American Academy of Family Physicians – Coca-Cola Alliance, Conflict of Interest or Ethical Relationship?
In an essay addressing the recent controversy over the American Academy of Family Physicians accepting a large corporate donation from The Coca-Cola Company to fund patient education materials on obesity prevention, family physician and AAFP member Howard Brody, M.D., Ph.D., argues that accepting funds from commercial sources that seek to influence physician organization behavior in a direction that could run counter to the public health constitutes a conflict of interest. He asserts that many of the defenses offered by AAFP leadership are rationalizations rather than sound ethical counterarguments. He concludes that medical organizations, as the public face of medicine and as formulators of codes of ethics for their physician members, have special obligations to adhere to high ethical standards, and he raises concern about the development of a corporate culture within a medical professional society. Family physicians, he concludes, have demonstrated a commitment to putting the health needs of their patients ahead of personal financial gain. As such, they deserve to be represented nationally by an organization that fully reflects those high ethical commitments and standards.
In response to the editorial by Howard Brody, M.D., Ph.D., AAFP President, Lori Heim, M.D., F.A.A.F.P., counters in a separate essay that the AAFP's new consumer alliance agreement with The Coca-Cola Company illustrated the AAFP's adherence to its ethical foundation, demonstrated the AAFP's commitment to serving physicians and the public, and maintained the trust Americans put in their family physicians and the organization that represents them. She contends that throughout the development of the program, the AAFP consistently addressed possible conflicts of interest openly and directly, sharing with its members and the public exactly what measures it was taking to ensure that no unethical conduct or breach of trust would occur. The AAFP saw a public health and education need that was both unmet and undermined by the barrage of marketing messages and confusing information and acted to fill that need by developing unbiased educational materials to help patients make good nutrition decisions. In so doing, she concludes, the AAFP hewed to its high ethical standards, its core values, and its mission in the decisions made and the actions that followed.
Professional Medical Organizations and Commercial Conflicts of Interest: Ethical Issues
By Howard Brody, M.D., Ph.D.
Institute for the Medical Humanities, University of Texas Medical Branch, Galveston
Identifying and Addressing Potential Conflict of Interest: A Professional Medical Organization's Code of Ethics
By Lori Heim, M.D., F.A.A.F.P.
American Academy of Family Physicians, Leawood, Kan.
Cholesterol Screening Rates Low Among Young Adults Despite Prevalence of Cardiovascular Risk Factors
Approximately two-thirds of all young adults have one or more risk factors for coronary heart disease, yet less than 50 percent are screened for high cholesterol. Analyzing nationally representative data for 2,587 young adults from the National Health and Nutrition Examination Surveys, researchers found about 59 percent of young adults had CHD or CHD equivalents, or one or more risk factors (high blood pressure, smoking, family history or obesity). The prevalence of high cholesterol levels increased with the number of CHD risk factors, yet no significant difference in screening for cholesterol was observed among those with one or two or more risk factors for CHD compared with those with no risk factors. High cholesterol levels were observed in 65 percent of young adults with CHD or CHD equivalents, 26 percent of young adults with two or more risk factors, 12 percent of young adults with one risk factor and 7 percent with no risk factors. The authors call for the improvement of risk assessment and management for cardiovascular disease among young adults.
Prevalence of Coronary Heart Disease Risk Factors and Screening for High Cholesterol Levels Among Young Adults, United States, 1999-2006
By Elena V. Kuklina, M.D., Ph.D., et al
Centers for Disease Control and Prevention, Atlanta, Ga.
New Method for Estimating Complexity of Patient Visits Finds Family Medicine Is More Complex Than Cardiology
As primary care physicians continue to fight for a system of compensation that recognizes the complexity of the primary care encounter, researchers elucidate a new approach for calculating the complexity of patient visits. The method estimates complexity based on the amount of care provided weighted by its diversity and variability. Analyzing data from the 2000 National Ambulatory Medical Care Survey using this method, researchers find that when adjusted for duration of visit, family medicine has a greater complexity density per hour (167) than either cardiology (125) or psychiatry (31). An accompanying editorial draws out the implications of this work, asserting that complex systems models describe important phenomena in primary care not adequately described by complicated linear models and deliver answers that differ from those of linear models in meaningful ways. Estimates of clinical complexity, the authors assert, could have broad use for interspecialty, interpractice, and interphysician comparisons as well as longitudinal applications.
