(Press-News.org) Reinvigorating the 1967 Folsom Report's 'Communities of Solution' to Address Today's Fragmented U.S. Health Care System
In the wake of federal efforts to reform the U.S. health care system, a group of rising family medicine leaders call for a reinvigoration of community-centered health systems, as originally outlined in the landmark 1967 Folsom Report. They contend the vision of the original Folsom commission could not be more pertinent to America's current pressing needs. The group revitalizes and modernizes the Folsom Report's blueprint, offering an updated series of 13 grand challenges to facilitate a vision for nationwide integrated patient-centered community health services. The renewal of the Report's "Community of Solution" concept serves as the anchor point for improving overall health and decreasing health costs. Other key lessons drawn from the original report include the integration of public health and clinical care and the importance of local decision making. It is the group's hope that these updated challenges might serve as a springboard for health care professionals, public health organizations, community groups and policy makers to take concrete steps to reengage at the community level.
Communities of Solution: The Folsom Report Revisited
By The Folsom Group
American Board of Family Medicine Young Leaders Advisory Group
Nasal Steroids Offer Small Therapeutic Benefit for Sinus Infection Sufferers
As evidence and clinical policy recommendations move away from antibiotic use for acute sinusitis, a systematic review and meta-analysis finds a therapeutic benefit from intranasal corticosteroids—but the effect is small and not apparent until two to three weeks. Analyzing six studies with a total of 2,495 patients, researchers found intranasal corticosteroids resulted in a small increase in the resolution or improvement of symptoms at days 14 to 21, with the most consistently significant benefits being relief of face pain and congestion. The effect was most marked when patients were given longer durations of treatment (21 days) and higher doses of medication. In their analysis, the researchers found that whereas 66 percent of patients would experience improvement or resolution of symptoms at 14 to 21 days using a placebo, an additional 7 percent of patients would achieve this outcome with corticosteroids, equating to a number needed to treat of 13. This clinical benefit, the authors note, must be set against the potential harms of medication and cost implications. They call for additional research comparing intranasal corticosteroids with placebo in the absence of antibiotics to clarify the time-course of clinical benefit and the impact on work and quality of life.
In an accompanying editorial, a family physician argues nasal steroids are not the answer for most patients. Most patients, he asserts, want to get better in a few days, not three weeks. Furthermore, he argues, the symptom relief offered by nasal steroids is minimal, and the cost is high relative to other over-the-counter drugs, like pseudoephedrine and ibuprofen, that offer similar relief at a fraction of the cost. He concludes instead of writing a prescription, treatment should focus on symptom relief.
Intranasal Corticosteroids in Management of Acute Sinusitis—A Systematic Review and Meta-Analysis
By Gail Hayward, MBBChir, DPhil, et al
Oxford University, England
Intranasal Steroids for Acute Sinusitis?
By John Hickner, MD, MSc
Case Western Reserve School of Medicine, Cleveland
Study: Electronic Health Record Use Does Not Lead to Better Diabetes Care
Even after the potentially disruptive phase of initial electronic health record implementation, quality improvements may remain elusive. Analyzing data over three years for 798 diabetic patients at 16 EHR-using and 26 non‒EHR-using practices, researchers found EHR use was not associated with better adherence to care guidelines or a more rapid improvement in adherence. In fact, patients in practices that did not use an EHR were more likely than those in practices that used an EHR to meet outcome targets for hemoglobin A1c, low-density lipoprotein cholesterol and blood pressure at the 2-year follow-up. The authors conclude that achieving truly meaningful use of EHR technology will require more than time and experience; it will require recognition that until population health is improved, use does not equal success. They assert practices will need assistance with implementation and achieving successful use to improve care and population health outcomes, especially with regard to redesigning work processes to make the best use of these new technologies by all members of the primary care delivery team.
Typical Electronic Health Record Use in Primary Care Practices and the Quality of Diabetes Care
By Jesse C. Crosson, PhD, et al
UMDNJ - Robert Wood Johnson Medical School, New Jersey
Paying Patients for Performance: A Novel Twist on Quality Improvement
In a novel proposal, a family physician proposes paying patients for performance by rewarding them for achieving evidence-based health goals. Citing preliminary studies showing traditional pay-for-performance programs come up short despite considerable investment of resources, Joanne Wu, MD, MPH, suggests that offering direct incentives, such as discounts toward co-payments, procedures and medications, to patients for reaching health goals, has the potential to foster a stronger partnership between doctors and patients and improve health outcomes. The current system, which places all the responsibility and reward of quality of care on physicians, she asserts, perpetuates a paternalistic approach that is neither cost-effective nor sustainable. She concludes that patients deserve a greater role in improving their wellness and reaping the rewards from it.
