Table of Contents
The Issue in Brief
W. Perry Dickinson , and colleagues
Background Many practice redesign efforts focus on implementing the Chronic Care Model, which summarizes basic elements for improving care in health systems at the community, organization, practice and patient levels. The current study compares the effectiveness of three different Chronic Care Model-based approaches to improve diabetes care in primary care. The three approaches are 1) Continuous Quality Improvement (CQI) in which practices follow a strategy of implementing registries to have diabetes quality measures motivate practice action, identify needed changes, and monitor progress; 2) Reflective Adaptive Process (RAP) in which practices follow a more practice-determined approach for improving practice culture; and 3) Self-Directed (SD) in which practices are given information and resources about the Chronic Care Model and quality improvement but without the assistance of a facilitator.
What This Study Found All methods resulted in significant improvement in diabetes care measures, but there were differences in the extent and duration of improvement and trade-offs in work culture change. Although measures of the quality of diabetes care improved in all three groups, improvement was greater in CQI practices compared with both SD and RAP practices, and greater in SD practices compared with RAP practices. In RAP practices, change culture scores showed a trend toward improvement at nine months, but decreased below baseline at 18 months, and work culture scores decreased from nine to 18 months. Both scores were stable over time in SD and CQI practices.
Implications
- Traditional CQI interventions are effective at improving measures of the quality of diabetes care, but may not improve practice culture.
- Short-term practice facilitation based on RAP principles appears to be less effective at improving quality measures and does not produce sustained improvements in practice culture.
- Recognizing that not all primary care practices need the same type, intensity, or duration of assistance, the authors call for practices to tailor the approach to their practice. They also call for the development and testing of new models that can produce the long-term improvements in both quality measures and practice cultures necessary for sustained care enhancement.
Lars E. Peterson , and colleagues
Background This study examines nearly 8,000 diabetes quality improvement projects. The projects were conducted by family physicians across the United States who completed a Performance in Practice module to meet recertification requirements of the American Board of Family Medicine.
What This Study Found Nearly all projects were associated with significant and meaningful improvements in diabetes care. Successful completion of the module required quality measure abstraction from 10 patient charts before and after an improvement effort. Almost one-half of participating physicians selected diabetic foot examination or eye examination as their quality improvement measure. Other quality measures included testing for microabluminauria, checking hemoglobin A1C or lipid levels, assessing blood pressure control, and counseling for smoking cessation. Analysis showed all quality measures improved after the intervention, except measuring LDL cholesterol. In particular, foot examination documententation increased from 68 percent to 86 percent, and retina examination documentation increased from 56 percent to 71 percent. The most common interventions were standing orders and patient education.
Implications
- These findings, the authors assert, add to the evidence base for integration of quality improvement into practice.
Targeted Melanoma Prevention Intervention: A Cluster Randomized Controlled Trial
Cedric Rat , and colleagues
Background Giving patients personalized information about whether or not they are at increased risk for melanoma could affect their perception of the risk. The Self-Assessment Melanoma Risk Score (SAMScore) provides such information. This study compares the effect of a targeted screening and education strategy using the SAMScore on patient prevention behavior with that of a conventional prevention campaign based on mass communication.
What This Study Found A targeted intervention to reduce risk and increase early detection of melanoma using the SAMSScore screening tool appears to be efficient and effective. Patients were randomized to either an intervention group, which was assessed using the SAMScore tool and underwent a total skin examination and counseling using information leaflets; or a control group, whose physicians displayed a poster and leaflets in their waiting room and examined patients' skin at their own discretion. Compared with control patients, intervention patients were more likely to remember the campaign and correctly identify their increased risk of melanoma. Intervention patients also had higher levels of prevention behaviors: they were less likely to sunbathe in summer and more likely to have performed skin self-examinations in the past year.
Implications
- The combination use of the SAMScore and physician examination and counseling during consultations appears to be an efficient way to promote patient behaviors that may reduce melanoma risk.
Managing Expectations of Antibiotics for Upper Respiratory Tract Infections: A Qualitative Study
Mohammed Mustafa , and colleagues
Background A number of studies have looked at doctor visits in which antibiotics are expected by patients or parents but may not be indicated by the clinical findings. There have been few efforts, however, to ask family physicians about the ways in which they handle expectations for antibiotics. This study explores how and why family physicians elicit and address patient or parents' expectations for antibiotics in visits for upper respiratory tract infections.
What This Study Found Family physicians prefer not to explore patient expectations for antibiotics in a direct manner or early on in visits for upper respiratory tract infections, contrary to the advice of many communications experts. Clinicians prefer more indirect methods to explore treatment expectations in an effort to avoid conflict and potential threats to the ongoing physician-patient relationship and trust. They report using open questions and building a foundation for nonantibiotic management by using strategies to indicate their reasoning and influence expectations, including running commentary on physical examination findings.
