Adolescents Rarely Visit the Doctor for Preventive Care
Despite guidelines by the American Medical Association and American Academy of Pediatrics recommending annual preventive care services visits for all patients aged 11 to 21 years, researchers found that less than 2 percent of those studied met these recommendations. An analysis of claims data from a large Midwest health plan with more than 700,000 members found that one-third of teenagers with four or more years of continuous enrollment had no preventive care visits from age 13 through 17 years, and another 40 percent had only one such visit, despite the fact that they all had insurance without a deductible or co-pay for such visits. Nonpreventive care visits were more frequent in all age groups, averaging about one per year at 11 years, climbing to about 1.5 per year at 17 years. That adolescents are visiting the doctor for other reasons, the authors assert, argues strongly for viewing all visits as an opportunity to provide preventive care services, and systems should be set up to make that possible, even in busy practices with short clinician encounters.
Adolescent Primary Care Visit Patterns
By James D. Nordin, M.D., M.P.H., et al
HealthPartners Research Foundation, Minneapolis, Minn.
Many Family Physicians Refer Patients Elsewhere for Some Vaccines
Although many family medicine practices provide most routinely recommended child, adolescent and adult vaccines, smaller practices report difficulty offering a full array of vaccine products, instead referring patients elsewhere. In a survey of 637 of its members, the American Academy of Family Physicians found that 80 percent reported providing most routinely recommended vaccines at their practice sites. A significant proportion, however, reported referring patients elsewhere for some vaccines (44 percent for children and adolescent vaccines and 54 percent for adult vaccines), with the most frequent referral location being a public health department. The authors note that a higher proportion of solo and two-physician practices than larger practices reported referring patients. Lack of adequate payment was cited by half of those who refer patients as the primary reason for referral outside the practice. Notably, one-half of respondents indicated they did not participate in the federally-funded Vaccines for Children program. Administrative requirements were cited as a reason by a large proportion of nonparticipants. The authors assert that nonparticipation in VFC and the inability of many practices to offer a full array of vaccine products has implications for the role of family medicine practices as medical homes, as well as for the nation's vaccine infrastructure. Given that one-third of parents name a family physician as the source of care for their children, not addressing these issues in a comprehensive fashion increases the vulnerability of children in our country to suffer from inadequate preventive services, they conclude.
Vaccines Provided by Family Physicians
By Doug Campos-Outcalt, M.D., M.P.A., et al
University of Arizona College of Medicine, Phoenix
UK Policy Changes to Improve Access to Care Have Detrimental Effect on Continuity
Analyzing the effects of policy and practice changes in the United Kingdom intended to improve patient access, researchers found that although there was a modest improvement in access to care for patients with chronic illness, the changes had negative effects on continuity. Patients reported seeing their usual physician less often and gave lower ratings for care continuity and satisfaction. Analyzing data from serial samples of patients from 42 family practices in England, researchers found no significant changes in quality of care reported by patients before and after the introduction of the government Quality and Outcomes Framework program for communication, nursing care, coordination and overall satisfaction. For patients with chronic disease, some aspects of urgent access improved significantly (ability to book an urgent appointment and the satisfaction with this experience); however, this improvement wasn't experienced by patients without a long-term condition. Importantly, patients in both groups reported seeing their usual physician less often and gave lower satisfaction ratings for continuity of care in 2007 compared with 2003. The authors conclude that policy initiatives privileging access to primary care in the United Kingdom – including incentivizing the availability of appointments within 48 hours – need to be balanced against the fundamental primary care tenant of continuity. That continuity of care may be compromised by initiatives oriented toward enhanced access should inform the current discussion in the United States about the patient-centered medical home.
Changes in Patient Experiences of Primary Care During Health Service Reforms in England Between 2003 and 2007
By Stephen M. Campbell, Ph.D., et al
University of Manchester, United Kingdom
Alcohol Consumption Not Associated with Sleep Problems
The widely held belief that drinking and sleep problems go together did not hold up in a study of 1,699 adult patients from 40 different primary care practices. While hazardous drinking and numerous sleep problems were prevalent in this large cross-sectional national survey of primary care patients, researchers found no associations between drinking status and self-reported measures of insomnia, overall sleep quality or restless legs syndrome symptoms. They did find, however, that self-reported use of alcohol for sleep was strongly associated with hazardous drinking (odds ratio of 4.6). The authors assert that using alcohol to sleep might be used as a prompt for physicians to inquire about excessive alcohol use.
