In a large U.S. health plan, nearly one-half of patients who initiated biennial fecal occult blood test (FOBT) screening did not adhere to subsequent colorectal screening in the ensuing 2-year period, compromising the effectiveness of the screening endeavor which hinges on regular screening. Analyzing data on 11,110 patients enrolled in a Washington State health plan who completed an FOBT during the baseline period (2000-2001), researchers found 47 percent received no colorectal screening of any type in the subsequent 2-year observation period. The strongest predictor of FOBT screening adherence was having received a preventive health exam. As compared with patients who did not have a preventive health examination, the relative rate of FOBT adherence was more than 11 times greater among patients who did. The authors contend that during visits dedicated to prevention, physicians may be more likely to recognize an FOBT is due and to devote time to counseling patients regarding barriers to adherence or alternative methods of colorectal cancer screening. In contrast, physicians may find it difficult to address the topic of screening during primary care visits for acute or chronic illness.
Longitudinal Adherence With Fecal Occult Blood Test Screening in Community Practice
By Joshua J. Fenton, M.D., M.P.H., et al
University of California, Davis
Depression Management Program Delivers Very Promising Long-Term Results
In a report from the Robert Wood Johnson Foundation-funded Depression in Primary Care Project, researchers report that a low-intensity, tailored depression management program based on the Chronic Care Model can lead to sustainable improvement in clinical outcomes for chronically depressed primary care patients. Analyzing remission rates and Patient Health Questionnaire scores for up to 18 months after program enrollment for depressed patients at five primary care practices, researchers found that all primary outcome comparisons between the 728 program participants and 78 usual care patients favored program participants. Moreover, the relative impact of the intervention was sustained at 18 months, long after the frequency and intensity of care management support had declined. Specifically, the authors found that the mean PHQ-8 scores were lower for program participants than usual care patients at 6 months (7.48 vs. 8.70), 12 months (6.87 vs. 8.58) and 18 months (6.89 vs. 8.77). The proportion of program participants in remission was higher than usual care patients at 6 months (43.4 percent vs. 33.3 percent), 12 months (52 percent vs. 33.9 percent) and 18 months (49.2 percent vs. 27.3 percent). The mean improvement in reduced-function days during the enrollees' time in the program was more than 36 percent across all sites. The authors point out that the robust findings are comparable to or better than published outcomes for interventions focused on acute-phase treatment. They conclude that this program – focused on more flexible, lower-intensity and longer-term protocols and results than the current acute-phase treatment model – is feasible and highly effective over time and can be implemented in real-world primary care settings where change is constant, clinician turnover is high and workflow is highly complex.
Long-Term Clinical Outcomes of Care Management for Chronically Depressed Primary Care Patients: A Report From the Depression in Primary Care Project
By Michael S. Klinkman, M.D., M.S., et al
University of Michigan Medical School
Drug Sample Removal and Elimination of Visits from Pharmaceutical Reps Produces Modest Reductions in Branded Drug Use in Family Practice Clinic
Evaluating the effect of a rural family practice's new policy prohibiting prescription drug samples and visits from pharmaceutical representatives, researchers found modest reductions in brand name drug use within several drug classes. Analysis of more than 270,000 pharmacy claims from the town's independent pharmacy revealed that overall, levels of brand name drug use did not change significantly after the policy was implemented – the use of promoted agents decreased by 1.43 percent, while nonpromoted branded agents increased by 3.04 percent 18 months after policy implementation. Branded drugs prescribed for respiratory disease, however, declined significantly by 11.34 percent, compared with a control group of prescribers. Additionally, relative to the control group, prescriptions of promoted cholesterol-lowering drugs and antidepressants were reduced by approximately 9.98 percent and 11.34 percent respectively. Researchers also found that the trend in average cost per prescription for lipid-lowering drugs was significantly reduced by $0.70 per prescription per month. Overall, however, average prescription drug costs increased by $5.18 immediately after policy implementation.