An accompanying editorial supports the concept of reinforcing positive behavior but argues that the literature on incentives does not yet justify such a proposal. In the editorial, Bruce Christiansen, PhD, asserts the size of incentive needed for meaningful behavior change has implications for both feasibility and cost-effectiveness. He concludes because there is a strong relation between the size of the incentive and the degree of behavior change, it seems unlikely that sufficient resources would be available to change the major, refractory behaviors that undermine health.
Rewarding Healthy Behaviors—Pay Patients for Performance
By Joanne Wu, MD, MPH
Northwest Primary Care, Portland, Oregon
What Does It Cost to Change Behavior?
By Bruce A. Christiansen, PhD
University of Wisconsin, Madison
Major UK Pay-for-Performance Program Has Limited Effect on Health Inequalities
Pay-for-performance schemes have been touted as a route to reducing health care disparities, yet this analysis of the Quality and Outcomes Framework, a major pay-for-performance program in the United Kingdom, finds the introduction of the program had no effect on health care inequalities in the practices studied. Analyzing outcomes data on diabetes patients registered with 29 practices in London, researchers found the introduction of the pay-for-performance scheme was associated with initial accelerated improvements in systolic blood pressure in white and black patients, but these improvements were sustained in only black patients. Initial improvements in diastolic blood pressure in white patients and in cholesterol levels in black and white patients were not sustained after QOF was introduced. There was no beneficial impact of QOF on HbA1c levels in any ethnic group. Furthermore, the authors note existing disparities in risk factor control remained largely intact at the end of the study period. The authors conclude that targeted quality improvement strategies may be required to address disparities in chronic disease management. Designers of pay-for-performance schemes, they assert, should consider incorporating targeted incentives to address the persistence of disparities.
Effect of a UK Pay-for-Performance Program on Ethnic Disparities in Diabetes Outcomes: Interrupted Time Series Analysis
By Riyadh Alshamsan, MSc, et al
Imperial College London
Pedometer-based Green Prescriptions Increase Physical Activity in Older Adults
A pedometer-based "Green Prescription" — a recommendation for physical activity with pedometer monitoring — results in a greater increase in leisure walking activity among older adults than green prescriptions that rely only on time-based goals. Comparing the effectiveness of the two physical activity prescriptions in 330 older adults with low levels of physical activity, researchers found leisure walking increased by 50 minutes per week among the pedometer-based green prescription group compared with 28 minutes per week among the standard Green Prescription group. For both groups, there were significant increases in physical activity that were largely maintained throughout the 12-month study period. BMI did not change in either group, but significant improvements in blood pressure (10 mm Hg systolic and 4.5 mm Hg diastolic) were observed for both groups without any difference between them. The authors hypothesize pedometers likely improve the efficacy of the activity prescription by providing regular objective monitoring and feedback to assist motivation. The findings of this study combined with the cost-effectiveness of the intervention, the authors conclude, should encourage health funding agencies to consider the use of such approaches to improve activity levels.
Healthy Steps Trial: Pedometer-Based Advice and Physical Activity for Low-Active Older Adults
By Gregory S. Kolt, PhD, et al
University of Western Sydney, Australia
Nonprofessional Home Coaching Improves Blood Pressure Control
Blood pressure control in low-income minority patients can be improved by teaching patients to monitor their blood pressure at home and having nonprofessional health coaches assist patients by counseling them on medication adherence. Monitoring the change in systolic blood pressure over 6 months in 237 patients randomized to receive in-home health coaching with or without in-home adjustment of their antihypertensive medications, researchers found both arms had significant reductions in systolic blood pressure (mean 22 mm Hg decrease), as well as a decrease in the number of primary care visits from 3.5 in the 6 months before the study to 2.6 in the 6-month study period and 2.4 in the 6 months after the study. The more coaching encounters patients had, the greater their reduction in blood pressure. As less than one-fifth of patients in the home titration arm actually undertook an adjustment of their antihypertensive medication at home, the feasibility of home titration still remains uncertain. The authors conclude that because blood pressure control was improved using minimally trained nonprofessional staff, this intervention holds promise for improving hypertension control without increasing demand on physician time.
