Index by author
In Brief
Donna R. Parker , and colleagues
Background Growing evidence suggests that metabolic, hormonal and hemostatic changes associated with pregnancy loss may contribute to the development of coronary heart disease. This study, in a diverse, geographically dispersed cohort of women, examines the association of miscarriages and stillbirths with cardiovascular conditions.
What This Study Found Women with a history of pregnancy loss appear to be at increased risk of future coronary heart disease but not ischemic stroke. The association between pregnancy loss and heart disease appears to be independent of hypertension, body mass index, waist-to-hip ratio, and white blood cell count. The risk appears greater among women with a history of stillbirths than among women with a history of miscarriage.
Implications
- Women with a history of miscarriage or a single stillbirth may be considered candidates for closer surveillance and/or early intervention by their primary care physicians so that risk factors can be carefully monitored and controlled.
Charles A. Jennissen , and colleagues
Background More American youth are killed each year in all-terrain vehicle (ATV) crashes than on bicycles, and since 2001, one-fifth of all ATV fatalities have involved victims aged 15 years or younger. This study set out to better understand ATV riding practices among 11-16 year-old students in Iowa.
What This Study Found Most survey participants have ridden an ATV, practiced unsafe riding behaviors, and experienced at least one crash. 77% of students, regardless of rural or urban location, have been on an ATV, with 38% of those riding daily or weekly. Among ATV riders, 57% have been in a crash. Most riders have engaged in risky behaviors, including riding with passengers (92%), on public roads (81%) or without a helmet (64%). Almost 60% report engaging in all three behaviors, and only 2% engage in none.
Implications
- The authors recommend that primary care clinicians determine if their patients, even relatively young and non-rural patients, are exposed to ATVS and, if so, consider injury prevention counseling.
Effect of Payment Incentives on Cancer Screening in Ontario Primary Care
Tara Kiran , and colleagues
Background Pay for performance, in which clinicians are rewarded for meeting targets for delivering health care services, has been seen by many as a promising approach to reducing health system cost and improving quality. This study evaluates a large-scale pay for performance program, introduced in Ontario in 2006, aimed at improving primary care screening for cervical, breast, and colorectal cancers.
What This Study Found Despite substantial expenditures, a large-scale pay-for-performance plan had limited impact on cancer screening rates three years after its introduction. The year after incentives were introduced, there was no significant step change in screening rates for the three cancers. Yet, between 2006-2007 and 2009-2010, a total of $28.3 million, $31.3 million, and $50 million in incentive payments were paid to physicians for cervical, breast, and colorectal cancer screening, respectively. For all three types of cancer screening, disparities in screening related to neighborhood income persisted over time. The size and structure of Ontario?s incentive program may have played key roles in limiting its impact; although preventive care incentives were among the largest financial incentives introduced for primary care physicians in Ontario, they constituted only about 3% of their gross income. By contrast, in a pay-for-performance plan for primary care physicians in the United Kingdom, which accelerated improvements in the quality of care for some chronic diseases, incentive payments made up approximately 25% of physicians' income.
Implications
- These findings are in keeping with other published studies finding limited evidence for the effectiveness of pay-for-performance plans in improving cancer screening. As a result, the authors conclude policy makers should consider other strategies for improving rates of cancer screening and reducing gaps in care.
The Influence of Shared Medical Appointments on Patient Satisfaction: A Retrospective 3-Year Study
Leonie Heyworth , and colleagues
Background In shared medical appointments (SMAs), multiple patients are seen as a group by a health care team for follow-up care or management of chronic conditions. SMAs represent an innovation that could improve access, cost, disease management outcomes, and patient-centeredness in primary care. This study examines satisfaction and patient-centered care experiences among patients attending SMAs compared with usual care appointments.
What This Study Found In a large multispecialty group practice, patients attending group appointments report greater overall satisfaction compared with those attending individual primary care office visits. SMA patients are more likely to rate their overall satisfaction with care as "very good" and rate their visits as more accessible and more sensitive to their needs. Usual care patients consistently report higher levels of satisfaction with their relationship with their clinician, including time spent and communication during the encounter, compared with SMA peers.
Implications
- In an understaffed primary care system facing growing numbers of eligible patients, SMAs may accommodate a greater number of patients in a timely fashion.
- The authors call for additional research to examine satisfaction with group visits over time and identify strategies to enhance patient-clinician communication within shared medical appointments.
Practice Environments and Job Satisfaction in Patient-Centered Medical Homes
Shehnaz Alidina , and colleagues
Background The medical home is a patient-centered, team-based model for organizing and delivering primary care. This study evaluates how transforming primary care practices to medical homes affects job satisfaction for clinicians and staff.
What This Study Found 20 primary care practices participating in medical home projects in Rhode Island and Colorado had only inconsistent changes in job satisfaction in the 30 months after the changes were implemented. Job satisfaction improved in Rhode Island but not in Colorado. For both projects, difficulties in providing safe, high-quality care decreased during the study period, but emphasis on quality and the level of chaos did not change significantly. Fewer difficulties in providing safe, high-quality care and more open communication were associated with greater job satisfaction; in contrast, greater office chaos and an emphasis on electronic information were associated with greater stress and burnout.