Implications
- The authors suggest that interventions to promote appropriate antibiotic prescribing include a focus on training in communication skills that integrates indirect methods as a part of building collaborative physician-patient relationships and uses the running commentary of examination findings to facilitate participation in clinical decisions.
Strategies for Achieving Whole-Practice Engagement and Buy-in to the Patient-Centered Medical Home
William K. Bleser , and colleagues
Background The Patient-Centered Medical Home (PCMH) shows promise in strengthening quality of care, but often requires organizational change. This study aims to understand and illustrate how practices achieve staff "buy-in" to (belief in) and engagement in the PCMH transformation process.
What This Study Found This study identifies 13 distinct strategies for obtaining organizational buy-in and whole-staff engagement in PCMH transformation and practice improvement efforts. The strategies cluster into three areas that facilitate practice buy-in: effective internal communication, effective resource utilization, and creation of a team environment.
Implications
- These strategies can be particularly useful for facilitating PCMH transformation in primary care.
Measuring Capability for Healthy Diet and Physical Activity
Robert L. Ferrer , and colleagues
Background Unhealthy diet and lack of physical activity contribute to illness and death. Success in promoting healthy behaviors is limited, however, if social and environmental contexts are not accounted for. This study was part of the development of a measure of practical opportunities for healthy behavior. To understand the individual support needed to create opportunities for healthy behavior, the study assesses how personal circumstances interact with resources in the environment.
What This Study Found There is a wide range of opportunity for healthy behavior, driven by variations in neighborhood environments, physical and mental health status, family composition, family and peer support, and personal autonomy. Availability, convenience, safety, and cost of food and activity resources interact with individual circumstances such as illness, depression, family and non-family supports, and scope of personal agency to shape practical opportunities.
Implications
- Practical opportunities for healthy behavior can be measured as a primary target for clinical and public health assessment and intervention. Developing interventions responsive to both personal and environmental determinants may help close the gap between intention and achievement.
- The variability in findings suggest it is important not to make assumptions about what is feasible for a given person.
Self-Rated Health and Long-Term Prognosis of Depression
Gilles Ambresin , and colleagues
Background Self-rated health has been used as a reliable, quick way to assess and monitor population health. This study examines whether self-rated health (SRH) predicts long-term depression outcomes in primary care using the following question: "In general, would you say your health is excellent, very good, good, fair or poor?"
What This Study Found Self-rated health appears to be a strong and consistent predictor of the risk of future depression in patients with recent experience of depressive symptoms. Patients who rated their health as poor to fair had a two-fold greater risk of major depression up to five years later compared with those who rated their health as good to excellent. The association between self-rated health and future depressive status remained strong even after adjusting for age, sex, multimorbidity, and baseline depression status or severity.
Implications
- Few tools exist to help physicians identify those at increased risk of persistent or recurring depression. SRH provides enough information to indicate long-term increased risk of poor depression outcome for primary care patients with recent experience of depressive symptoms.
Joachim P. Sturmberg , and colleagues
Background Over the past seven decades, theories about systems and complexity have had a major influence on academic thinking and research. This paper examines general practice/family medicine (GP/FM) literature from the 1970s to the present, in order to review the co-evolution of general practice/family medicine and systems sciences.
What This Study Found Complex systems theories and GP/FM emerged during the second half of the 19th century; 30 to 40 years later, GP/FM began engaging with systems theories as a means to better understand the nature of health and illness. The past 15 years have seen an expansion of systems and complexity thinking in primary care, exploring practice organization and organizational learning, the nature of health, illness and dis-ease, the nature of clinical practice and the behavior of illnesses in patients.
Implications
- The authors call for a continued expansion of systems and complexity thinking in primary care.
A View From Cheyenne Mountain: Generation III's Perspective of Keystone III
Elizabeth Steiner , and colleagues
Background This is an archival report from the youngest generation of participants in the Keystone III conference, held in October 2000. The conference stimulated the Future of Family Medicine Project and, in turn, influenced the genesis of the patient-centered medical home movement that has been at the forefront of family medicine's reform efforts over the past decade.
What This Study Found At the turn of the 21st century, newer family physicians were committed to perpetuating core values of family medicine, including a commitment to whole person care, a wide scope of practice and community health. They were shaped by new influences as well, such as diversity, changing practice demands, and technology.
Implications
- According to the authors, despite the changes in family medicine over the decades, it remained a viable and vibrant specialty.