Finding that patients who have not finished high school have a 2.4 percent higher risk of dying of coronary heart disease (CHD) than those with more schooling, Fiscella and colleagues suggest that educational level of less that 12 years should be incorporated into the current CHD treatment guidelines. The findings were drawn from a prospective cohort study of 6,479 adults aged 25 to 74 years who participated in the National Health and Nutrition Examination Survey and for whom ascertainment of risk factors and 10-year status was available. The authors point out that the risk associated with low education level is comparable in magnitude to many of the traditional risk factors, including cholesterol level, smoking status, sex and age, which are included in the current treatment guidelines. The authors suggest that use of low education level to identify persons at higher risk of CHD, who are not otherwise identifiable under current guidelines, may facilitate progress toward individualized treatment and the elimination of socioeconomic disparities in health.
Should Years of Schooling Be Used to Guide Treatment of Coronary Risk Factors?
By Kevin Fiscella, M.D., M.P.H., et al
Expensive New Medications Significantly Increase Drug Expenditures in the North Carolina Medicaid Program
An increase in the number of prescriptions for new and more expensive medications resulted in a significant rise in drug costs in the North Carolina Medicaid program. Analyzing claims for more than 1,204,000 North Carolina Medicaid enrollees between 1998 and 2000, researchers found that prescription drug coverage costs rose 22.8 percent annually during the study period, from $503 per person per year in 1998 to $759 in 2000. The average number of prescriptions filled per person per year also increased – from 13 in 1998 to 15.5 in 2000. The authors point out that increased prescribing for six drugs (Prilosec, Zyprexa, Risperdal, Prevacid, Celebrex and Claritin) accounted for more than 25 percent of the total increase in expenditures. They add that some of the drugs with the greatest expenditures in this study are among those with the largest marketing budgets, and they note that for most of the newer drugs, improved cost-effectiveness has not been shown. To help control rising prescription drug expenditures, they suggest that efforts should be undertaken to improve appropriate and cost-effective prescribing. A possible solution to the issue of rising prescription costs is offered in a study by McMullin and colleagues also in this issue of Annals. Their study findings point to the effectiveness of electronic decision support systems in lowering prescription expenditures.
Changing Prescribing Patterns and Increasing Prescription Expenditures in Medicaid
By Kenneth S. Fink, M.D., M.G.A., M.P.H., et al
Fewer Arrests, Auto Accidents and Emergency Room Visits Among Young Adults Counseled About High-Risk Drinking
Physicians who spent only a few focused minutes counseling young patients about reducing their alcohol use successfully reduced high-risk drinking among those patients as well as the number of motor vehicle crashes, arrests for substance or liquor violations and emergency room visits. Analyzing the results from 226 young adults between the ages of 18 and 30 who participated in a randomized clinical trial testing the effectiveness of brief alcohol counseling, the authors found that counseling resulted in long-term reductions in high-risk drinking behaviors and adverse events. Comparing results of those who received counseling with those who did not, the authors found that counseling resulted in a 40 to 50 percent decrease in alcohol use, 42 percent fewer emergency department visits (103 vs. 177), 55 percent fewer motor vehicle crashes (9 vs. 20), and 23 percent fewer total motor vehicle events (114 vs. 149). They also found significant differences in the number of arrests for controlled substance or liquor violations (0 vs. 8). The authors suggest that these compelling findings point to the efficacy of brief counseling – one of the most important therapeutic modalities used by physicians. With alcohol-related mortality still the most common cause of death in young adults, the authors recommend primary care providers make counseling for high-risk drinking in young adults a critical priority.
Brief Physician Advise for High-Risk Drinking Among Young Adults
By Paul M. Grossberg, M.D., et al
Family Physicians Care for Many Problems, Record Fewer on Bill
Visits to family physicians frequently involve the concurrent care of multiple problems that billing data do not adequately reflect. Analyzing physician logs from 572 patient encounters, researchers found that physicians report managing an average of 3.05 problems per encounter but record only 2.82 in the chart and 1.97 on the bill. For all patients, 37 percent of encounters logged addressed more than three problems, and 18 percent addressed more than four. For patients older than 65, physicians recorded an average of 3.88 problems per visit; for diabetic patients, they recorded an average of 4.6. The authors posit that these findings suggest a mismatch between family medicine and current approaches to quality assessment, guideline implementation, education, research, administration and funding. Future work in these areas, they assert, needs to address the primary care physician's task of prioritizing and integrating care for multiple problems concurrently.
