September/October 2008 Annals of Family Medicine tip sheet

Federal efforts to improve access to health care for underserved populations by expanding community health center capacity may be futile without continued federal support of Title VII primary care training grants. Analyzing data from the American Medical Association Physician Masterfile, the Health Resource Services Administration, and Medicare claims, researchers found that physicians who did their medical training in programs that received federal grant funding through the Title VII program were more likely to work in community health centers and participate in the National Health Service Corps. Specifically, they found that 3 percent of physicians who had attended Title VII-funded medical schools worked in community health centers in 2001-2003, compared with 1.9 percent of physicians who attended medical schools without Title VII funding – a relative difference of 57.9 percent. These data suggest that without exposure to Title VII, 2,210 fewer physicians would have worked in community health centers during this period, more than doubling the number of vacant positions for physicians in community health centers. A similar association was found between Title VII funding during residency and subsequent work in community health centers. These findings come as the federal government continues to make drastic cuts in funding for Title VII, Section 747 Primary Care Training Grants – from $92.4 million in fiscal year 2003 to $48 million in 2008. The authors assert that ongoing federal investment in the medical education pipeline to prepare and motivate physicians to work in community health centers should be considered an integral component of efforts to improve access to care for the underserved.

Impact of Title VII Training Programs on Community Health Center Staffing and National Health Service Corps Participation
By Diane R. Rittenhouse, M.D., M.P.H., et al
University of California, San Francisco

White coat hypertension, a phenomenon in which patients exhibit elevated blood pressure in a clinical setting but not when recorded by themselves at home, confers significantly less risk of death than sustained hypertension, in which patients' blood pressure is elevated both in the clinic and at home. Analyzing data from 5,182 patients, researchers found that compared to their counterparts with sustained hypertension, patients with white coat hypertension had an estimated 36 percent lower risk of death and an estimated 37 percent lower risk of cardiovascular mortality. The authors call for future research trials of stepped approaches to hypertension management that include home blood pressure monitoring.

Comparing the Effects of White Coat Hypertension and Sustained Hypertension on Mortality in a UK Primary Care Setting
By Martin G. Dawes, M.B.B.S., Ph.D., et al
McGill University, Montreal

China, facing growing disparities in health and health care, is embarking on a major reemphasis on primary care. At the heart of the transformation is its community health services program, consisting of more than 2,400 health centers and 9,700 affiliated stations across the country. Six years after the program's initiation, this article provides a snapshot of the organizations' staffing and service delivery. The authors describe how the program has made significant strides in the delivery of basic clinical and public health services. Specifically, they note that health records are being used in most locations and most are offering patient and public health education programs. The authors also identify numerous areas where improvement is needed. Specifically, they note inadequate staffing and the low level of medical training of health care providers. They also cite insufficient hours of operation at most stations. The authors call for training programs to improve the competency of less educated doctors and nurses with a focus on the delivery of basic clinical services and management of noncommunicable chronic diseases. They also advocate for changes in government policies to support the development of China's community health services program.

Human Resource Staffing and Service Functions of Community Health Services Organizations in China
By Jun Yang, M.S., et al
Beijing Municipal Health Bureau

Three articles and an accompanying editorial in this issue of Annals explore different aspects of the role of spirituality in primary care. A study by Daaleman and colleagues explores the role of spiritual care at the end of life and discovers the importance of being present – physically, temporally, and with openness – to the patient's life course. The article by Katerndahl reports on health outcomes associated with self-reported spiritual "symptoms" such as peacefulness, harmony, meaning and sense of purpose. An expansive conceptual framework presented by Anandarajah offers both secular and religious pathways for understanding the spiritual dimension of medical care. In an accompanying editorial, Davidson reflects on the studies and makes a case for studying the biological mechanisms of spiritual phenomenon.

An Exploratory Study of Spiritual Care at the End of Life
By Timothy P. Daaleman, D.O., M.P.H, et al
University of North Carolina at Chapel Hill

Impact of Spiritual Symptoms and Their Interactions on Health Services and Life Satisfaction
By David A. Katerndahl, M.D., M.A.
University of Texas Health Science Center at San Antonio

The 3 H and BMSEST Models for Spirituality in Multicultural Whole-Person Medicine
By Gowri Anandarajah, M.D.
Brown Medical School

Spirituality and Medicine: Science and Practice
By Richard J. Davidson, Ph.D.
University of Wisconsin-Madison

Analyzing data from a national study of 1,383 patients seeking treatment for alcohol dependence, researchers find that medically trained clinicians with minimal specialty training in alcohol dependence can deliver effective treatment using a medical management approach suitable for the primary care setting. Specifically, researchers found that study participants who attended more medical management visits but spent less total time in treatment reduced their drinking and had better outcomes. Additionally, they found that patients' positive perceptions of their alliance with their clinician and their satisfaction with treatment predicted significantly more days of abstinence from alcohol during treatment.

An Intervention for Treating Alcohol Dependence: Relating Elements of Medical Management to Patient Outcomes With Implications for Primary Care
By Denise B. Ernst, Ph.D., et al
University of New Mexico, Center on Alcoholism, Substance Abuse, and Addiction

With previous research finding low identification rates of hearing disorders in primary care, Hidalgo et al design and validate a scale for identifying the impact of hearing loss on daily life in older persons. The Hearing-Dependent Daily Activities Scale, designed for use in primary care, effectively measures capacity to carry out hearing-dependent activities.

The Hearing-Dependent Daily Activities Scale to Evaluate Impact of Hearing Loss in Older People
By Jesús López-Torres Hidalgo, M.D., et al
Gerencia de Atención Primaria, Spain

Primary care physicians trained to read retinal photographs have acceptable accuracy in screening for diabetic retinopathy, a leading cause of acquired blindness in the United States. Of 1,040 patients screened at a community health center, the clinicians missed 10.2 percent of the referrals an ophthalmologist deemed necessary. The authors conclude this program may offer a cost-effective way to reduce vision loss in diabetic patients who have limited access to ophthalmologists.

Accuracy of Primary Care Clinicians in Screening for Diabetic Retinopathy Single-Image Retinal Photography
By Tillman F. Farley, M.D., et al
Salud Family Health Centers, Colorado

In this essay, Kottke and colleagues present a framework for optimizing practice through research to keep the research agenda focused on the task of improving health. They describe five principles upon which such research initiatives should be based.

Optimizing Practice Through Research: A New Perspective to Solve an Old Problem
By Thomas E. Kottke, M.D., M.S.P.H., et al
HealthPartners Research Foundation, Minnesota

In this personal essay, Sussman and Rivera describe a novel way to engage communities in practice-based research by eliciting and interpreting a story shared by a respected local leader during a focus group about traditional medicine in New Mexico.

'Be Gentle and Be Sincere About It': A Story About Community-Based Primary Care Research
By Andrew L. Sussman, Ph.D., M.C.R.P. and Marino Rivera
University of New Mexico School Health Sciences Center