A Method for Estimating Relative Complexity of Ambulatory Care
By David A. Katerndahl, M.D., M.A., et al
University of Texas Health Science Center at San Antonio, Texas
The Implications of Measuring Complexity
By Lee A. Green, M.D., M.P.H.,
University of Michigan Medical School, Ann Arbor
Personal Doctoring Alive and Well in America
In a moving essay, two family physicians reflect on their experience witnessing a community share the life and loss of their family doctor of 33 years at a memorial service held in the town's high school gymnasium. They relate how, in public reflections on their personal doctor, people revealed how their friend had seen needs, understood fears, and partnered with them to create futures. The authors assert that these stories are compelling evidence that personal doctoring, practiced with compassion in the context of families and community, is alive and well and held deeply in the heart of America. The experience, they conclude, renewed their resolve that as we work for health care reform, system change and practice redesign, innovation must empower personal doctoring. No computer, no insurance company, no hospital system can replace the personal doctor.
A Public Celebration of a Personal Doctor
By William R. Phillips, M.D., M.P.H. and Larry A. Green, M.D.
University of Washington, Seattle and University of Colorado, Denver
Education Program Doubles Health Care Workers' Influenza Vaccination Rates
A simple promotional and educational intervention program can substantially increase the low influenza vaccination rate among primary care workers, a high-priority group because of their proximity to patients. The study of 344 staff members in 27 primary care clinics in Jerusalem, Israel, found that an intervention consisting of a lecture session by a family physician, literature distributed by e-mail, and solicitation by a key figure from the local staff resulted in a doubling of the immunization rate in intervention clinics compared with control clinics. Specifically, the immunization rate was 53 percent in the intervention group compared with 27 percent in the control group. When compared with the previous season, the absolute increase in the immunization rate was 26 percent in the intervention clinics and only 7 percent in the control clinics. The authors conclude that the program, which requires little investment of time and resources, could be easily replicated in other clinics with low immunization rates. They hypothesize that the program's success was due to its multifaceted approach involving respected and familiar family physicians and including a local staff member. They call for future research to determine whether this or a similar intervention program aimed at increasing staff influenza immunization rates may also substantially increase patient immunization.
Randomized Trial of a Program to Increase Staff Influenza Vaccination in Primary Care Clinics
By Zvi Howard Abramson, M.D., M.P.H., et al
Hebrew University-Hadassah Medical School, Jerusalem, Israel
Disparities in Colorectal Cancer Screening Persist Despite Medicare's Expansion of Coverage
Despite the 2001 Medicare expansion of colorectal cancer screening coverage, Medicare enrollees who do not have supplemental health insurance or a usual place of health care have disproportionately lower rates of testing. Analyzing Medicare Current Beneficiary Survey data on 8,330 enrollees who participated in the survey in 2000, 7,889 enrollees who participated in 2003 and 7,614 enrollees who participated in 2005, researchers found that those who received regular care from primary care physicians had the highest rates of testing and had increasing rates of recent endoscopy and decreasing rates of fecal occult blood test use over time. In contrast, those who did not have a usual place of health care had the lowest rates of testing: 21 percent had a recent endoscopy in 2000, 18 percent in 2003, and 21 percent in 2005, and the proportion of unscreened increased during the study period. Medicare beneficiaries who did not have additional insurance to supplement Medicare Part B had lower rates for colonoscopy or sigmoidoscopy than those with supplemental insurance. Among beneficiaries with supplemental insurance plans, the use of endoscopy to test for colorectal cancer increased while FOBT use decreased over the 6-year period. The authors assert these findings suggest that expanding health insurance benefits without additional targeted efforts to improve utilization of appropriate health care services will not eliminate disparities. Moreover, they reinforce the important role of primary care and a medical home in the delivery of screening services. The authors conclude that outreach programs that include efforts to encourage enrollees to have regular visits with a primary care physician and to undergo an annual preventive health examination, as well as reminder systems for patients and primary care physicians to carefully consider all screening options, including FOBT, may further increase colorectal cancer screening rates and mitigate disparities for vulnerable populations.
