May/June 2005 Annals of Family Medicine tip sheet

05/20/05

At a time when chronic diseases have become more widespread and are often poorly controlled, a cluster of three articles in the current issue of Annals tackles important questions about comorbidity and chronic disease. Collectively, they make a compelling argument for a health care system that integrates, rather than fragments, care. A study by Fortin and colleagues defines the extent of the problem, finding that comorbidity is the rule rather than the exception in primary care. A second study out of Duke University Medical Center concludes that it is ineffective, inefficient and impossible to provide appropriate care one disease at a time. Despite this, research in this issue by Barbara Starfield and colleagues out of Johns Hopkins School of Public Health shows that older people with multiple conditions are more likely to get their care from specialists rather than primary care physicians, whose primary role is to integrate the care of the whole person. Collectively, the findings call into question the very organization of our health services. The authors challenge policy makers to consider the staggering extent of comorbidity within the population in any attempt to reengineer primary care.

PRIMARY CARE PHYSICIANS DON'T HAVE ENOUGH TIME TO PROVIDE RECOMMENDED CARE FOR PATIENTS WITH CHRONIC DISEASES
Current practice guidelines for only ten chronic illnesses require more time than primary care physicians have available for patient care overall. Applying guideline recommendations for ten common chronic diseases to a panel of 2,500 primary care patients, researchers found that 3.5 hours a day were required to provide care for these diseases, assuming the conditions were in stable and good control. When accounting for patients whose illness was poorly controlled, the time demand for chronic disease care increased to more than 10 hours per day - exceeding the total amount of physician time available for patient care by 27 percent.

The authors assert that the time required to fully adhere to current guidelines is a fundamental obstacle to the delivery of appropriate and recommended chronic disease care, and they caution guideline developers to carefully consider the time required to follow recommendations, noting that while guidelines may be reasonable when considered one by one, they are impossibly burdensome in the aggregate. They suggest that recommendations be written collaboratively to include diseases that are highly correlated in the same guideline. They also suggest that group visits and patient education by print, video and the Internet can complement care by the clinician. Lastly, they call for a team approach to care wherein physician assistants, nurse practitioners and health educations assume some of the time-consuming tasks of patient education and follow-up.
Is There Time for Management of Patients with Chronic Diseases in Primary Care?
By Truls Ostbye, M.D., Ph.D., et al

PATIENTS WITH MORE THAN ONE ILLNESS ARE THE RULE RATHER THAN THE EXCEPTION IN FAMILY PRACTICE
Most primary care patients have more than one chronic condition, according to a study of 980 adult patients seen in family practice. Researchers found that nine out of ten patients studied had more than one chronic condition, and approximately half of the patients had five or more. The authors assert that such a high prevalence of multiple chronic conditions calls into question the very organization of our health services. They point out that interventions that suit patients with a single disease may not be appropriate for patients with many comorbid conditions, and they suggest that practice guidelines should address special recommendations for patients with multiple conditions. Likewise, clinical trials of drugs would improve their external validity by including such patients. They assert that new health care models that will meet the needs of these patients must emphasize the importance of innovative interventions and the development of new skills in the delivery of primary care.
Prevalence of Multimorbidity Among Adults Seen in Family Practice
By Martin Fortin, M.D., M.Sc., C.M.F.C., et al

ELDERLY PATIENTS WITH MORE THAN ONE DISEASE MORE LIKELY TO RECEIVE MUCH OF THEIR CARE FROM SPECIALIST PHYSICIANS RATHER THAN PRIMARY CARE PHYSICIANS
Elderly patients with more than one disease are likely to receive much of their care from specialist physicians, even though the highly prevalent conditions are not generally considered to require specialist care. Using a five percent random sample of Medicare beneficiaries taken from 1999 Medicare files, researchers examined the frequency of primary care physician and specialist visits in the context of the patients' overall morbidity burdens. They found that a higher morbidity burden is associated with more visits to specialists, but not to primary care physicians. Those patients with the greatest number of conditions had more visits to both primary care and specialist physicians for comorbid conditions than for any individual diagnosis. The authors point out that although patients generally made more visits to specialists than to primary care physicians, this finding was not always the case. For patients with 66 diagnoses, primary care visits for those diagnoses exceeded specialist visits in all morbidity burden groups, but for patients with 87 diagnoses, specialty visits exceeded primary care visits in all morbidity burden groups.