Implications
- The authors suggest that, in light of the modest and variable impact of medical home intervention on clinician satisfaction, benefits of intervention may be opposed by the stresses of transformation.
- Interventions that reduce difficulties in providing safe, high-quality care without increasing office chaos may offer the best chance of improving job satisfaction.
David T. Liss , and colleagues
Background Telephone- and internet-based communication is increasingly common in primary care, but it is uncertain how these forms of communication affect demand for in-person office visits. This study assesses how, among diabetes patients, use of secure messaging and telephone visits is associated with office visit use.
What This Study Found Increases in electronic and phone messaging are associated with an increase in primary care office visits for individuals with diabetes.
Implications
- Secure messages and telephone encounters could stimulate demand for visits by reducing barriers to access and allowing patients to address previously unmet needs.
Alex Dregan , and colleagues
Background Because implementing cluster randomized trials can be logistically challenging, costly and time-consuming, researchers sought to evaluate the feasibility of conducting intervention research remotely using primary care electronic health records. Specifically, the authors looked at the effectiveness of electronically delivered decision support tools at reducing antibiotic prescribing for respiratory tract infections in a randomized trial of 603,409 primary care patients in England and Scotland.
What This Study Found Intervention arm practices used decision support tools remotely installed and delivered during consultations that were activated when family physicians entered a medical code for the respiratory tract infection. The tools provided information for education and decision support, including a summary of antibiotic prescribing recommendations, a patient-information sheet, summary of research evidence concerning no-antibiotic or delayed-antibiotic prescribing strategies, information on the definite indications for antibiotic prescription and information and evidence on the risks from nonprescribing. The researchers found the use of the intervention and its effect on care were low ? one-quarter of intervention family practices made little or no use of the intervention, and antibiotic prescribing was only slightly lower at practices that made greater use of the intervention (a 1.85% reduction in the proportion of consultations with antibiotics prescribed). Despite the limited impact, however, the study demonstrates that cluster randomized trials can be conducted remotely through electronic health records.
Implications
- Using electronic health records in intervention research, the authors assert, has the potential to allow large studies to be conducted at a low cost in settings where care is routinely delivered, making it suitable for the evaluation of important clinical and public health interventions.
Michael K. Rakotz , and colleagues
Background Hypertension (high blood pressure) can be difficult to diagnose. This study describes the development and evaluation of a technology-based strategy to screen for undiagnosed hypertension and the implementation of a continuous quality improvement process to improve the accuracy of hypertension diagnosis.
What This Study Found 1,432 patients at risk for undiagnosed hypertension were invited to complete an automated office blood pressure protocol to obtain multiple blood pressure measurements. A quality improvement process was then implemented, including regular physician feedback and office-based computer alerts to further evaluate the 1,033 at-risk patients not screened in phase one. The initiative successfully identified patients at risk for undiagnosed hypertension and classified most patients based on their automated office blood pressure reading. Specifically, this process reduced the rate of being at risk for undiagnosed hypertension over a 30-month follow-up period by more than 72%. By the end of the follow-up period, 293 patients (28%) had not yet been classified and remained at risk for undiagnosed hypertension.
Implications
- The authors suggest that these strategies not only have the potential to eliminate undiagnosed hypertension, they also may be applicable to other common undiagnosed chronic diseases. In addition, similar methods can be adapted to inform clinicians and patients on blood pressure control after the diagnosis of hypertension.
Tom Fahey , and colleagues
Background Clinical prediction rules (CPRs) are tools that quantify the impact of multiple predictors from a patient's history, physical examination or laboratory results to inform a diagnosis, prognosis, or treatment response. An international web-based register of CPRs is being developed for use in primary care as resource for clinicians. This study summarizes the types of CPRs relevant to primary care used to create this register.
What This Study Found 434 unique and relevant rules were identified, of which slightly more than one-half have been validated at least once; less than 3% have been subjected to an analysis of impact on the process or outcome of clinical care. The rules most commonly pertained to cardiovascular disease, respiratory, and musculoskeletal conditions.
Implications
- These findings, the authors assert, support the development of an international register of prediction rules coded by clinical domain and stage of development to help guide areas for needed research and identify those that are ready for use at the point of patient care.
Tyler Williamson , and colleagues
Background Electronic medical records (EMRs) are a potential source of clinical data that can improve our understanding of the epidemiology of disease and effectiveness of disease prevention and management. Canada has established a national EMR data repository, but case definitions used to analyze the data must accurately reflect diagnoses within the EMR. This study develops and validates EMR-based case definitions and case finding algorithms used to identify eight common chronic conditions presenting in primary care.
What This Study Found Valid diagnostic algorithms can be used to identify chronic conditions from electronic health record data for both research and public health purposes. Researchers reviewed 1,920 patient charts and validated algorithms for chronic obstructive pulmonary disease, dementia, depression, hypertension, osteoarthritis, parkinsonism, and epilepsy.
Implications
- These case definitions can be used for a variety of data-driven activities in primary care, including surveillance, routine practice evaluation, feedback, and quality improvement, and research.
Timothy Gallagher
What This Study Found A medical student reflects on a patient who taught him that every past experience is a future tool, and everyone has a skill set from which to build. Anchoring yourself in that skill set and using it as a stable platform can help you to venture into areas where you may feel less confident.