News Release

July/August 2007 Annals of Family Medicine tip sheet

Peer-Reviewed Publication

American Academy of Family Physicians

Preventive Labor Induction Associated with Lower Cesarean Rates

At a time when national cesarean delivery rates have surpassed 30 percent, this study finds there is a safe alternative method of maternity care that is associated with high rates of successful vaginal delivery. The Active Management of Risk in Pregnancy at Term, or AMOR-IPAT, approach uses accurate pregnancy dating and risk scoring to estimate an optimal time of delivery for each woman. If spontaneous labor has not occurred by this gestational age, then preventive labor induction with cervical ripening, if needed, is used to increase the likelihood that labor occurs before the fetus has grown too large for the maternal pelvis and/or before the placenta has grown too old to support the fetus during labor.

The four-year study of 1,869 women at a rural New England hospital finds that those women exposed to the AMOR-IPAT approach had a lower cesarean delivery rate than those who received more traditional care (5.3 percent vs. 11.8 percent). Moreover, the rates of other adverse birth outcomes either appeared to be unchanged or were lower in those women who were exposed to preventive labor induction.

These findings contradict the current belief that labor induction leads to increased rates of cesarean delivery and other adverse birth outcomes and demonstrates that a preventive approach to reducing cesarean deliveries may be possible.

Accompanying editorials by Caughey and Klein present contrasting perspectives and considerable context for interpreting this study and for considering the application of its provocative findings in practice.

A Preventive Approach to Obstetric Care in a Rural Hospital: Association Between Higher Rates of Preventive Labor Induction and Lower Rates of Cesarean Delivery
By James M. Nicholson, M.D., M.S.C.E., et al

Preventive Induction of Labor: Potential Benefits if Proved Effective
By Aaron B. Caughey, M.D., Ph.D.

Association Not Causation: What Is the Intervention?
By Michael C. Klein, C.C.F.P., F.A.A.P., F.C.F.P.


What Influences a Patient’s Decision to Complete a Specialist Referral?

About 80 percent of patients referred to a specialist by their primary care physician complete the referral within three months finds a study of 776 patients from the offices of 133 physicians in 81 practices and 30 states.

According to the 132 referred patients who did not see a specialist, the most common reasons for choosing not to complete the referral were (1) the patient’s belief that the health problem had resolved (47.5 percent); (2) lack of time (37.3 percent); and (3) the patient disagreed with the physician on the need for the referral (26.5 percent). Moreover, patients who requested the referral were more likely to complete the referral than those who did not (92.4 percent vs. 81.9 percent).

Further analysis revealed that patients in Medicaid plans were less likely than others to complete the referral and more likely to experience a health plan denial. Moreover, the longer duration of the patient relationship with the primary care physician and the primary care physician/staff scheduling of the specialty appointment were both positive predictors of referral completion.

The authors conclude that referral completion is a negotiation process between doctors and patients and is strongly influenced by continuity of the doctor-patient relationship. They suggest that referral completion rates may be increased by assisting patients with scheduling their specialty appointments and promoting continuity of care.

Specialty Referral Completion Among Patients Referred From Primary Care Practices: Results from the ASPN Referral Study
Christopher B. Forrest, M.D., Ph.D., et al


Challenges in Counseling Adolescents about HPV and Cervical Cancer Prevention

With the recent approval of the first vaccine for human papillomavirus (HPV), this study takes a closer look at the implications for counseling about cervical cancer prevention in primary care. It finds that the unique conditions of the preadolescent and young adolescent visit pose a challenge to the successful integration of HPV vaccine counseling.

In-depth interviews with 37 primary care clinicians in New Mexico, revealed four factors that influence physicians’ counseling strategies with their adolescent patients: 1) the need to build rapport with adolescent patients, 2) the presumption that adolescent patients engage in high-risk behaviors, 3) the situational delivery and complexity of HPV counseling, and 4) perceptions of clinician and community receptivity to the HPV vaccine.

The authors point out that the greatest HPV counseling challenges stem from the fact that the vaccine is recommended to be given when girls are 11 to 12 years old and before the onset of sexual activity. In the interviews, clinicians indicated that STD, and HPV counseling in particular, are typically initiated during “teachable moments,” such as when reporting an abnormal Pap smear result or finding genital warts; however, this is more likely to occur when the patient is much older than the age recommended for HPV vaccination. Moreover, younger adolescents are more likely to be accompanied by a parent to the visit, requiring involvement of the parent in these sensitive discussions.

They conclude it will be necessary to develop counseling strategies that emphasize a preventive focus, to include parents in the discussion at the time of vaccination, and to take into account the needs of people with different cultural values and beliefs.