Effect of Drug Sample Removal on Prescribing in a Family Practice Clinic
By Daniel M. Hartung, Pharm.D., M.P.H., et al
Oregon State University College of Pharmacy
Care for Chronic Disease Not Neglected Among UK Cancer Patients
Findings Contrast with Previous Research Showing Disparities Among US Cancer Patients
In sharp contrast to previous research from the United States, which has shown deficiencies in chronic disease care among long-term cancer survivors, this study from the United Kingdom finds that chronic disease is well managed in British primary care – most cancer survivors who are not at the end of life receive the same level of care as noncancer patients. Analysis of records on 21,366 adult cancer patients reveals that in British primary care, history of cancer is not associated with poorer management of hypertension, diabetes, cerebrovascular disease or coronary artery disease. The researchers note some differences in the receipt of monitoring among patients near the end of life; however, they suggest such changes in disease maintenance strategies are likely appropriate in patients receiving palliative care given the circumstances. The authors attribute the divergence in quality of care between the United States and the United Kingdom to differences in health care delivery. They posit that the introduction of incentives for chronic disease monitoring, universal health care and a clear role for primary care in the United Kingdom may play a role in ensuring appropriate provision of comprehensive care in older age.
Quality of Care for Chronic Diseases in a British Cohort of Long-Term Cancer Survivors
By Nada F. Khan, M.Sc., et al
University of Oxford, United Kingdom
Game Theory Informs Understanding of Continuity and Trust in Primary Care
Interviews with 20 patients in the United Kingdom suggest that game theory – developed by mathematicians in the 1920s to specify how players will act and what outcomes will result in particular games – provides a theoretical basis for understanding the relationship between continuity of care and the development of patient trust. Analysis reveals that patients are often willing to draw on institutional trust, derived from expectations of medicine as an institution and doctors as professionals, to engage with unfamiliar doctors. The authors note this is consistent with behavioral game theory, which holds that people can and do trust each other enough to cooperate even in single encounters. They point out that this trust is a convenient heuristic, which provides a pragmatic starting point, and can be reinforced or undermined by cues to trustworthiness picked up from interpersonal aspects of the patient-physician encounter. Consistent with game theory, repeated positive interactions with the same doctor, however, can allow patients to develop more secure expectations based on a history of other interactions and anticipation of future interactions. They assert this provides a context that makes it possible for trust to build and become secure. The authors conclude these findings have important implications for the health care service delivery, which in the United Kingdom and elsewhere is increasing focused on enhancing access rather than continuity. They suggest that patients do not see doctors as interchangeable and the move toward organizing services around single encounters between patients and often unfamiliar physicians may disrupt the development of secure trust, which, apart from its intrinsic value, is associated with desirable outcomes, including patient satisfaction, adherence to treatment and perceived effectiveness of care.
Continuity and Trust in Primary Care: A Qualitative Study Informed By Game Theory
By Carolyn Tarrant, Ph.D., et al
University of Leicester, United Kingdom
Actively Involving Diabetic Patients in Decision Making Results in Improved Clinical Outcomes
Among diabetic patients, participatory decision making, in which patients actively participate in the medical encounter, results in improved clinical outcomes, including control of hemoglobin A1C levels and LDL cholesterol levels by improving patient activation, which in turn improves medication adherence. The findings of this observational study of 141 diabetic patients at five family physician offices illustrate a clear pathway between participatory decision making and improvements in key clinical outcomes: (1) patients who report a higher level of participatory decision making are more likely to actively participate in the medical encounter; (2) active participation in the encounter is associated with medication adherences; (3) and medication adherence is associated with improvement in control of glucose and lipids. Medication adherence, however, was not related to improvement in systolic blood pressure. The researchers posit this exception may be explained by clinical inertia on the part of the physician or by the fact that patient adherence may not be sufficient to achieve adequate blood pressure control. The authors conclude that while participatory decision making is a promising approach for managing chronic illness such as diabetes, this type of care requires sufficient encounter time to discuss treatment options and elicit patient preferences, and most primary care settings do not have the time and resources to involve patients in active decision making about their care.
Participatory Decision Making, Patient Activation, Medication Adherence, and Intermediate Clinical Outcomes in Type 2 Diabetes: A STARNet Study
By Michael L. Parchman, M.D., M.P.H., et al
South Texas Veterans Health Care System, San Antonio
Losing Touch: Do Physicians Lose Connectedness with Patients When They Wear Exam Gloves?
One Physician's Personal Reflection
In a thoughtful essay, a physician reflects on how his own drug resistant staphylococcus infection affected his work in the hospital. In particular, he discusses how his subsequent decision to wear gloves during patient encounters created a barrier, not only to infection, but also between himself and his patients. He reflects on the value of touch as a communication tool in the doctor-patient relationship, especially as means of bridging large socioeconomic and cultural gaps. He concludes the implications of contact precautions must be considered as health care providers reflect on balancing patient-centered care with infection control.
Losing Touch in the Era of Superbugs?
By Leif Hass, M.D.
Alta Bates Summit Medical Center, Oakland, Calif.