How Many Problems Do Family Physicians Manage at Each Encounter? A WReN Study
By John W. Beasley, M.D., et al
Rethinking How Provider Continuity Is Defined: A Case for Including Patients and Informal Caregivers
In a thought-provoking essay, Stephen Buetow, M.D. calls for a fundamental shift in the way we think of provider continuity, arguing the need to expand the meaning to include the patient and informal caregivers. Currently, provider continuity is defined by visits over time to the same clinician. Buetow points out that many patients and informal caregivers are co-providers of health care and need to be included in the definition. He argues that provider continuity will not happen if different caregivers attend during successive office visits, fragmenting clinician interaction with the patient or those who care, speak or decide for the patient, and thereby reducing the consistency of the care. Such fragmentation, he posits, may weaken knowledge of the patient and information exchange. This reconceptualization of continuity is especially relevant for young children, older persons and other dependent patients who rely on informal caregivers for health care. Buetow points out that the issue of continuity will only become more critical as the population continues to age.
Towards a New Understanding of Provider Continuity
By Stephen A. Buetow, Ph.D.
Family Practice Networks: Possible Surveillance System for Bioterrorism?
In this study, the authors examine the potential of practice-based research networks to rapidly gather data on time-sensitive topics, such as the early detection of a bioterrorism event. Comparing the results of an electronic survey sent to members of a regional practice-based research network with an instrument mailed to a nationwide random sample of family physicians, researchers found that 1) response rates from electronic practice-based research network surveys are as good as those from traditional surveys using mailed survey instruments to a larger population, 2) the timeliness of response is greatly enhanced using electronic communication within practice-based research networks, and 3) the validity of results emerging from the network is consistent with that obtained by conventional methods. The authors suggest that because the infrastructure already exists and because they are on the front lines of primary care, practice-based research networks offer a promising mechanism for bioterrorism surveillance and early detection.
Rapid Assessment of Agents of Biological Terrorism: Defining the Differential Diagnosis of Inhalational Anthrax Using Electronic Communication in a Practice-Based Research Network
By Jonathan L. Temte, M.D., Ph.D., et al
During Major Life Events, Patients Desire Contact with their Family Physician
A mixed methods study of 875 patients in the Netherlands found that many patients want contact with their personal physician at the time of hospital admission and other life events, like a birth or death in the family. The study further found that although patients want contact, most would never initiate it – they consider that the responsibility of the physician. Patients anticipated needing contact with their personal physician if admitted to the hospital for a serious condition such as a malignancy (98 percent) or heart attack (97 percent). However, in the case of a minor foot operation, only 33 percent wanted contact with their physician. At the time of major life events, many patients anticipated needing contact as well: 81 percent in the case of a birth within the family and 90 percent in the case of a death in the family. Qualitative interviews with patients shed light on why patients desire contact with a physician. While most wanted physician-initiated emotional support, a small sub-group expressed a need for patient-initiated tangible support, such as prescribing and organizing. Importantly, the authors note that in the Netherlands, general practitioners act as the gatekeepers to secondary care. As a rule, patients are listed with one physician who receives daily information on admissions and discharges from hospitals.
Patients' Needs for Contact with Their GP at the Time of Hospital Admission and Other Life Events: A Quantitative and Qualitative Exploration
By Henk Schers, M.D., M.Sc., et al
OTHER STUDIES IN THIS ISSUE:
Impact of an Evidence-Based Computerized Decision Support System on Primary Care Prescription Costs
By S. Troy McMullin, Pharm.D., et al*
Electronic decision support systems that provide clinicians with evidence-based information about treatment options during the prescribing process are a possible solution to rising prescription costs. In a retrospective cohort study using a pharmacy claims database, researchers found that physicians using an electronic prescribing system with computerized decision support had significantly lower prescription costs than those in a control group. Among those using the system, the average cost per new prescription was $4.16 lower and the average cost for new and refilled prescriptions was $4.99 lower. The projected six-month savings from new prescriptions and their refills is estimated to be $3,450 per clinician. This article points to a possible solution to the problem of rising prescription expenditures that Fink and colleagues address in a study also published in this issue of Annals.
