LESSONS LEARNED FROM HURRICANE KATRINA MAY GUIDE FUTURE DISASTER PLANNING
This essay offers lessons learned by a primary care health care network in Fort Worth, Texas, after caring for a surge of evacuees from Hurricane Katrina. The network, made up mostly of family physicians and administrators, took responsibility for 3,700 evacuees. They provided medical care for nearly half (1,664) of the evacuees in a two-week period. Notably, the network prevented its emergency department from being overwhelmed by creating a triage center located several miles away from the hospital and referring almost all evacuees with health care needs to one of the network's primary care clinics. This proved to be an effective approach – the emergency department only saw 148 evacuees.
The authors reflect the valuable lessons learned that may aid in future disaster planning:
- family physicians are an invaluable asset because of their breadth of knowledge and skills,
- integrated health networks are well equipped to handle the complexities of a major disaster,
- the greatest medical need for displaced adult disaster victims is continuation of chronic disease care, and
- immediate mental health efforts should focus on practicalities, such as finding lost relatives.
The authors suggest that these lessons and the success of their approach may help guide future planning efforts for future natural or manmade disasters, particularly for pandemic threats.
Caring for a Surge of Hurricane Katrina Evacuees in Primary Care Clinics
By Thomas D. Edwards, D.O., et al.
ADVERSE LITIGATION DOES NOT ALTER FUTURE BEHAVIOR OF CLINICIANS
The impact of a lost legal case did not have an effect on physicians engaging patients in decision-making for prostate cancer screening. This study compared 432 patient and physician responses on an exit questionnaire after health maintenance exams about the quality of the decision-making process over three time periods: before, during and after physicians became aware of the lawsuit against the practice. The lawsuit occurred after a family medicine resident and a patient shared the decision about whether the patient would be screened for prostate cancer. The patient, who decided not to be screened, was later diagnosed with prostate cancer and successfully sued the practice. Most patients in the three time periods studied (91 percent, 87 percent and 90 percent respectively) reported having substantial control over the screening decision. Approximately one third described having shared control of the decision with the physician. The authors point out that these findings do not support the premise of defensive medicine – whereby the threat or experience of adverse litigation alters clinician behavior.
How Physicians Approach Prostate Cancer Screening Before and After Losing a Lawsuit
By Alex H. Krist, M.D., M.P.H., et al.
OTHER STUDIES IN THIS ISSUE
DEPRESSIVE SYMPTOMS SEEN IN PRIMARY CARE JUST AS SEVERE AS THOSE SEEN BY PSYCHIATRIC SPECIALISTS
Patients with major depression seen in primary care settings are equally as depressed, with similar symptoms, as those in specialty care, finds this review of data from 2,541 patients. Overall, levels of depressive symptom severity for primary care and specialty care participants were similar, and the authors suggest that these findings indicate a need for aggressive management strategies for depressed patients in both the primary and specialty care settings. Major Depression Symptoms in Primary Care and Psychiatric Care Settings:
A Cross-Sectional Analysis
By Bradley N. Gaynes, M.D., M.P.H., et al.
GOOD PERFORMANCE IS NOT NECESSARILY GOOD CARE
The author of this essay reflects on how the use of performance measures as one of the means to improve health care quality may actually sacrifice good care. The authors conclude that while performance measures are well-intentioned, pressure to improve performance can come at the sacrifice of good care for the individual patient.
Clinical Concerns About Clinical Performance Measurement
By Rachel M. Werner, M.D., Ph.D., et al.
PATIENT EDUCATION MATERIALS ON PROSTATE CANCER INFORM AND ENGAGE PATIENTS
This randomized controlled study finds that patients who have exposure to patient education materials about prostate cancer screening before their doctor's visit are more informed and engaged in the screening decision than those with no prior exposure to patient educational materials. When comparing a Web-based and a paper-based decision aid with no previsit education, exposure to either decision aid increased the patient's involvement in the decision-making process, with 56 percent of those exposed to the Web-based aid and 54 percent of those exposed to the brochure reporting an active decision-making role. The authors conclude from these findings that the decision aid improved two elements of shared decision making – knowledge of the disease and of screening – but it is unclear whether the aid improved consideration of patients' values and engagement in the decision at the desired level.
Patient Education on Prostate Cancer Screening and Involvement in Decision Making
By Alex H. Krist, M.D., M.P.H., et al.