Alcohol and Sleep Problems in Primary Care Patients: A Report from the AAFP National Research Network
By Daniel C. Vinson, M.D., M.S.P.H., et al
University of Missouri, Columbia
Web-based Adverse Drug Event Reporting System Feasible for Office Practices
Medication errors and adverse drug event reporting using a Web-based system appears to be feasible in the outpatient setting, where it has historically had minimal uptake because of cost, busy workflows, liability concerns, and the complexity of outpatient prescribing. Field testing of a national medication event reporting system designed specifically for office practice by 220 physicians and staff from 24 primary care practices revealed little difficulty and minimal time demand on the part of participants.
During the course of the 10-week field test, participants identified errors nearly equally distributed throughout the medication management spectrum in four major categories: ordering, dispensing, receiving, and documenting. At least 43 percent of participants reported one or more medication events during the study period, an extraordinary participation rate for event reporting. The most frequent contributors to medication errors and adverse drug events were communication problems (41 percent) and knowledge deficits (22 percent). Many participants indicated the reporting process positively impacted the safety culture of their practices by increasing awareness of medication errors and adverse drug events and prompting changes in office routines for managing medications; however, 36 percent of participants also felt the event reporting increased the fear of repercussion in the practice. Participants identified time pressure as the main barrier to reporting.
Field Test Results of a New Ambulatory Care Medication Error and Adverse Drug Event Reporting System – MEADERS
By John Hickner, M.D., M.Sc., et al
Cleveland Clinic, Ohio
Impact of Reassigning Patients to New Physicians as Part of Practice Redesign
Practice redesign initiatives aimed at improving the patient experience may have unanticipated consequences. A major quality improvement initiative of the Seattle-based Group Health Cooperative's medical home project was to strengthen the doctor-patient relationship by reducing clinician panel size, requiring the reassignment of approximately one-quarter of the practice's 8,000 patients to new clinicians. Examining the effects of reassignment, researchers found that reassigned patients were less likely to use primary care services but equally likely to use expensive emergency room care as patients who were retained by their existing physicians. Interestingly, the authors report that even with the disruption, reassigned patients were no less satisfied with their care experience. They note that contrary to policy concerns, physicians in this demonstration project, when given the chance to retain patients in their panels, chose to retain – not drop – those patients who were older and sicker. Patients who were less connected with a physician were more likely to be reassigned. The authors express concern about the decreased use of primary care among reassigned patients, given that one of the goals of medical home implementation is to strengthen the connection between patients and their primary care physician to prevent episodes requiring emergency care. To ensure that practice redesign does not adversely affect relationships with these younger, healthier patients, the researchers call for more to be done proactively to bind patients to their new physicians and practice teams after being reassigned.
Implications of Reassigning Patients for the Medical Home: A Case Study
By Katie Coleman, M.S.P.H., et al
Group Health Research Institute, Seattle, Wash.
Patients Say Oncology Team, Not Family Physician, Responsible for Cancer Care During Treatment
Throughout the cancer care trajectory, less than half of patients with lung cancer report a high degree of family physician involvement in most aspects of cancer care. The study of 395 patients with lung cancer in the province of Quebec, Canada, found that a majority of patients (more than 90 percent) identified the oncology team or oncologists as mainly responsible for their cancer care throughout their cancer journey, except in the advanced/terminal phase, where a majority (70 percent) attributed this role to their family physician. Immediately following diagnosis, only 15 percent of patients perceived a shared care pattern between their family physician and oncologists, but this proportion increased with cancer progression. Interestingly, most patients would have liked their family physician to be more involved in all aspects of cancer care. In light of this desire, the authors call for better communication and collaboration between family physicians and the oncology team to facilitate shared care in cancer follow-up.
