climate: A Survey in Family Practices
Barbara Hoffmann , and colleagues
Background This analysis of more than 2,100 questionnaires evaluates the impact of different individual and practice features on perceptions of the safety climate--shared employee perceptions of the priority of safety at an organization--in German primary care practices.
What This Study Found Though the family practice safety culture is positive overall, health care professionals' use of incident reporting and a systems approach to errors is fairly rare. The safety climate as perceived by doctors and health care assistants is not significantly influenced by individual and practice team characteristics. Participation of the whole practice team in the survey has a positive influence on safety climate, and doctors have more positive perceptions of 4 of the 7 climate factors evaluated than health care assistants.
Implications
- The authors call for German primary care doctors and health care assistants to learn more about the causes of errors and adopt a systems approach to patient safety incidents in order to learn from past errors.
Tobias Freund , and colleagues
Background Reducing avoidable hospitalizations lowers health care spending and improves both quality of care and quality of life. Hospitalizations for conditions that can typically be managed effectively on an outpatient basis (ambulatory care - sensitive hospitalizations) are potentially avoidable by optimal primary care. This study examines how primary care physicians rate these hospitalizations and whether and how they can be avoided.
What This Study Found Primary care physicians consider most ambulatory care - sensitive hospitalizations potentially avoidable, attributing the causes to 5 possible categories: system-related causes (eg, unavailable outpatient services), physician-related causes (eg, suboptimal monitoring), medical causes (eg, medication side effects), patient-related causes (eg, delayed help seeking) and social causes (eg, lack of social support). System-related causes aare attributed to 30 hospitalizations (29 percent), physician-related causes to 32 (31 percent), medical causes to 101 (97 percent), patient-related causes to 83 (80 percent), and social causes to 20 (19 percent).
Implications
- Strategies to avoid such hospitalizations include after-hours care, optimal use of outpatient services, intensified monitoring of high-risk patients, and initiatives to improve patients' willingness and ability to seek timely help as well as patients' medication adherence.
Wilson D. Pace , and colleagues
Background Americans In Motion--Healthy Interventions (AIM-HI) promotes healthy lifestyle choices related to nutrition, physical activity, and emotional well-being. This study compares patient-level outcomes between family medicine practices using 2 different methods to implement the AIM-HI tools.
What This Study Found There were impressive before and after improvements in patient outcomes but no differences between 2 different approaches to implementing AIM-HI. Pratices used either an enhanced practice approach (used AIM-HI tools to help office staff make personal changes and create a healthy practice environment) or a traditional practice approach (were trained and asked to use the tools directly with patients). There were no significant differences in patient-outcomes between the 2 groups. Regardless of practice group, 16 percent of patients who completed a 10-month visit (378 patients) and 10 percent of all patients enrolled lost 5 percent or more of their body weight. Of the patients who completed a 10-month visit, 17 percent had a 2-point or greater increase in their fitness level and 29 percent lost 5 percent or more of their body weight and/or increased their fitness level by 2 or more points.
Implications
- The lack of difference between the 2 groups may be due to study design, patient selection, the nonprescriptive approach of AIM-HI, and already established physician workplace wellness activities that motivated clinicians to intervene with patients.
Women in Medicine and the Ticking Clock
Lisa N. Miura , and colleagues
What This Study Found In this essay, 2 female physicians reflect on the consequences of postponing motherhood in the pursuit of successful medical careers. They share their personal stories of difficulty conceiving, miscarriages, and stillbirth, reflecting on how their intense career focus led them to gamble away their fertility. Because delayed childbearing can result in unintended childlessness, the need for assisted reproductive techniques, adoption, and having smaller than desired family size, the authors call for training programs and employers to provide more information and support to women in medicine and adopt policies that are consistent with today�s trainees' and physicians' complex lives. They caution men and women in medicine to carefully consider how medical school, residencies, and fellowships can impinge on family planning.