January/February 2011 Annals of Family Medicine tip sheet

(Press-News.org) Medicare Preventive Services Coverage Not Aligned with USPSTF Recommendations Evaluating the alignment of Medicare preventive services coverage with the recommendations of the U.S. Preventive Services Task Force, researchers find that of the 15 USPSTF recommended interventions for adults aged 65 years and older, Medicare reimburses fully for only one.* For most preventive services (60 percent), Medicare reimburses fully for the service or test, but only partially for the coordination of obtaining that service. For four services (27 percent), Medicare reimburses clinicians partially for both the preventive coordination and the actual service. For one service, Medicare reimburses fully for the coordination and assessment but not for the test/service itself. Further, instead of providing payment to clinicians for recommended preventive services, Medicare pays clinicians to provide 7 services that are not recommended, potentially increasing harm to patients as well as medical costs. The authors assert that given the evidence-based rigor of the USPSTF recommendations and that the USPSTF is mandated by federal law, a reasonable policy would be for Medicare to cover USPSTF-recommended services. They call for Medicare – the country's largest payer for health services and the standard by which other payers model their reimbursements – to align itself with the USPSTF recommendations and usher in an era of improved quality of care through effective prevention. They note that the new health care reform law has the potential to improve the provision of preventive services to Medicare beneficiaries. *Note: All analyses were based on Medicare coverage prior to the implementation of the Affordable Care Act passed in 2010. Comparison Between U.S. Preventive Services Task Force Recommendations and Medicare Coverage
By Lenard I. Lesser, M.D., et al
Robert Wood Johnson Clinical Scholars Program and Department of Family Medicine, University of California, Los Angeles

The Promise of Recent Health Care Reforms for Improving Equity Reflecting on recent health care reforms, Kevin Fiscella, M.D., M.P.H., with the University of Rochester, offers a compelling commentary on their potential promise, pitfalls and the prescriptions needed to jump-start progress toward more equitable health care. He asserts that recent reforms, particularly the Patient Protection and Affordable Care Act of 2010, offer a historic opportunity to make inroads in addressing health care disparities. He identifies six key health care reform provisions relevant to promoting equity: improved access, strengthening primary care, enhanced information technology, new payment models, a national quality strategy, and improved disparity monitoring. He concludes that with effective implementation, improved alignment of resources with patient needs, and most importantly, revitalization of primary care, these reforms could create a more equitable and responsive health care system. Health Care Reform and Equity: Promise, Pitfalls, and Prescriptions
By Kevin Fiscella, M.D., M.P.H.
University of Rochester, New York

Familial Risk May Be Effective Motivator of Health Behavior Change Taking a closer look at whether family history assessment in primary care improves health outcomes, researchers find that using a Web-based tool to screen for family history and tailor prevention messages to familial risk improves some health behaviors. Researchers find preventive messages tailored to family risk for six common diseases (coronary heart disease, stroke, diabetes, and colorectal, breast and ovarian cancers) modestly increases fruit and vegetable consumption and physical activity. Specifically, the randomized clinical trial of 3,326 patients found that intervention participants were more 3 percent more likely to increase daily fruit and vegetable consumption from five or fewer servings a day to five or more servings a day (odds ratio: 1.29) and 4 percent more likely to increase physical activity to five to six times a week for 30 minutes or more a week (odds ratio: 1.47) compared with patients receiving a generic preventive health message. Notably, participants who received the tailored health messages were 15 percent less likely to move from not having a cholesterol test in the last five years to having it done within five years than control participants. There was no significant intervention effect on smoking cessation or blood pressure and blood glucose testing. The authors conclude the modest positive impact of the intervention on dietary intake and exercise behaviors suggests that familial risk may be an important motivator of health behavior change, and they call from future research to determine how to effectively implement family history assessment in primary care. Effect of Preventive Messages Tailored to Family History on Health Behaviors: The Family Healthware Impact Trial
By Mack T. Ruffin, M.D., M.P.H., et al
University of Michigan, Ann Arbor

