Table of Contents
The Issue in Brief
Elements of the Patient-Centered Medical Home in Family Practices in Virginia
Debora Goetz Goldberg , and colleagues
Background The Patient-Centered Medical Home (PCMH) is a new model of care designed to help primary care practices improve access, quality of care, and business functions. This study reports on characteristics of family practices in Virginia and how they compare to core features of the PCMH.
What This Study Found Most family practices in this study have components of the PCMH model pertaining to whole-person orientation and care by a personal physician. Fewer practices have components that require considerable financial and knowledge resources. Specifically, most practices report use of continuity-of-care processes (87 percent) and clinical guidelines (77 percent). Fewer report use of patient surveys (48 percent), electronic medical records for internal coordination (38 percent), community linkages for care (31 percent) and clinical performance measurement (28 percent). A small number report patient registries for multiple diseases (19 percent).
Implications
- These study results can help guide efforts, evaluate progress, and develop policies for health care model reform.
- Increased attention is needed to transform family practices in the areas of quality and safety, coordination of care, team-based care, and enhanced access to care.
Managing Chronic Disease in Ontario Primary Care: The Impact of Organizational Factors
Grant M. Russell , and colleagues
Background Primary care is well-suited to treating patients with chronic diseases, but there are many differences in how chronic disease management programs and services are delivered. This study analyzes the impact of different primary care models and practice features on chronic disease management in Ontario, Canada.
What This Study Found Community health centers provided superior chronic disease management because of longer patient visits and collaboration with other professionals. Across all practice types, regardless of model, what accounted most for high-quality management was the presence of a nurse-practitioner, smaller practices, and lower patient load. Quality of care decreases with patient load and in practices with more than 4 full-time-equivalent family physicians. There is no evidence that a practice's use of electronic medical records influences the quality of chronic disease management.
Implications
- These findings suggest that having a nurse-practitioner and the organization of the primary care team influences the delivery of quality care.
- Further research should examine the effects of larger practices and greater patient-physician ratios on quality care.
Anthony Jerant , and colleagues
Background Previous research suggests that peer-led self-management training improves chronic illness outcomes by strengthening patients' confidence to manage their illness. This study tests the effectiveness of an in-home self-management program for chronically ill patients.
What This Study Found Compared with usual care, a chronic disease self-management program delivered in the home led to more effective illness self-management at 6 weeks and at 6 months but not at 1 year. Neither the in-home program nor a similar program delivered by phone had significant effects on overall mental and physical health or on use of health care resources.
Implications
- Peer-led chronic illness self-management programs appear to result in small to moderate, short-term effects on health outcomes, with no apparent effect on overall mental or physical health or health care expenditures.
- These findings challenge previous suggestions that wider use of peer-led illness self-management programs would be cost-effective.
Does Diabetes Double the Risk of Depression?
Patrick J. O'Connor , and colleagues
Background This study analyzes data on more than 17,000 patients to better understand the relationship between diabetes and depression.
What This Study Found Although patients with diabetes appear to be at higher risk of a depression diagnosis, this may be because they have other medical conditions and/or more contact with the medical care system than patients who do not have diabetes. Data analyses show that patients with diabetes have little or no increased risk of a new depression diagnosis compared with patients without diabetes.
Implications
- A better understanding of the complex relationships between depression and other chronic diseases may eventually lead to more effective care for millions of adults with multiple chronic conditions.
Promise of Professionalism: Personal Mission Statements Among a National Cohort of Medical Students
Michael W. Rabow , and colleagues
Background Throughout history, doctors have taken oaths intended to reflect their professional values, personal goals, and commitments to society. It is not known whether such guidelines are accepted by medical students or whether they reflect students' professional priorities. This study looks at medical students' professional commitments and values by analyzing their individual mission statements.
What This Study Found Three main themes emerged from medical students' individual mission statements: professional skills, personal qualities, and scope of professional practices. Compared with classic oaths and more contemporary professionalism statements, students offer an expanded view of physicianhood that includes such elements as dealing with fears, personal-professional balance, love, equal relationships, self-care, healing, and awe. While recognizing the central role of the patient, students appear to recognize the importance of ties to their own families and the need for balance and a supportive community, as well as the need to maintain personal wholeness and deal with negative aspects of training.