HPV and Cervical Cancer Prevention Counseling with Younger Adolescents: Implications for Primary Care
By Andrew Sussman, Ph.D., M.C.R.P., et al


OTHER STUDIES IN THIS ISSUE

Religious Physicians Are No More Likely to Care for the Underserved

In a large survey of 1,144 U.S. physicians from all specialties, researchers found that religious physicians, as measured by intrinsic religiosity or frequency of attendance at religious services, were not more likely to report caring for underserved patients. They were, however, more likely to view their practice of medicine as a calling. Physicians who were more likely to practice in underserved communities included those with high spirituality, those who strongly agreed that their religious beliefs influenced their practice of medicine, those with no religious affiliation, and those who grew up in families that strongly emphasized service to the poor.

Do Religious Physicians Disproportionately Care for the Underserved?
By Farr A. Curlin, M.D., et al


Family Physicians Effective in Diagnosing Herpes Zoster Clinically; Blood Testing Unnecessary

Family physicians have good clinical judgment with regard to diagnosing herpes zoster, a common disease affecting 2.2 to 4.8 per 1,000 people per year. In a study of 272 herpes-zoster patients, the physician’s clinical diagnosis could be confirmed using serologic, or dried blood spot, testing in 91 percent of patients. The authors conclude that while dried blood spot analysis is a logistically convenient method for diagnosis of herpes zoster in primary care, it is rarely needed.

Clinical Diagnosis of Herpes Zoster in Family Practice
By Wim Opstelten, M.D., Ph.D., et al


A Promising Approach for Managing Patients Who Seek Care for Medically Unexplained Physical Symptoms

This study of 172 patients demonstrates that a cognitive behavior therapy-type intervention is effective for managing patients with medically unexplained physical symptoms in the primary care setting. The intervention tested in the study focused on the reduction of physical distress and somatic preoccupation through training in relaxation techniques, activity regulation, facilitation of emotional awareness, cognitive restructuring and interpersonal communication. A significantly greater proportion of those patients in the intervention group had physical symptoms rated by clinicians as “very much improved” or “much improved” compared with those in the usual care group (60 percent vs. 25.8 percent). While this intervention was previously shown to be effective in patients with more severe forms of somatization when delivered in a mental health setting, this study extends those findings to an ethnically diverse sample of primary care patients with less severe somatic symptoms.

Effectiveness of a Time-Limited Cognitive Behavior Therapy-Type Intervention Among Primary Care Patients with Medically Unexplained Symptoms
By Javier Escobar, M.D., et al


Phone-based Intervention Improves Cancer Screening Rates

A telephone-based intervention to improve screening rates for breast, cervical and colorectal cancer among 1,316 women who were not up-to-date was effective in modestly improving screening rates for colorectal cancer. Screening rates for cervical and breast cancer were not improved. A previous study also found this intervention to be efficacious; however, the authors note that as previously implemented, the intervention required substantial research support. For this study, the intervention was successfully adapted to fit into a managed care organization’s existing outreach program, demonstrating that the concept can be effectively translated into a real-world infrastructure.

Translation of an Efficacious Cancer-Screening Intervention to Women Enrolled in a Medicaid Managed Care Organization
By Allen J. Dietrich, M.D., et al


Understanding Physicians’ Information-Seeking Patterns

During the average 7.8 minute patient visit, physicians have time to answer only one in five of their clinical questions that arise finds this observational study of 112 primary care physicians in Madrid, Spain. Analyzing 3,511 recorded patient consultations, researchers found the physicians’ most frequent questions were related to diagnosis (53 percent) and treatment (26 percent), and that physicians searched for answers to 23 percent of the questions. They conclude that better methods are needed to provide answers to questions that arise in the practice setting.

Information Needs and Information-Seeking Behavior of Primary Care Physicians
By Ana I. González- González, et al


Experts Establish a Framework for Evaluating Primary Care

Using a written consensus process, 20 Canadian primary health care experts generated operational definitions for 25 attributes of primary care. It is hoped that this common lexicon will provide an evaluation framework for assessing the impact of primary care renewal initiatives in Canada and other countries.

Operational Definitions of Attributes of Primary Health Care: Consensus Among Canadian Experts
By Jeannie Haggerty, Ph.D., et al


An Oral History of One of Family Medicine’s Founding Fathers

This essay and accompanying oral history trace the origins of family medicine through the life of someone who helped found it – John P. Geyman, M.D. He is one of the most published family physicians in the United States. In addition to being a rural family physician, he was one of the first residency directors in family medicine and the editor of the discipline’s first academic journal.

Five Careers and Eight Airplanes: An Oral History of John Geyman, M.D.
By John J. Frey III, M.D.

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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 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.

An indicator of the young journal’s influence, Annals of Family Medicine’s inaugural impact factor (the frequency with which the average article in the journal has been cited in a particular period) of 3.8 as of July 2007 places the journal in the top tier of general and internal medicine journals (#15/103).


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