EHR-based Clinical Decision Support Tool Improves Some Diabetes Measures Pilot testing a novel EHR-based diabetes decision support tool that offers physicians drug-specific treatment suggestions based on each patient's current treatment, distance from clinical goal, comorbidities, and renal and hepatic function, researchers find modest but significant improvements in glucose and some aspects of blood pressure control. Specifically, the randomized trial of 2,556 diabetic patients found significantly better hemoglobin A1c values among patients in the intervention group than those in the control arm (intervention effect -0.26 percent), better maintenance of systolic blood pressure control among intervention patients (80 vs. 75 percent), and borderline better maintenance of diastolic blood pressure control (86 vs. 82 percent). Notably, patients in the intervention group had no better low-density lipoprotein cholesterol levels than patients in the control arm of the study. The researchers report 94 percent of intervention group physicians were satisfied or very satisfied with the intervention, with many reporting continued use of the technology even after the trial's conclusion. The authors conclude that in the coming era of genomic medicine and personalized chronic disease care, clinical support decision strategies like the one tested in this trial, capable of simultaneously standardizing and personalizing clinical care, will become essential to effective primary care. Impact of EHR-Based Clinical Decision Support on Diabetes Care: A Randomized Trial
By Patrick J. O'Connor, M.D., M.P.H., et al
HealthPartners Research, Minneapolis, Minn.

EHR-Based Clinical Decision Support for Patients on NSAIDs Results in Only Small Improvements in Quality of Care A study assessing the impact of electronic health record alerts on physicians' adherence to guidelines for reducing gastrointestinal complications in high-risk patients on nonsteroidal anti-inflammatory drugs finds only a small impact, adding to the growing literature about the complexity of EHR-based clinical decision support for improving quality of care. The study, which included 5,234 patients, found the EHR intervention had a significant effect for the main outcome of discontinuing the traditional NSAID or co-prescribing a gastroprotective medication, but the absolute difference was only 3 percent, with just 25 percent of patients in the intervention group receiving guideline-concordant care. Analzying the impact of the intervention on the care of patients with different risk factors, researchers found a significant impact for only one subgroup of patients – those on low-dose aspirin. Even for this group, however, the impact was relatively small, with less than a 5 percent difference between intervention and control patients (25 vs. 21 percent). For patients in other high-risk groups, the differences were not statistically significant. These findings, the authors conclude, suggest that EHRs, even when coupled with robust clinical decision support, might not result in large improvements in quality of care. They assert that in order to fulfill the promise of improving quality of care, EHRs must be implemented in a manner that fits into the clinical work flow of primary care offices. Impact of EHR-Based Clinical Decision Support on Adherence to Guidelines for Patients on NSAIDs: A Randomized Controlled Trial
By James M. Gill, M.D., M.P.H., et al
Delaware Valley Outcomes Research, Newark

Review Finds Lack of Validated Clinical Decision Rules for Diagnosing Influenza A systematic review of 12 articles regarding clinical decision rules for the diagnosis of influenza finds that although influenza is a common cause of illness and death, studies about diagnosing this infection are largely small, use varied inclusion criteria and reference standards, and do not report their results in a way that would be helpful to clinicians. In their review, researchers found no studies that prospectively evaluated a clinical score or multivariate model for diagnosing influenza. Rather, the studies validated only simple clinical heuristics, such as "fever and cough" and "fever, cough and acute onset," and even then, the sensitivity and specificity varied considerably, and it was not possible to calculate summary measures of accuracy for these rules. The authors call for future research to validate multivariate models for the diagnosis of influenza, as well as the validation of point scores that are easier for clinicians to use at the point of care. A Systematic Review of Clinical Decision Rules for the Diagnosis of Influenza
By Mark H. Ebell, M.D., M.S., and Anna Afonso, B.S.
The University of Georgia, Athens