Accounting for Socioeconomic Status in Cardiac Risk Estimation
Proposed Changes Could Reduce Growing Disparities
As a means to help reduce the growing socioeconomic disparity in coronary heart disease, researchers from the University of California, Davis, developed an approach to incorporating socioeconomic status into cardiac risk stratification. Adding two measures of socioeconomic status into coronary heart disease risk estimation, they contend, can reduce the biases inherent in the widely used Framingham risk score that currently results in undertreatment of patients of lower socioeconomic status. Analyzing data on 15,495 adults, researchers find that modifying the score to include a geographic area-based measure of income (using block group US Census data) and individual education level eliminated the significant socioeconomic bias observed using the Framingham risk score alone. The revised approach suggests more aggressive cholesterol treatment thresholds for those with low socioeconomic status—thresholds of 10 percent and 20 percent should be lowered to 6 percent and 13 percent for low SES persons. The authors assert the proposed modifications should be easy for clinicians to accommodate.
Including Socioeconomic Status in Coronary Heart Disease Risk Estimation
By Peter Franks, M.D., et al
University of California, Davis
Ethics of Community-Based Health Research
Human research protections established over the last 60 years to protect individuals during the research process are not adequate to safeguard communities, according to focus groups with Hispanic and Native American community members in New Mexico. Analyzing transcripts from 18 focus groups, researchers found that although participants recognize the value of health research, many also identified adverse social (labeling, stigmatization, and discrimination) and economic (job losses, increased insurance rates, loss of income) effects of research in their communities. Participants also emphasized no or ineffective return of information about research results to the communities. The authors conclude the issues raised by focus group participants support the addition of a fourth principle (requiring respect for communities) to The Belmont Report, which provides the ethical foundation for all current human research. They assert that the issues raised also call for more broadly applying the three principles of the Belmont Report (respect for persons, beneficence, and justice) to communities as well as individuals. They conclude that researchers should adopt additional approaches to community-based research by engaging communities as active partners throughout the research process, focusing on community priorities, and taking extra precautions to assure individual and community privacy. Furthermore, plans for disseminating meaningful results to communities should be part of the research design.
Ethics of Health Research in Communities: Perspectives From the Southwestern United States
By Robert L. Williams, M.D., M.P.H., et al
University of New Mexico
Using Practice Improvement Teams in Primary Care to Improve Adherence to Clinical Guidelines
A trial to evaluate the effectiveness of facilitated practice improvement teams, called reflective adaptation process teams, in improving adherence to guidelines for chronic diseases, revealed that while primary care practices can successfully engage in facilitated team meetings (18 of 25 practices successfully convened improvement teams despite a history of not meeting regularly), they may choose not to spend the time focusing on issues related to guideline adherence. Analysis of field notes and interviews from the 18 practices that successfully convened improvement teams showed that not a single practice focused on improving adherence to specific chronic disease guidelines during the meetings. Instead, they found that when given a choice, RAP team members focused on patient care and practice improvement issues related to communication, access to care, and access to information, brainstorming solutions and implementing changes to address these issues. The seven practices that failed to engage in the RAP process did so primarily because of key leaders dominating the meeting agenda or staff members hesitating to speak up in meetings. The authors call for additional strategies to engage practice leaders, particularly physicians, and to target issues related to guideline adherence.
Using Learning Teams for Reflective Adaptation (ULTRA): Insights from a Team-Based Change Management Strategy in Primary Care
By Bijal A. Balasubramanian, M.B.B.S., Ph.D., et al
Robert Wood Johnson Medical School, New Jersey
Applying the Capability Framework to Chronic Disease Management and Behavior Change
Researchers discuss the clinical application of the capability framework for addressing chronic disease management and lifestyle change. Because it focuses attention on the conditions that constrain opportunity and how opportunity emerges from the interaction between personal resources and social environment, the capability framework has the potential to expand the informational basis for making clinical assessments, illuminating areas where patients' knowledge and motivation may be hobbled by difficult circumstances. They conclude that by focusing on external as well as internal supports, the capability framework can potentially augment the effectiveness of self-management and empowerment strategies. It may also help to more efficiently manage health behaviors and chronic disease by prospectively identifying patients who are at high risk of failing to change key behaviors.
Capability and Clinical Success
By Robert L. Ferrer, M.D., M.P.H, and Alejandra Varela Carrasco, M.D.
University of Texas Health Science Center at San Antonio and Austin Family Medicine Residency Program, Texas
###
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.
END