Family Physician Involvement in Cancer Care Follow-up: The Experience of a Cohort of Patients with Lung Cancer
By Michèle Aubin, M.D., Ph.D., C.C.F.P., F.C.F.P., et al
Quebec Center of Excellence on Aging, Canada
Dearth of Guidelines for the Primary Care of Lesbian, Gay and Bisexual People
A systematic review of existing guidelines in the United States, Canada, United Kingdom, Australia, Ireland and New Zealand for the primary care of lesbian, gay and bisexual people identified only 11 worthy of full appraisal, none of which met appropriate standards of quality and developmental rigor as measured by the validated Appraisal of Guidelines for Research and Evaluation instrument, and only two of which were specifically designed for primary care. Researchers did find, however, that the currently available guidelines are philosophically and practically consistent, and provide a degree of evidence-based clinical and systems support to primary care clinicians. There is a need, they conclude, for evidence-based LGB guidelines that are more rigorously developed, disseminated, and evaluated specifically for the primary care setting.
Guidelines for the Primary Care of Lesbian, Gay, and Bisexual People: A Systematic Review
By Ruth McNair, M.B.B.S., D.R.A.N.-Z.C.O.G., D.A. (UK), F.R.A.C.G.P., Ph.D., et al
University of Melbourne, Australia
Pramlintide As Adjunct Therapy for Type 1 and Type 2 Diabetes, A Review
A review of randomized controlled trials for a new supplemental drug, pramlintide, as a complementary therapy for maintaining glycemic and weight control in adults with type 1 or type 2 diabetes finds modest effectiveness. The analysis, which included seven short-term trials, found pramlintide improved glycated hemoglobin levels by 0.2 to 0.4 percent compared with placebo in both type 1 and type 2 diabetes populations, except when type 1 was managed with intensive insulin treatment, for which there was no significant difference between groups. Weight loss was observed with pramlintide in both type 1 and type 2 diabetes, whereas placebo-treated patients tended to gain weight. The authors found little evidence to suggest that pramlintide is significantly better than placebo at reducing fasting plasma glucose, postprandial glucose, or total insulin dose. Moreover, the authors found pramlintide-treated patients experienced more frequent nausea and severe hypoglycemia compared with patients treated with placebo. The authors conclude that although improvements in glycated hemoglobin levels were small, incremental improvements from the addition of pramlintide may ultimately contribute to long-term glycemic control and cardiovascular health when combined with other means of improving glycemic control. They call for further studies to evaluate the long-term health outcomes and adverse events associated with pramlintide to determine whether the benefits outweigh risks.
Efficacy and Harms of the Hypoglycemic Agent Pramlintide in Diabetes Mellitus
By Nancy J. Lee, Pharm.D., et al
Oregon Health & Science University, Portland
What One Physician's Foot Injury Taught Him About Dealing with Chronic Disease
A primary care physician reflects on how his experience with a chronic foot injury taught him important lessons about living with a chronic condition: people with chronic conditions may blame themselves, may feel guilty that other people have to help them, often have depression that may be worse than the chronic condition itself, and may lose confidence in their capacity to do anything useful in life. He concludes these feelings need to be elicited and addressed when physicians provide care to people with chronic conditions.
Lessons From My Left Foot
By Thomas Bodenheimer, M.D., et al
University of California, San Francisco
Mentor-Mentee Experience Illustrates How Both Student and Teacher Can Learn Through Vulnerability
In an essay drawn from their work journals, a family physician resident and visiting clinical mentor chronicle their experiences together in an Advanced Clinical Mentoring program that included direct clinical observation and feedback sessions. The authors describe how they both developed personally as they revealed thoughts and emotions during teaching interactions.
Learning Through Vulnerability: A Mentor-Mentee Experience
By Kohar Jones, M.D. and Shmuel Reis, M.D., M.H.P.E.
University of Chicago Medical Center and Technion-Israel Institute of Technology, Haifa, Israel
A Physician's Reflection on His Relief Work in Haiti
A family physician shares his experience as a relief worker following the January 2010 earthquake in Haiti. Reflecting on his week-long stay, including the physical and emotional toll, and the challenge of giving adequate and meaningful health care in a country that is broken, the author concludes that humans are able to accomplish immense good when we work together for a common purpose.
Snapshots of Haiti: A Physician's Relief Work in a Country in Crisis
By Robert C. McKersie, M.D.
Greater Lawrence Family Health Center, Boxford, Mass.
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