*Conflicts of interest: Authors McMullin and Lonergan are salaried employees of WELLINX (St. Louis, Mo.), owner of the computerized decision support system used by the intervention group. Co-author Dr. Thomas D. Doerr, M.D. is one of the founders of WELLINX and has an ownership interest in the company.
Physician-Patient Relationship and Medication Compliance: A Primary Care Investigation
By Ngaire Kerse, Ph.D., M.B.Ch.B., et al
Patients are one-third more likely to be compliant in taking medications prescribed during consultation with their physician if they understand the physician and agree with the physician about the nature of the presenting problem and suggested management of it.
Patient-Physician Shared Experiences and Value Patients Place on Continuity of Care
By Arch G. Mainous III, Ph.D., et al
Analyzing data from the Direct Observation of Primary Care Study, researchers found that patients are more likely to value an ongoing relationship with their family doctor when they feel they have been through a lot with the doctor. The authors explain that there are two major paths to patients valuing continuity of care: 1) if they patient and physician have been together for a long time and 2) if the patient and physician have been together through major life events such as a serious illness, hospitalization, birth or death. When both are present, patients place a great deal of value on continuity of care. They note that simply seeing the same doctor over time does not guarantee that the patient will feel a personal relationship with or loyalty to the doctor.
Interpersonal Continuity of Care and Patient Satisfaction: A Critical Review
By John W. Saultz, M.D., et al
In a systematic review of 22 original research articles that studied the relationship between patient satisfaction with medical care and interpersonal continuity – a personal doctor-patient relationship characterized by loyalty and trust – the researchers found 19 studies showing significant positive associations between interpersonal continuity and patient satisfaction. None of the studies reviewed indicated a downside to continuity of care.
Age-Related Disparities in Cancer Screening: Analysis of 2001 Behavioral Risk Factor Surveillance System Data
By Anthony F. Jerant, M.D., et al
Analyzing a large, nationally representative sample, researchers found significant age-related disparities in several cancer screening interventions, including colorectal screening, mammography screening and PSA testing. The findings indicate a relative underuse of colorectal screening by younger adults, overuse of PSA screening – especially among older men, and underuse of mammography screening among older women.
The Primary Care Differential Diagnosis of Inhalational Anthrax
By Jonathan L. Temte, M.D., Ph.D., et al
When asked to assign nonanthrax diagnoses to inhalational anthrax case vignettes, family physicians' diagnoses were grouped into 35 categories, with pneumonia (42 percent), influenza (10 percent), viral syndrome (9 percent), septicemia (8 percent), bronchitis (7 percent), central nervous system infection (6 percent), and gastroenteritis (4 percent) accounting for 86 percent of all diagnoses. The authors point out that many of these disorders are relatively common in primary care practices. Consequently, surveillance systems for early detection of bioterrorism events that scan electronic medical data for these diagnoses or clusters of diagnoses are likely to produce high levels of false-positive signals.
The Spirituality Index of Well-Being: A New Instrument for Health-Related Quality-of-Life Research
By Timothy P. Daaleman, D.O., et al
Researchers determined that the Spirituality Index of Well Being, an instrument used to measure the effect of spirituality on well-being, is a valid and reliable measure of well-being in primary care outpatients. They suggest the instrument may be useful in studies that investigate health-related quality-of-life and chronic illness, aging and end-of-life care.
Adapting Psychosocial Intervention Research to Urban Primary Care Environments: A Case Example
By Luis H. Zayas, Ph.D., et al
Although practice-based research may have greater relevance and applicability to primary care patients than laboratory studies, it does have its challenges. The authors use a case study to discuss several challenges associated with psychosocial intervention research in community-based primary care. The authors posit several criteria, which may help shape future research design: assessing what the population is willing and able to accept, considering what treatment providers can be expected to implement, assessing the setting's capacity to accommodate intervention research, and collecting and using emerging unanticipated data.
Linking Ruth to Her Past
By Renate G. Justin, M.D.
A family physician shares the story of her 30-year relationship with a patient and the strong ties they formed. Although she was trained to keep emotionally distant from patients in order to maintain the best therapeutic milieu, this relationship taught her that in some instances, closeness, rather than distance, is more therapeutic because it recognizes the humanity physicians and patients share.
