Table of Contents
The Issue in Brief
Anthony Jerant , and colleagues
Background Colorectal cancer (CRC) screening is under-utilized. This study compares two CRC screening interventions delivered before office visits: an interactive multimedia computer program tailored to patients' beliefs about CRC screening and a non-tailored program providing basic CRC screening information.
What This Study Found An interactive multimedia computer program tailored to patients? specific beliefs about colorectal cancer screening was no more effective in improving colorectal cancer screening rates than a non-tailored informational program. In a multiethnic patient sample, the tailored program improved colorectal cancer screening knowledge, self-efficacy, readiness, test preference specificity, discussion and recommendation, however, in the subsequent year patients in both groups received screening at similar rates.
Implications
- The findings raise doubts about the effectiveness of sociopsychological tailoring approaches in promoting CRC screening. the utility of one-time tailoring of socio-psychological factors in promoting and reducing ethnic disparities in CRC screening.
Cardiovascular Risk and Statin Use in the United States: A Cross-Sectional Analysis
Michael E. Johansen , and colleagues
Background New guidelines from the American College of Cardiology and American Heart Association substantially broaden the number of individuals for whom statin medications are recommended, primarily by expanding the eligible population to lower levels of cardiovascular risk. This study examines the relationships between statin use and cardiovascular risk, diagnosis of hyperlipidemia (high cholesterol and triglyceride levels), and other risk factors.
What This Study Found Many people at high risk for cardiovascular disease, including those with coronary artery disease, diabetes or both, are not receiving statins. An estimated nine million people over 40 years of age with diabetes and 5.6 million people with coronary artery disease -- populations that have clearly been shown to benefit from the drugs -- are not on statins. Those with high cholesterol but without diabetes or heart disease are more likely to be on statins than those without high cholesterol but who have diabetes or heart disease. Given that individuals with heart disease or diabetes are at considerably higher cardiovascular risk, this pattern strongly supports the notion that statin use is being driven by high cholesterol instead of by overall cardiovascular risk.
Implications
- Recently released ACC-AHA guidelines offer an opportunity to reframe statins as medications that reduce cardiovascular risk rather than as medications that lower cholesterol.
Medication Taking in Coronary Artery Disease: A Systematic Review and Qualitative Synthesis
Mohammed A. Rashid , and colleagues
Background There is compelling evidence that cardiovascular medications help prevent coronary artery disease, but many patients discontinue treatment. This analysis of existing research seeks to understand the factors that influence patients' decisions to continue or stop taking medications.
What This Study Found Patients use complex decision-making processes when deciding whether to continue their medications. Some patients hold fatalistic beliefs about their disease, whereas others feel they have been cured by interventional procedures, both leading to decisions to discontinue medication. Patients who adapt to being a "heart patient" are positive about medication taking. Relationships with prescribing clinicians are critically important to patients; clinicians' inaccessibility and insensitive terminology negatively affect patients' perceptions of treatments. By adopting a more open approach, clinicians can engage patients in a discourse about their medications. Moreover, providing medication-specific information when initiating therapy, improving the transition between secondary and primary care, and explaining the risk of disease recurrence may help to modify patient attitudes toward drugs to prevent further cardiovascular disease.
Implications
- Strategies to encourage patients with coronary artery disease to continue taking medications should recognize the key role of the prescribing clinician.
James W. Mold , and colleagues
Background Implementing clinical practice guidelines for managing chronic diseases can be challenging for primary care practices. Two promising types of assistance are practice facilitation (PF) and learning collaboratives. This study compares the effectiveness of these two interventions, along with performance feedback and education (academic detailing) on practices' success in implementing the National Heart, Lung and Blood Institute's Asthma Guidelines.
What This Study Found Practice facilitation appears to be better than education, practical tools and performance feedback alone in helping primary care practices implement asthma guidelines. The intensity of the intervention appears to correlate with effectiveness.
Implications
- These findings may help efforts to improve guideline implementation in primary care practices.
Development and Validation of a Family History Screening Questionnaire in Australian Primary Care
Jon D. Emery , and colleagues
Background The family medical history is the most relevant genetic risk tool for use in clinical practice. This study reports the development and validation of a 9-question family history screening questionnaire designed to assess risk of multiple common diseases.
What This Study Found A set of nine simple questions can accurately screen for increased risk of seven common, potentially preventable, serious conditions: breast, ovarian, colorectal, and prostate cancer; melanoma, ischemic heart disease; and type 2 diabetes. This tool could help identify primary care patients who might benefit from more detailed assessment and discussion of their disease risk.
Implications
- Further work is required to understand the feasibility of implementing the screening questionnaire into routine clinical practice.
