May/June 2006 Annals of Family Medicine Tip Sheet

MAY/JUNE 2006 ANNALS OF FAMILY MEDICINE TIP SHEET

EVIDENCE FOR LEGISLATIVE REFORM OF THE U.S. MEDICAL LIABILITY SYSTEM
Significant reductions in malpractice payments could be realized if total or no economic damage caps were operating nationally and hard noneconomic damage and total damage caps could yield lower premiums according to an analysis of national medical liability payment data. Analyzing data from the National Practitioner Data Bank reported from 1999 through 2001, Guirguis-Blake and colleagues investigate the relationship between 10 specific state tort statutory reforms and malpractice payments and premiums. Of the 44,913 claims analyzed, total and noneconomic damage caps were significantly associated with lower dollar amounts per payment, payment per practicing physician and payment per person in the population. The average amount per payment was 22 percent less for those states with noneconomic caps than it was for those states without noneconomic caps. In addition, they find an association between total caps and lower insurance premiums and a suggestion that hard noneconomic damage caps are also associated with lower insurance premiums.

The authors suggest that if tied to a comprehensive plan for reform, the money saved could be used to implement alternative approaches to patient compensation or to achieve other system reforms benefiting patients, employers, physicians and hospitals.
The U.S. Medical Liability System: Evidence for Legislative Reform
By Janelle Guirguis-Blake, M.D., et al

DECLINE IN VAGINAL BIRTH AFTER CESAREAN DELIVERY
In 1999, the American College of Obstetricians and Gynecologists (ACOG) adopted more restrictive guidelines for vaginal birth after cesarean delivery (VBAC) requiring a physician to be immediately available to perform emergency care for a woman attempting vaginal birth after a prior cesarean section. This review of statistical birth data in California from 1996 through 2002, found that attempted vaginal birth after cesarean delivery decreased significantly from 24 percent before the ACOG guideline revision to 13.5 percent after guideline revision. However, California's decline seems to be a continuation of a trend that began in 1997 and mirrors national trends. Notably, of the 386,232 births that made up the sample, neonatal and maternal mortality rates did not improve despite increasing rates of repeat cesarean delivery during the years following the guideline revision.

Contrary to the researchers' expectations, they also found that differences in the decline of VBAC between rural and urban hospitals were not significant, and although VBAC deliveries declined more rapidly at rural hospitals after 1999, the decline started at least as early as 1997, prior to guideline revision.

The authors recommend that when counseling pregnant patients who have had a previous cesarean, physicians offer a balanced presentation of risk and inform them of the encouraging outcomes found in this analysis. They suggest an evidence-based approach to VBAC delivery incorporating these findings may lead to further refinements in guidelines for medically managing women with previous cesarean.
Vaginal Birth After Cesarean in California: Before and After a Change in Guidelines
By John Zweifler, M.D., M.P.H., et al

THE OPTION OF VAGINAL BIRTH SHOULD REMAIN A CHOICE FOR WOMEN
With cesarean delivery rates consistently on the rise (4.5 percent in 1965 to 26.1 percent in 2002), Leeman and Plante urge in a provocative essay that a woman's option to choose vaginal childbirth be preserved, specifically after a previous cesarean delivery or with a breech presentation. While patient- choice cesarean is increasingly offered, patient choice for vaginal delivery is less often respected. The authors assert that women desiring elective cesarean delivery are now being given this choice, while those with a breech-presenting fetus or prior cesarean section may no longer have the choice of vaginal birth.

The authors point out that the choice of a cesarean delivery affect a woman's reproductive future with a subsequent risk of pregnancy complications, such as placenta previa, placenta accreta and uterine rupture. In addition, neonatal outcomes in subsequent pregnancies may be worse in women who had a cesarean in their first pregnancy.

The authors suggest that before the right of women to choose elective primary cesarean delivery is universally endorsed, studies comparing the risks-both long and short term-with vaginal delivery must be conducted. They conclude if it is truly about patient choice, then the choice of vaginal birth must be accepted along with patient choice cesarean.
Patient-Choice Vaginal Delivery?
By Lawrence M. Leeman, M.D., M.P.H., et al

OTHER STUDIES IN THIS ISSUE

EXPLANATIONS OF CARDIOVASCULAR DISEASE RISK IN TERMS OF "HEART AGE" ARE MORE EFFECTIVE IN STIMULATING CHANGE
Complex explanations about cholesterol and cardiovascular disease risk appear to be ineffective in motivating behavior change. This qualitative study of 50 adults found that all participants were aware that "high cholesterol" adversely affects health, but they demonstrated inadequate knowledge about hypercholesterolemia and cardiovascular disease risk, and few knew their cholesterol numbers. Instead, researchers suggest that cardiovascular risk-adjusted age may be a useful strategy for communicating about risk and motivating behavior change. Furthermore, this approach may be helpful in communicating risk when coupled with information about risk reduction.
Patients' Perceptions of Cholesterol, Cardiovascular Disease Risk, and Risk Communication Strategies
By Roberta E. Goldman, Ph.D., et al