Primary Care, Economic Barriers to Health Care and Use of Colorectal Cancer Screening Tests Among Medicare Enrollees Over Time
By Chyke A. Doubeni, M.D., M.P.H., et al
University of Massachusetts Medical School, Worcester
Gradual EHR Implementation Delivers Positive Results for Residency Training Practice
A qualitative study examining the implementation of an electronic health record in a residency training practice finds both expected and unanticipated effects on the process of care and on relationships with patients and among practice members. The 22-month study, which included analysis of 170 clinical encounters, patient exit interviews, and focus groups and interviews with physicians and nursing staff, revealed that patient trust in the physician and security in the physician-patient relationship overrode most patients' concerns about information technology. Moreover, improved work flow and work efficiencies ameliorated staff resistance to implementation. The authors conclude that gradual EHR implementation may help support the development of beneficial physician and staff adaptations, while maintaining positive patient-physician relationships and fostering the sharing of medical information.
Gradual Electronic Health Record Implementation: New Insights on Physician and Patient Adaptation
By Renée R. Shield, Ph.D., et al
Brown University, Providence, R.I.
New Model for Caring for Chronically Ill Older Patients Aids Physicians
At a time when the ranks of primary care physicians are dwindling and the number of chronically ill older patients is rapidly growing, researchers find that a new Guided Care model of support, in which a specially educated registered nurse supplements the care provided by the practice team, yields promising outcomes from the physician's point of view. This cluster-randomized trial of 14 teams of two to five physicians and their chronically ill older patients finds that Guided Care physicians are significantly more satisfied than their usual care peers with their patient/family communication and their knowledge of their patients' clinical conditions. The authors report no statistically significant effects of Guided Care on physicians' satisfaction with management of chronic care, knowledge of patients' personal circumstances, or on their ratings of the practice's care coordination activities.
Physician Satisfaction With Chronic Care Processes: A Cluster-Randomized Trial of Guided Care
By Jill Marsteller, Ph.D., M.P.P., et al
Johns Hopkins Bloomberg School of Public Health, Baltimore, Md.
PHQ-2 Useful and Time-saving Tool for Depression Screening in Primary Care
Reporting on the largest validation study of the 2- and 9-question Patient Health Questionnaires, which have been recommended for depression screening in primary care, researchers find the 2-question screen is very sensitive (proportion of positives correctly identified) for diagnosis of major depression, but the price paid for the high sensitivity was a modest specificity (proportion of negatives correctly identified) when compared with the reference standard interview. Analyzing data on 2,452 patients, researchers found the sensitivity and specificity of the PHQ-2 for diagnosing major depression were 86 percent and 78 percent, respectively, with a score of two or higher, and 61 percent and 92 percent with a score of three or higher. For the longer PHQ-9, the sensitivity and specific were 74 percent and 91 percent, respectively, with a score of 10 or higher. For the PHQ-2, a score of two or higher detected more cases of depression than a score of three or higher. A PHQ-9 score of 10 or higher appeared to detect more depressed patients than the originally described PHQ-9 scoring for major depression. The authors conclude the PHQ-2 can be a useful and time-saving tool in assisting primary care physicians with screening for depression. They call for a reevaluation of the original PHQ-9 criteria for major depression, as the simple additive score of 10 or higher identified more depressed patients than the original and more onerous method for scoring the questionnaire.
Validation of PHQ-2 and PHQ-9 to Screen for Major Depression in the Primary Care Population
By Bruce Arroll, M.B.Ch.B., Ph.D., F.R.N.Z.C.G.P., et al
University of Auckland, New Zealand
Researchers Propose New Model to Describe Diabetics' Health-Seeking Behavior
Diabetic patients make decisions about disease self-management in a nonlinear fashion based on their current needs, seeking and incorporating diverse sources not traditionally viewed as providing health information. Analyzing the transcripts of nine focus groups with 46 diabetic adults, researchers identified five themes that fill important gaps in medicine's understanding of health information seeking, receipt and use by these patients: 1) patients passively receive diabetes health information, 2) patients actively weave their own information web, 3) patients' relationships help them understand and use information, 4) health care professionals help them understand and manage information, and 5) health literacy makes a difference in patients' ability to understand and use information. Based on these findings, the researchers propose a more dynamic model of health-seeking behavior that reflects its nonlinear nature and the interplay of both active information seeking and passive receipt of information.
Health Information Seeking, Receipt, and Use in Diabetes Self-Management
By Daniel R. Longo, Sc.D., et al
Virginia Commonwealth University School of Medicine, Richmond
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 seven 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, the North American Primary Care Research Group, and the College of Family Physicians of Canada. 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