Table of Contents
The Issue in Brief
Ann Fam Med 14: 198.
The Issue in Brief
Anjana E. Sharma , and colleagues
Background Most health coaching research focuses on effects during the period of active intervention. As a result, little is known about whether positive effects persist after health coaching has ended. This study follows up on a 12-month randomized controlled trial of a health coaching intervention for patients with poorly controlled diabetes, hypertension, and/or high cholesterol.
What This Study Found In the initial study, the health coaching intervention significantly improved achievement of clinical goals (systolic blood pressure, LDL cholesterol and hemoglobin A1c) at 12 months. In this follow-up, up to one year after health coaching patients in the study's intervention arm experienced only minimal declines in clinical goals, with the exception of hemoglobin A1c. Specifically, the proportion of patients in the coaching arm of the trial who achieved at least one clinical goal at 12 months dropped only slightly from 47 percent at 12 months to 46 percent at 24 months. Similarly, almost the same proportion achieved the secondary outcome of meeting all clinical goals for which they were eligible on study entry at 12 months (36 percent) and 24 months (34 percent).
Implications
- These findings suggest that most improved clinical effects are maintained up to one year after receiving health coaching.
Patients' Survival Expectations With and Without Their Chosen Treatment for Prostate Cancer
Jinping Xu , and colleagues
Background To make informed treatment decisions, patients with localized prostate cancer (LPC) need a realistic understanding of the likely benefits and harms of each treatment option. This study examines survival expectations of patients who choose one of three main types of treatment options (surgery, radiation, or observation).
What This Study Found Most men with localized prostate cancer underestimate their life expectancy without treatment and overestimate the gain in life expectancy with surgery or radiation ? misperceptions that may lead to overtreatment, decisional regret and decreased post-treatment quality of life. A survey of 260 men aged 75 or older with newly diagnosed LPC showed that without any treatment, 33 percent of patients expected to live less than 5 years, 41 percent five to 10 years, 21 percent 10 to 20 years, and 5 percent more than 20 years. With their chosen treatment (surgery, radiation or watchful waiting/active surveillance), 3 percent of patients expected to live less than five years, 9 percent five to 10 years, 33 percent 10 to 20 years and 55 percent more than 20 years. While only 25 percent of all patients in the study expected to live more than 10 years, the authors note that a recent update of the largest and longest-followed active surveillance cohort of men diagnosed with LPC showed 98 percent and 94 percent prostate cancer-specific survival rates at 10- and 15-year follow-up respectively. Moreover, while the patients who chose surgery in this study expected to gain 12 years of life from active treatment, recently published data showed surgery does not significantly improve prostate cancer specific survival compared with observation after 10 years follow-up. These unrealistic expectations, the authors write, are of particular concern because men who choose active treatment have survival almost identical to that of those who choose observation, yet active treatment is associated with high rates of impotence and incontinence.
Implications
- The authors conclude there is an urgent need for interdisciplinary and cross-specialty communication with patients who have prostate cancer. In collaboration with oncology specialists, primary care physicians, they note, are often best positioned to help patients develop realistic life expectancy estimates and associated treatment goals.
Symptomatic and Asymptomatic Colon Cancer Recurrence: A Multicenter Cohort Study
Laura A. Duineveld , and colleagues
Background This study evaluates how recurrent colon cancer presents and is diagnosed during the first five post-operative years.
What This Study Found Among 446 patients treated for colon cancer with curative intent, 74 patients (17 percent) developed recurrent disease. Fifty-eight percent of recurrences were detected during scheduled follow-up visits with 95 percent of patients asymptomatic at the time of detection; forty-two percent of recurrences were found during non-scheduled interval visits, with 84 percent of patients presenting with well-known symptoms (abdominal pain, altered defecation, and weight loss). Patients with asymptomatic recurrences had a significantly higher overall survival rate compared with patients with symptomatic recurrences, which were more often multisite recurrences. Tumor marker testing, imaging and colonoscopy identified all of the recurrences.