Health Coaching to Improve Hypertension Treatment in a Low-Income, Minority Population
By Thomas Bodenheimer, MD, et al
University of California, San Francisco
Family Physician Reflects on Why He Loves His Work
In an essay, a family physician in El Salvador reflects on the personal joys family medicine has brought him, touching on six themes that continue to rejuvenate his practice: love, faith, mystery, place, dance and medicine. By examining the emotional and psychological dimensions of these themes, he offers a path by which other family physicians may be able to find sustenance and joy in their daily work.
The Joy of Family Practice
By William Ventres, MD, MA
University of El Salvador School of Medicine, San Salvador
Lebanese Women Welcome Health Care System Involvement in Addressing Domestic Violence
Even in conservative societies such as Lebanon, addressing domestic violence through the health care system may be socially acceptable and not offensive to women. Although Arab women are generally expected to balance their needs and well-being against preservation of family reputation and loyalty to one's husband, the 72 Lebanese women who participated in this qualitative study encouraged involvement of the health care system in the management of domestic violence and considered it to be a socially accepted way to break the silence. Participants described characteristics of health professionals that would be conducive to disclosure, including open-mindedness, good listening skills, a caring and unhurried demeanor and respect for confidentiality. The participants did not, however, believe the health care system alone could reduce or end domestic violence, and recommended mass media and community awareness campaigns focusing on family relationships to change knowledge, attitudes, beliefs and social norms.
Involving the Health Care System in Domestic Violence: What Women Want
By Jinan Usta, MD, MPH, et al
American University of Beirut, Lebanon
Researchers Offer Estimates of Intraclass Correlation Coefficients to Aid Practice-Based Investigators
Thompson and colleagues provide information on clustering data from more than 5,000 patients in 61 practices in eight practice-based research networks across the United States obtained from the Prescription for Health program sponsored by the Robert Wood Johnson Fund. The details of these intraclass correlation coefficients across multiple patient characteristics, practices and networks will be of use to practice-based researchers in planning studies to ensure adequate statistical power.
Intraclass Correlation Coefficients Typical of Cluster-Randomized Studies: Estimates From the Robert Wood Johnson Prescription for Health Projects
By David M. Thompson, PhD, et al
University of Oklahoma Health Sciences Center, Oklahoma City
###
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.
Editor's Note:
To arrange an interview with one of the authors or for full-text copies of any of the embargoed articles included in the May/June 2012 issue of Annals of Family Medicine, contact Angela Sharma at (913) 269-2269 or via e-mail at asharma@aafp.org. The full text of all articles is available free at www. annfammed.org. Annals of Family Medicine welcomes diverse people with relevant experience or expertise to participate in online discussions of these studies at www. annfammed.org.
May/June 2012 Annals of Family Medicine tip sheet
2012-05-15
ELSE PRESS RELEASES FROM THIS DATE:
Embargoed news for Annals of Internal Medicine
2012-05-15
1. Self-management May Not be Safe or Suitable for COPD
Trial of Comprehensive Care Management Program for COPD Cut Short Due to Excess Mortality
Self-monitoring and management of some chronic diseases can improve patient outcomes. Hospitalizations for exacerbations of chronic obstructive pulmonary disease (COPD) are associated with decreases in quality of life, lung function, and life expectancy, so researchers hypothesized that a self-management program could benefit patients. The authors enrolled 960 COPD patients in 20 Veterans Affairs hospital-based outpatient ...
Laxative-free CT colonography may be as accurate as colonoscopy in detecting high-risk polyps
2012-05-15
A CT-scan-based form of virtual colonoscopy that does not require laxative preparation appears to be as effective as standard colonoscopy in identifying the intestinal polyps most likely to become cancerous. In the May 15 issue of Annals of Internal Medicine, a Massachusetts General Hospital (MGH)-based research team reports finding that the new technique, which uses computer-aided systems both to virtually cleanse and to analyze the images acquired, was able to identify more than 90 percent of the common polyps called adenomas that were 10 mm or larger.
"While we know ...