The Future Role of the Family Physician in the United States: A Rigorous Exercise in Definition
Robert L. Phillips, Jr , and colleagues
Background Amid strong shifts taking place in health care, clarification of the family physician's role is critical to the discipline?s future success and possibly even to its future existence. Representatives from seven family medicine organizations propose a statement defining the role to which family physicians aspire. They also offer a "foil" definition of what family medicine could become absent any change.
What This Study Found The following definition of the family physician's role was selected. "Family physicians are personal doctors for people of all ages and health conditions. They are a reliable first contact for health concerns and directly address most health care needs. Through enduring partnerships, family physicians help patients prevent, understand, and manage illness, navigate the health system and set health goals. Family physicians and their staff adapt their care to the unique needs of their patients and communities. They use data to monitor and manage their patient population, and use the best science to prioritize services most likely to benefit health. They are ideal leaders of health care systems and partners for public health."
Implications
- The authors conclude that embracing a new definition and, perhaps more importantly, rejecting the foil, are important steps as family medicine negotiates with government, payers, health systems, patients and communities and works to build the future of the specialty.
Richard A. Goodman , and colleagues
Background One-fourth of all adults, and at least 75% of older adults, have 2 or more chronic conditions. The presence of multiple chronic conditions (MCC) creates many challenges for clinicians, including determining what evidence to use in making clinical decisions and the need to consider patients' contexts and preferences in clinical decision-making. This report summarizes recent policy work by the US Department of Health and Human Services and the Institute of Medicine addressing the challenges of guidelines for people with multiple chronic conditions.
What This Study Found A meeting in May 2012 identified principles and action items for government, guideline developers and others to use in strengthening the applicability of clinical practice guidelines to the growing population of people with MCC. Participants identified 11 principles to improve applicability of guidelines to patients with multiple conditions. The principles were grouped into three categories, intended to: 1) improve the process of developing guidelines; 2) strengthen the content of guidelines in terms of multiple chronic conditions; and 3) increase focus on patient-centered care.
Implications
- The increasing prevalence of people with MCC is accelerating the need for improved clinical practice guidelines for patient management.
- In the absence of a central force for guideline development in the US, collective actions to address MCC in guidelines will require sustained will and commitment both within and outside the government.
Kurt C. Stange , and colleagues
Background More than one in four Americans lives with more than one ongoing health condition. Despite the growing prevalence and cost of multiple chronic conditions, many current health care and research approaches are focused on single diseases. This report synthesizes insights from 45 experts, including people with multiple chronic conditions, family and friend caregivers, researchers, policy makers, and funders, on how to bring context into research efforts to improve the health of people with multiple chronic conditions.
What This Study Found To generate new knowledge to improve the health of people with multiple chronic conditions, consistent attention to contextual factors is needed. Efforts must consider complementary perspectives across multiple levels, including public policy, community, health care systems, family and person as well as the cellular and molecular levels where most research is currently focused. This shift will require new partnerships between researchers, clinicians, patients, caregivers, policy makers and other stakeholders, and dynamic research methods that are participatory, flexible, multilevel, longitudinal and mixed-method.
Implications
- Developing an evidence base that includes context will ultimately lead to more integrated, effective, high value health care that is responsive to individual needs, preferences, and desires.
Glyn Elwyn , and colleagues
Background Different clinical situations require different communications approaches. Clinicians must be able to determine appropriate communication methods and, when necessary, integrate them. This report explores two communication approaches--shared decision making and motivational interviewing--and the application of these methods across a range of clinical problems.
What This Study Found In shared decision making, the clinicians' role is to help patients understand reasonable options and then elicit, inform and integrate patients' informed preferences. This method is effective when patients face difficult treatment decisions. Motivational interviewing is most often applied when a patient feels ambivalent about necessary behavior change, such as lifestyle choices or adherence to medications. Using motivational interviewing, clinicians can help patients identify and resolve ambivalence by exploring their personal perspectives and perceived barriers. Although these methods have been considered distinct and non-overlapping, practitioners may benefit from drawing on both approaches to provide patient-centered care in real-world clinical situations when behavior change and choosing between competing options are relevant.
Implications
- There are considerable challenges in implementing shared decision making and motivational interviewing into routine practice. Nonetheless, the authors posit that there will be little progress in patient-centered care until these methods are valued as core elements of good practice. This will require that they are taught, assessed, and integrated into practice, and appropriately measured and rewarded.
I Remember . . . It Was December
Richard Colgan
What This Study Found A family physician continues to draw meaning from the home care he provided to a dying woman and her family in his early years of practice. His memories of these home visits reinforce his love for medicine and his belief that, in spite of the interruptions, requiriements and measures in medical practice, passion for this vocation can be sustained through a focus on caring for others.