PRACTICE-BASED RESEARCH NETWORK STUDIES:
Practice-based research networks (PBRNs), networks of community-based practices taking part in primary care research, are emerging as essential laboratories for the generation of new knowledge relevant to the types of problems and patients seen in primary care. This expanded issue of Annals of Family Medicine features nine studies from PBRNs. From an original research study examining the potential of PBRNs for rapid assessment of bioterrorism, to a methodology study addressing the unique challenges inherent in international primary care research, these papers help develop the methods for PBRN research and showcase the involvement of research networks in studies of importance for practice and policy.
Opportunities, Challenges, and Lessons of International Research in Practice-Based Research Networks: The Case of an International Study of Acute Otitis Media
By Larry A. Green, M.D., et al
Using the case of an international study of acute otitis media, the authors illustrate the unique challenges and opportunities inherent in international research. They remind investigators that although international primary care research is extremely valuable, it is infused with complexities and requires additional effort, administrative skill and patience.
Prevalence and Predictors of Night Sweats, Day Sweats, and Hot Flashes in Older Primary Care Patients: An OKPRN Study
By James W. Mold, M.D., M.P.H., et al
A cross-sectional study of 795 patients confirms that a significant proportion of elders experienced night sweats, day sweats and hot flashes. The authors suggest that the presence of these symptoms should prompt additional questions about febrile illnesses, diabetes, anxiety, depression, somatic and visceral pain, sensory deficits, and restless legs syndrome in addition to standard, recommended evaluations for uncommon serious diseases, such as tuberculosis and malignancies.
Comfortably Engaging: Which Approach to Alcohol Screening Should We Use?
By Daniel C. Vinson, M.D., M.S.P.H., et al
Two brief screening instruments for problem drinking, the CAGE questions and a single-question screening tool are equally comfortable for both patients and physicians. Both tools also are equal in their ability to engage the patient in discussion.
Seasonal Variation in Diagnoses and Visits to Family Physicians
By Wilson D. Pace, M.D., et al
Analyzing data from the National Ambulatory Medical Care Survey, researchers found little seasonal variation in the patient problems primary care physicians diagnose and treat, though they did find variation in the rank order of the diagnoses depending on the season. Concluding that diagnoses collected at two points in time are similar to those collected across the course of a year, the authors suggest that a sampling strategy using any quarter of the year but spring (when the diagnoses of pregnancy and coronary artery disease are significantly lower) could be used to understand the diagnoses frequently seen within a PBRN. The authors point out that their findings are good news for PBRNs because the ability to collect data at fewer points in time could decrease costs, increase practice and clinician participation in practice-based research, and result in improved data quality and better estimates.
Evaluating Computer Capabilities in a Primary Care Practice-Based Research Network
By Adolfo J. Ariza, M.D., et al
In a survey of 40 pediatric practices, researchers found wide variability in the computer hardware and software used in the pediatric practice setting. The authors conclude that implementing electronic data collection in primary care practice-based research networks would require a substantial start-up effort and ongoing training and support at the practice site.
Exploring Patient Reactions to Pen-Tablet Computers: A Report from CaReNet
By Deborah S. Main, Ph.D., et al
In exit interviews with 168 patients, researchers found that patients were able and willing to complete questionnaires administered on pen-tablet computers and that they required little training on the use of the device. The authors conclude this novel, easy-to-use technology has the potential to increase patient involvement in practice-based research.
How and Why to Study the Practice Content of a Practice-Based Research Network
By Kevin A. Pearce, M.D., M.P.H., et al
This study by the Kentucky Ambulatory Network shows how using the methods of the National Ambulatory Medical Care Survey can help to establish the representativeness of a new PBRN, while beginning the study of topics relevant to participating clinicians.
Annals of Family Medicine is a peer-reviewed research journal that provides a cross-disciplinary forum for new, evidence-based information affecting the primary care discipline. Launched in May 2003, the journal is sponsored by six family medical organizations, including the American Academy of Family Physicians, the American Board of Family Practice, the Society of Teachers of Family Medicine, the Association of Departments of Family Medicine, the Association of Family Practice Residency Directors and the North American Primary Care Research Group. The journal 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. A board of directors with representatives from each of the sponsoring organizations oversees Annals. Complete editorial content and interactive discussion groups can be accessed free of charge on the journal's Web site, www.annfammed.org.
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The Annals of Family Medicine