Implications
- Too large a gap between the personal goals of students and the basic skills outlined in standardized professional guidelines may contribute to cynicism, alienation, and depression as students move through their training.
- Medical school curricula may need to be adapted to support the personal goals of those now entering medicine.
Management of Test Results in Family Medicine Offices
Nancy C. Elder , and colleagues
Background The management of laboratory test results in primary care offices is an important element of care quality. This study set out to determine and describe components of quality management of test results in primary care practices.
What This Study Found Among 4 family practices studied, 2 offices had written protocols or procedures; no office consistently had or followed office-wide results management practices. Most patients surveyed acknowledged receiving their test results, but fewer medical records documented patient notification, clinician response to the result, and follow-up for abnormal results. An office's level of safety awareness and appropriate adoption of technology were important factors in quality results management.
Implications
- The degree to which primary care offices are aware of safety and appropriately adopt technology are important factors in high-quality test results management and in designing systems that for higher quality of care.
- Because of the complexity of managing test results, multiple aspects of the process must be evaluated to determine quality.
Musculoskeletal Problems in Overweight and Obese Children
Marjolein Krul , and colleagues
Background Childhood obesity is spreading at alarming rates in children. This study compares the frequency of musculoskeletal problems in overweight and obese children with the frequency of problems in children with normal weight.
What This Study Found Overweight and obese children experience musculoskeletal problems more often than normal-weight children. In a study of 2,459 children aged 2 to 17 years seen in Dutch family practices, researchers found that overweight and obese children aged 2 to 11 years were 1.86 times more likely to report musculoskeletal problems in daily life than were their normal-weight peers. Overweight and obese children aged 12 to 17 years were 1.69 times more likely to do so. Additionally, overweight and obese children across both age-groups more frequently sought medical help for ankle and foot problems. Children older than 12 years of age more frequently sought help for problems with their lower extremities than did normal-weight children.
Implications
- Overweight and obesity in children creates a vicious cycle in which being overweight, having musculoskeletal problems, and a low fitness level reinforce each other.
- It is important for clinicians to be aware of the higher occurrence of musculoskeletal problems in overweight and obese children, to provide adequate management of their problems, and proactively give healthy lifestyle advice.
Defining Comorbidity: Implications for Understanding Health and Health Services
Jose M. Valderas , and colleagues
Background Even though clinicians often treat patients with multiple medical conditions (comorbidity), there is no agreement about how to define and measure comorbidity. This article reviews concepts and definitions related to comorbidity from the perspective of health care professionals.
What This Study Found There are several definitions of comorbidity. Although always applied to the individual patient, these definitions distinguish between the nature and relative importance of the health conditions, the order in which the conditions present themselves, and expanded conceptualizations. There are 3 main research areas that use and measure these concepts: (1) clinical care, (2) epidemiology and public health, and (3) health service planning and financing. Each area needs to apply different concepts of comorbidity for its purposes. The article also explores mechanisms that may underlie comorbid conditions in a patient.
Implications
- Use of explicit definitions and concepts, along with established disease classifications, would make research findings more precise and generalizable, and could increase understanding of the causes and consequences of co-occurring diseases.
- More research is needed into patients' perspectives on the ways in which multiple conditions affect their health, well-being, and clinical care.
Importance of Evidence Grading for Guideline Implementation: The Example of Asthma
David L. Hahn
Background Most current evidence-based guidelines address only evidence quality, but not clinical judgment in the care of individual patients or the role of patient preferences. This article examines strengths and limitations of current evidence-based guidelines using the National Heart, Lung and Blood Institute's new expert panel report on the management of asthma as an example.
What This Study Found The new asthma guidelines, like most other evidence-based guidelines, are limited by a flawed evidence-grading system. Guidelines could be strengthened by more attention to applicable patient populations, patient-oriented outcomes and shared decision making.
Implications
- According to the author, more attention should be paid to the limitations of guidelines and their underlying evidence base as causes for gaps between recommendations and practice.
- Use of more applicable evidence-grading systems with effective decision aids could improve the overall effectiveness of care delivery.