OPIOID ADDICTION CAN BE TREATED IN PRIMARY CARE SETTINGS
Opioid-addicted patients can be treated effectively in nonresearch primary care settings with limited on-site resources, but greater numbers of patients should have access to buprenorphine-naloxone treatment. In a study of 99 patients enrolled in buprenorphine-naloxone treatment for opioid dependence at two urban primary care practices, 54 percent were sober at six months. There was no significant correlation between sobriety and site of care, drug of choice, neighborhood poverty level or dose of buprenorphine-naloxone. Sobriety was linked to those with private health insurance, older age, length of treatment and attending self-help meetings. The authors suggest that these findings lend support to recent efforts to loosen access to buprenorphine-naloxone treatment in nonspecialized settings, as federal regulations currently limit the number of concurrent patients receiving the treatment per physician.
Treating Opioid Addiction With Buprenorphine-Naloxone in Community-Based Primary Care Settings
By Ira L. Mintzer, M.D., et al.
HEART ATTACK MORTALITY SAME IN RURAL AND URBAN HOSPITALS AFTER ACCOUNTING FOR PATIENT DIFFERENCES
Death from heart attack in rural hospitals in Iowa is not higher than that in urban hospitals after taking into account unmeasured patient factors that may have been left out of previous analyses. The authors point out that this study confirms earlier studies that show patients with heart attack admitted to rural hospitals were significantly older and sicker than their counterparts admitted to urban hospitals, and that rural hospitals, because of their size and limited personnel, often act as triage hospitals. This provides, the authors assert, evidence to support the continued importance of rural hospitals and their role in caring for patients with heart attack.
Myocardial Infarction Mortality in Rural and Urban Hospitals: Rethinking Measures of Quality of Care
By Paul A. James, M.D., et al.
STANDARDIZED PATIENTS PROVIDE INSIGHT INTO PATIENT COMMUNICATION
Standardized patients – people trained to portray a specific patient case and visit a doctor unannounced as a method of rating doctors' communications skills – represent an objective means for assessment of physician communication that provides different and complementary information than studying real patients. In comparing real and standardized patient ratings for 96 physicians, this study found that unannounced standardized patient ratings have better psychometric properties than real patient ratings of physicians' communication behaviors, and that real and standardized patient ratings correlated poorly.
Ratings of Physician Communication by Real and Standardized Patients
By Kevin Fiscella, M.D., M.P.H., et al.
COMPARATIVE FEEDBACK PROMPTS MORE REFERRALS TO TOBACCO CESSATION QUIT LINE
Comparative feedback reports – a report showing a comparison of referrals with those of other doctors – prompted more referrals to a tobacco cessation quit line than did general reminders, finds this study of 308 clinicians. After 18 months, there were 484 referrals from physicians receiving the feedback reports versus 220 referrals from physicians receiving general reminders. The authors assert that providing simple, clear and comparable feedback on referrals to a quit-line service had a modest impact on the referral performance of the clinicians. They point out, however, that to become effective, comparable feedback reports may require major integration of practice and system supports.
Practice-Based Referrals to a Tobacco Cessation Quit Line: Assessing the Impact of Comparative Feedback vs General Reminders
By William C. Wadland, M.D., M.S. et al.
GRANT PROGRAM A SUCCESS
Sixty-nine grants awarded by the Joint Grant Awards Program (JGAP), a program jointly supported by the American Academy of Family Physicians (AAFP) Foundation and the AAFP for early career family medicine researchers, resulted in 91 publications and 129 presentations deriving from the JGAP-supported research. The authors assert that projects supported by the JGAP have generated a considerable body of publications and presentations, as well as subsequent grant activity, which, the authors suggest, makes the program important in supporting the early career development of family medicine researchers.
Research Productivity Among Recipients of AAFP Foundation Grants
By Martin C. Mahoney, M.D., Ph.D., et al
LESSON FROM JAZZ IMPROVISATION FOR THE MEDICAL ENCOUNTER
In this essay, the author uses examples from jazz to demonstrate how the foundation of improvisation in jazz can help inform the communication process of the medical encounter. The accompanying jazz pieces along with the article can be downloaded through commercial links at www.annfammed.org. Jazz and the 'Art' of Medicine: Improvisation in the Medical Encounter
By Paul Haidet, 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.
Journal
The Annals of Family Medicine