Implications
- The authors conclude that primary care physicians who take care of colon cancer patients should be aware of the relatively high rate of symptomatic recurrences and typical presenting symptoms.
Encouraging Patient-Centered Care by Including Quality-of-Life Questions on Pre-Encounter Forms
Becky A. Purkaple , and colleagues
Background Patient participation in clinical decision-making improves outcomes including quality of life (QOL). Yet physicians tend to focus on diseases and symptoms rather than patient-oriented outcomes, such as the ability to participate in meaningful life activities. This study explores whether patients can encourage primary care physicians to pay attention to their QOL goals by writing them on pre-encounter forms. Studying whether patients could encourage their primary care physicians to be more patient-centered by using pre-encounter forms to alert their physicians to quality of life goals and concerns
What This Study Found The intervention questionnaire led to little focus on quality of life during physician visits, when compared to a questionnaire that simply asked about symptoms. Although patients effectively articulated their quality of life goals on paper, quality of life was mentioned in only two of 64 encounters, once by a patient and once by a physician. In neither case was the QOL information used in decision making. Furthermore, directly observed empathy was greater in encounters in the control group, compared to the intervention group.
Implications
- Recording QOL goals on paper does not prime patients or physicians to alter the process or content of clinical encounters and suggests that QOL information is hard to incorporate into the patient encounter.
- With previous research showing that patient participation in clinical decision making improves outcomes, including quality of life, the authors call for training and pre-visit coaching for both patients and physicians to adopt this new behavior.
Janneke Hendriksen , and colleagues
Background Formal prediction models are often considered a more accurate way to estimate the probability of disease compared with a physician?s intuitive estimate ("gestalt"). Standardized prediction models, however, do not allow for consideration of individual patient characteristics. The aim of this paper is to compare the diagnostic performance of gestalt and the Wells decision rule for safely and efficiently ruling out pulmonary embolism (PE) in primary care.
What This Study Found Among 598 adult patients with suspected PE, both gestalt and the Wells rule were safe for ruling out PE when combined with D-dimer testing, however the Wells rule was more efficient at ruling out PE in a larger proportion of patients. While family physicians were very capable of identifying patients at both ends of the probability spectrum, for a large group of patients at intermediate risk, application of the Wells rule and D-dimer testing optimized risk stratification better than using gestalt alone.
Implications
- These findings, the authors conclude, support the use of a prediction model, but leave room for relying on gestalt if disease presence or absence is highly likely or unlikely.
Sophia Papadakis , and colleagues
Background The Ottawa Model for Smoking Cessation (OMSC) provides clinicians with multiple components to help patients quit smoking. It includes use of the three As: Ask (identify smoking status), Advise (counsel patients to quit smoking), and Act (assist with cessation). This study examines the association between implementation of the OMSC program and rates at which the 3As are delivered to tobacco users in primary care practices.
What This Study Found The OMSC is successful in increasing rates of tobacco treatment delivery. In 32 primary care practices with 481 clinicians and 3,870 patients, rates of delivery of the three As increased significantly following implementation of the program. Clinicians are significantly more likely to address tobacco use during periodic exams, indicating that they may be missing opportunities when patients present for other reasons.
Implications
- The results of this evaluation lend support to existing evidence about the effectiveness of multicomponent interventions in influencing tobacco treatment delivery in primary care settings.
Rural Women Family Physicians: Strategies for Successful Work-Life Balance
Julie Phillips , and colleagues
Background Women are an essential component of the rural physician workforce, yet female family physicians experience unique challenges in maintaining work-life balance while practicing in rural communities. Seeking to better understand the personal and professional strategies that enable women in rural family medicine to balance work and personal demands and achieve long-term career satisfaction, researchers interviewed 25 women family physicians practicing in rural communities in the United States
What This Study Found Supportive employers, relationships and patient approaches provide a foundation for successful careers. The participants describe the following strategies to achieve work-life balance: 1) reduced or flexible hours; 2) supportive relationships with spouses, partners, parents or other members of the community enabling them to be readily available to their patients; and 3) maintaining clear boundaries around their work lives, helping ensure adequate time for parenting, recreation and rest.