Two Different Decision Rules to Rule Out Deep Vein Thrombosis Both Safe and Efficient Comparing the diagnostic performance of two clinical decision rules to rule out deep vein thrombosis in primary care patients, researchers find that both, when used in combination with a point-of-care D-dimer blood test, are effective and can spare almost half of patients an unnecessary referral for ultrasonography. The analysis of 1,002 patients with clinically suspected DVT, found a venous thromboembolic event occurred during follow-up in seven patients with a low score and a negative blood test both with the Wells rule (7 of 447 or 1.6 percent) and primary care rule (7 of 495 or 1.4 percent). Direct medical costs per patient were about the same using both rules. Using the Wells rule, 447 patients (45 percent) would not need referral for further testing compared with 495 (49 percent) when using the primary care rule. Because more unnecessary ultrasound procedures could be prevented using the relatively compact primary care rule, it appears to be slightly more convenient for both patients and physicians. Comparing the Diagnostic Performance of 2 Clinical Decision Rules to Rule Out Deep Vein Thrombosis in Primary Care Patients
By Eit Frits van der Velde, M.D., et al
University of Amsterdam, The Netherlands

Primary Care Clinicians Committed to Offering Time Alone for Adolescents During Office Visits Interviews with 18 primary care clinicians in urban health centers provide clinician perspectives on the challenges of providing confidential services to adolescents. Despite competing time demands, clinicians reported a commitment to offering time alone during preventive visits, and to infrequently offering time alone during other types of visits depending upon the chief complaint and parent-child dynamics. Clinicians cited time constraints as a major barrier to offering time alone more frequently, and they perceived parents were receptive to time alone. Many clinicians noted feeling conflicted about providing confidential services to adolescents with serious health threats and regard their role as facilitating adolescent-parent communication to optimize health outcomes. The authors call for the development of office systems to enhance the consistency of the delivery of confidential services. Challenges of Providing Confidential Care to Adolescents in Urban Primary Care: Clinician Perspectives
By M. Diane McKee, M.D., M.S., et al
Albert Einstein College of Medicine, New York

Puerto Rican Americans Describe Asthma Treatments Based on interviews with 30 Puerto Rican Americans, researchers developed a typology of asthma remedies rooted in patients' cultural beliefs and practices. The remedies identified during the interviews were predominantly behavioral strategies rather than ingested or topical therapies. Moreover, patients reported greater use and perceived efficacy of the behavioral strategies, which included lifestyle changes, air exposure, mind/body exercises and religious spiritual practices. The authors conclude that clinicians should ask Puerto Rican patients about their use of ethnomedical therapies for asthma to better understand their health beliefs and try to integrate these therapies into patients' treatment plans. Knowledge and Use of Ethnomedical Treatments for Asthma Among Puerto Ricans in an Urban Community
By Luis E. Zayas, Ph.D., et al
Arizona State University, Phoenix

Card Studies Remain Robust Primary Care Research Tool Drawing on the experiences of practice-based research networks at the University of Colorado School of Medicine, researchers offer a descriptive review of card studies, a 30-year-old field-tested method for gathering data at the point of care. They conclude that card studies remain a robust research tool for primary care practice-based research networks because they are inexpensive, flexible, standardized, customizable, and easy develop and deploy. Card Studies for Observational Research in Practice
By John M. Westfall, M.D., M.P.H., et al
University of Colorado Denver School of Medicine, Aurora

Method for Achieving High Interrater Reliability in Medical Chart Review Studies Researchers from Ontario, Canada, describe a 4-part data quality monitoring procedure for achieving high interrater reliability in data collection from primary care medical records. Their findings offer a guide and benchmark for other medical chart review studies in primary care. Methods to Achieve High Interrater Reliability in Data Collection From Primary Care Medical Records
By Clare Liddy, M.D., M.Sc., C.C.F.P., F.C.F.P., et al
University of Ottowa, Ontario, Canada

### Annals of Family Medicine is a peer-reviewed, indexed research journal that provides a cross-disciplinary forum for new, evidence-based information affecting the primary care disciplines. Launched in May 2003, Annals is sponsored by seven family medical organizations, including the American Academy of Family Physicians, the American Board of Family Medicine, the Society of Teachers of Family Medicine, the Association of Departments of Family Medicine, the Association of Family Medicine Residency Directors, the North American Primary Care Research Group, and the College of Family Physicians of Canada. Annals is published six times each year and contains original research from the clinical, biomedical, social and health services areas, as well as contributions on methodology and theory, selected reviews, essays and editorials. Complete editorial content and interactive discussion groups for each published article can be accessed free of charge on the journal's Web site, www.annfammed.org.