Smoked cannabis can help relieve muscle tightness and pain in people with multiple sclerosis
2012-05-15
People with multiple sclerosis may find that smoked cannabis provides relief from muscle tightness — spasticity — and pain, although the benefits come with adverse cognitive effects, according to a new study published in CMAJ (Canadian Medical Association Journal).
Many patients with multiple sclerosis suffer from spasticity, an uncomfortable and disabling condition in which the muscles become tight and difficult to control. While there are drugs to relieve spasticity, they can have adverse effects and do not always sufficiently improve the condition in some patients.
Researchers ...
Back pain improves in first 6 weeks but lingering effects at 1 year
2012-05-15
For people receiving health care for acute and persistent low-back pain, symptoms will improve significantly in the first six weeks, but pain and disability may linger even after one year, states a large study published in CMAJ (Canadian Medical Association Journal).
Low-back pain is a common condition that results in significant health care costs, disability and absenteeism in workplaces. However, there are differing views on how quickly and completely people recover from this condition.
Researchers from Australia and Brazil examined data from 33 studies (11 166 participants) ...
Managing obesity in adults: Tips for primary care physicians
2012-05-15
Managing adult obesity is challenging for primary care physicians, but a new review published in CMAJ (Canadian Medical Association Journal) aims to provide an evidence-based approach to counselling patients to help them lose weight and maintain weight loss.
"Even though evidence suggests that patients are considerably more likely to lose weight when they are advised to do so by their primary care physicians, most patients who are clinically obese do not receive weight-loss counselling in primary care," writes Dr. Gilles Plourde, Cliniques Médicales de Nutrition et d'Amaigrissement ...
Smoked cannabis reduces some symptoms of multiple sclerosis
2012-05-15
A clinical study of 30 adult patients with multiple sclerosis (MS) at the University of California, San Diego School of Medicine has shown that smoked cannabis may be an effective treatment for spasticity – a common and disabling symptom of this neurological disease.
The placebo-controlled trial also resulted in reduced perception of pain, although participants also reported short-term, adverse cognitive effects and increased fatigue. The study will be published in the Canadian Medical Association Journal on May 14.
Principal investigator Jody Corey-Bloom, MD, PhD, ...
Physical fitness may reduce hypertension risk in people with family history
2012-05-15
If your parents have a history of high blood pressure, you can significantly reduce your risk of developing the disease with moderate exercise and increased cardiovascular fitness, according to new research in the American Heart Association's journal Hypertension.
In a study of more than 6,000 people, those who had a parent with high blood pressure but were highly fit had a 34 percent lower risk of developing high blood pressure themselves, compared to those with a low-fitness level who had the same parental history.
"Understanding the roles that family history and ...
Sleepwalking more prevalent among US adults than previously suspected, Stanford researcher says
2012-05-15
STANFORD, Calif. — What goes bump in the night? In many U.S. households: people. That's according to new Stanford University School of Medicine research, which found that about 3.6 percent of U.S. adults - or upward of 8.4 million - are prone to sleepwalking. The work also showed an association between nocturnal wanderings and certain psychiatric disorders, such as depression and anxiety.
The study, the researchers noted, "underscores the fact that sleepwalking is much more prevalent in adults than previously appreciated."
Maurice Ohayon, MD, DSc, PhD, professor of ...
Colon cancer risk when a first-degree relative has precancerous polyps is not clear
2012-05-15
INDIANAPOLIS -- Current colorectal cancer screening guidelines for individuals with first-degree relatives with precancerous colon polyps are based on studies that were not properly designed or were too limited to shape those guidelines, according to a new systemic review of research on the topic. The review authors call for new studies to measure the risk and identify the factors that modify it.
"We found that most studies that are cited for the risk for colorectal cancer when first-degree relatives -- parents, siblings or children -- have a precancerous polyp do not ...
Measuring CO2 to fight global warming
2012-05-15
SALT LAKE CITY, May 14, 2012 – If the world's nations ever sign a treaty to limit emissions of climate-warming carbon dioxide gas, there may be a way to help verify compliance: a new method developed by scientists from the University of Utah and Harvard.
Using measurements from only three carbon-dioxide (CO2) monitoring stations in the Salt Lake Valley, the method could reliably detect changes in CO2 emissions of 15 percent or more, the researchers report in the online edition of the Proceedings of the National Academy of Sciences for the week of May 14, 2012.
The method ...