Implications
- Female physicians considering rural practice may be more satisfied and successful if they seek flexible employers and choose communities where support is available, or if they look for ways to build support networks as they are choosing practice settings. They may also benefit from developing strategies to negotiate boundaries with patients and developing skills to maintain their wellness.
Jose M. Valderas , and colleagues
Background Despite the growing interest in patient safety, major gaps remain in our understanding of patient safety in primary care. This is due in part to the lack of appropriate measurement methods, limiting the ability to obtain reliable and repeatable rates of events. In an effort to fill this gap, researchers in the United Kingdom developed and validated an instrument for measuring patient-reported experiences and outcomes of safety in primary care.
What This Study Found This study provides preliminary evidence supporting the reliability and validity of the Patient Reported Experiences and Outcomes of Safety in Primary Care (PREOS-PC) instrument. Initial testing shows its potential for use in primary care, and future developments will further address its use in actual clinical practice.
Implications
Self-Measured vs Professionally Measured Waist Circumference
Teresa B. Jensen , and colleagues
Background Body mass index (BMI) is used to identify people at increased risk of weight related problems. Measuring waist circumference can improve the predictive value of BMI. This study looks at whether self-measured waist circumference by patients using written and pictorial instructions might be sufficiently accurate to replace professionally measured waist circumference.
What This Study Found Self-measurement of waist circumference has a high false negative rate with a worrisome proportion of patients misclassifying themselves as low risk. Among 585 women and 165 men, the false-negative rate of self-measurements approaches or exceeds 20 percent for some groups at high risk for poor health outcomes. Specifically,11 percent of normal-weight and 52 percent of overweight women had professionally measured waist circumference putting them in a high risk category for metabolic syndrome; however 57 percent and 18 percent of these women, respectively, under-measured their waist circumference as falling below that cutoff. Fifteen percent and 84 percent of overweight and class I obese men, respectively, had a professionally measured waist circumference putting them in a high-risk category, however 23 percent and 16 percent of these men, respectively, undermeasured their waist circumference as falling below that cutoff.
Implications
- According to the authors, these findings demonstrate that self-measured waist circumference has an unacceptably high rate of underestimation. They call for further research on how to improve instruction, techniques or measuring devices.
Racism in Medicine: Shifting the Power
J. Nwando Olayiwola
Background n/a
What This Study Found A black female family physician shares a personal experience in which a racist rant by a patient seemingly reverses the usual power dynamic. She describes the resilience she has developed over time and the tools and strategies she has turned to over the years to handle the aggressions she has experienced from patients, colleagues and institutions.
Sticker Shock: The Experience of a Health Care Consumer
David T. Grande
Background A family physician shares his family's experience attempting to navigate urgent medical decisions in a high-deductible health plan and how he resolved that it is unrealistic to price-shop in urgent and emergent situations.
What This Study Found The author describes how in accessing urgent care for his child's arm fracture, he unknowingly encountered 10-fold pricing variation for a plain film x-ray, a routine, low-cost technology. He asserts that if insurers are going to sell high-deductible health plans, they need to do a better job identifying outlier prices and making those prices part of their negotiations with providers. Moreover, he contends that physicians also need access to better pricing information--ideally situated within the electronic health record--to make prices part of routine discussions so that patients can avoid unnecessary and potentially disruptive out-of-pocket expenses.
Jennifer E. DeVoe
Background A family physician shares how being both a daughter and a doctor brought meaning to her and help to her father as they made decisions during the last week of his life.
What This Study Found The author describes how the unique combination of professional and personal knowledge enabled her to help her father choose the end-of-life path that was right for him. She suggests that everyone should have someone--or a team of family, friends and health care professionals, including a primary care clinician--who together offer a combination of professional and personal knowledge and can serve as navigators and advocates both in and out of the hospital.