PATIENTS WITH SEVERE ALCOHOL MISUSE READY FOR CHANGE
The majority of primary care patients who screen positive for alcohol misuse indicate some readiness to change. This analysis of 6,419 patients who screened positive for alcohol misuse also finds that those with more severe alcohol misuse are more likely to report readiness to change. The authors suggest that these findings should help counter clinician attitudes that patients with alcohol misuse deny excessive drinking or will not be interested in changing, and therefore should motivate clinicians to ask questions to elicit statements reflecting readiness to change, expect motivated patients and have systems available to follow up on positive patient responses.
Readiness to Change in Primary Care Patients Who Screened Positive for Alcohol Misuse
By Emily C. Williams, M.P.H., et al

UNITED STATES AND DUTCH PHYSICIANS DIFFER IN TREATMENT DECISIONS
Differences in physician training and health care delivery in the United States and the Netherlands influence the way physicians perceive their role regarding treatment decisions. This cross-cultural qualitative study of 12 physicians in each country shows that different physician perceptions of their role in treatment decisions, family wishes and knowledge of the patient may explain different treatment styles of demented nursing home patients with pneumonia. The authors assert that efforts to improve the care of these patients must involve consideration of the context of societal values, location of physician training and processes by which physicians determine and negotiate patient and family preferences regarding care.
A Cross-Cultural Study of Physician Treatment Decisions for Demented Nursing Home Patients Who Develop Pneumonia
By Margaret R. Helton, M.D., et al

HOW PATIENTS WITH FAMILIAL HYPERCHOLESTEROLEMIA PERCEIVE RISK
Patients with familial hypercholesterolemia, a genetic disease characterized by high cholesterol and early cardiovascular disease, use a two-step process to develop a personal sense of vulnerability to coronary heart disease. In this qualitative study of 40 patients, participants first consulted their family history to assess their genetic and inherited risk and then negotiated a personal sense of vulnerability through comparisons between themselves and family members. Frich and colleagues assert that in order for physicians to individualize their clinical management of patients, they should determine the patient's understanding of their family history and their personal vulnerability.
Perceived Vulnerability to Heart Disease in Patients with Familial Hypercholesterolemia: A Qualitative Interview Study
By Jan C. Frich, M.D., M.Sc., et al

INHALED CORTICOSTEROIDS AN EFFECTIVE TREATMENT FOR PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE
The use of inhaled corticosteroids (ICSs) for treatment of patients with moderate to severe chronic obstructive pulmonary disease (COPD) is effective in improving health outcomes. COPD is one of the leading causes of morbidity and mortality worldwide and the beneficial effect of ICS for treatment remains controversial. This systematic review finds that COPD patients treated with ICSs experienced 33 percent fewer exacerbations than patients on placebo. The reviewed evidence, however, does not show a treatment benefit for patients with mild COPD.
Efficacy and Safety of Inhaled Corticosteroids in Patients with COPD: A Systematic Review and Meta-Analysis of Health Outcomes
By Gerald Gartlehner, M.D., M.P.H., et al

TOOL TO ASSESS PATIENT TRUST IN MEDICAL RESEARCHERS
The Trust in Medical Researchers Scale, a measurement tool to assess patient trust in medical researchers, may be useful in trying to recruit historically hard-to-reach populations for medical research. The authors suggest that this scale could be a useful tool for researchers in recruiting often unrepresented populations for research studies as past research indicates that African American and other minority populations historically have had little trust in medical researchers.
Development of a Measure to Assess Patient Trust in Medical Researchers
By Arch G. Mainous III, Ph.D., et al

ORGANIZATION OF PRIMARY CARE RESEARCH NETWORKS AFFECTS OUTCOMES
The way in which primary care research networks organize themselves is associated with different outcome profiles. This comparative case study of leaders of four practice-based research networks with very different ways of organizing demonstrates how different initial conditions and processes for running a network (such as shared project and learning space to help develop trusted relationships) are associated with different outcomes.
How Can Primary Care Networks Help Integrate Academic and Service Initiatives in Primary Care?
By Paul Thomas, F.R.C.G.P.

THE IMPORTANCE OF COMMUNICATION
This essay depicts a physician's experience in another country where he does not speak the native language and its transforming effect on his views of the importance of communication. The author's experiences offer lessons on communicating with patients who do not speak the same language.
Thoughts on Communication
By Paul R. Gordon, M.D., M.P.H.

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. Annals is sponsored by six 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 and the North American Primary Care Research Group. 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.