The authors point out that while it is intuitively obvious that patients with more morbidity use more services, it is not obvious that they should be receiving so much care from specialist physicians. They assert that most comorbid conditions receiving care from specialists are extremely common, and there may be legitimate questions about the need for specialist care. They suggest that for many conditions, specialists might better serve as consultants to the primary care physician rather than undertake management strategies directly with individual patients. They conclude that in the search for effectiveness, efficiency and equity in health care services delivery, it is necessary to find alternatives to unnecessary specialty care, especially given the staggering extent of morbidity burden within the population.
Comorbidity and the Use of Primary Care and Specialist Care in the Elderly
By Barbara Starfield, M.D., M.P.H., F.R.C.G.P., et al

HIGH-RISK WOMEN RELUCTANT TO TAKE TAMOXIFEN FOR PREVENTION OF BREAST CANCER
Despite recent trials showing the effectiveness of tamoxifen in reducing the incidence of breast cancer in high-risk women, this study of 345 women at an elevated risk for developing breast cancer found that few women chose to take it. Of the 89 high-risk women studied, only one decided to take tamoxifen for breast cancer chemoprevention. Among the 48 women who discussed the option with their family physician, only three family physicians recommended preventive tamoxifen use. Fear of serious side effects, the perception of being at low risk, and the lack of physician recommendation were the most frequently cited factors in patients' decision not to use tamoxifen.
Tamoxifen for Breast Cancer Chemoprevention: Low Uptake by High-Risk Women After Evaluation of a Breast Lump
By Rebecca Taylor, M.D., M.Sc., et al

LOWER RATES FOR BREAST AND CERVICAL CANCER SCREENING AMONG LATINA IMMIGRANTS HIGH UNINSURANCE RATES CITED AS POSSIBLE CAUSE
Comparing cancer screening rates for 3,340 foreign-born Latinas, U.S.-born Latinas and non-Latina white women, researchers found that foreign-born Latinas had the highest rates of never receiving mammography (21 percent), clinical breast examinations (24 percent), and Pap smears (9 percent). After controlling for socioeconomic factors, however, foreign-born Latinas were more likely to report mammography use in the previous two years and a Pap smear in the previous three years than non-Latina whites. The researchers found that lack of health insurance coverage was the strongest predictor of cancer screening underutilization. They suggest that if access to care for foreign-born Latinas was improved, they would use cancer screening services appropriately.
Breast and Cervical Cancer Screening: Impact of health Insurance Status, Ethnicity, and Nativity of Latinas
By Michael A. Rodriguez, M.D., et al

REPORT RECOMMENDING EXPANSION OF PHYSICIAN WORKFORCE MISSES MARK
In an analysis of the Council on Graduate Medical Education's (COGME) recent physician workforce report, Phillips and colleagues call into question COGME's recommendation to expand the physician workforce. The researchers assert that COGME fails to account for exploding nurse practitioner and physician's assistant workforces combined with a physician workforce that is growing much faster than the general U.S. population. Moreover, they contend that the report fails to accommodate what physicians will actually do in a redesigned healthcare system. They conclude that producing a physician surplus could be far worse than wasted because the investment required and resulting rise in healthcare costs may harm, not help, the health of the people in the United States. Instead, these resources could be applied in ways that improve health.
COGME's 16th Report to Congress: Too Many Physicians Could Be Worse Than Wasted
By Robert L. Phillips, Jr., M.D., M.S.P.H., et al

PATIENTS WANT PHYSICIANS TO INQUIRE ABOUT FAMILY CONFLICT
In a survey of 253 male and female patients, nearly all (97 percent) believed physicians should ask patients about family stress and conflict, and most (94 percent) thought physicians could be helpful. Despite this, only one third of the respondents remembered ever being asked about family conflict by their physicians. Even those reporting a history of relationship violence - perpetrators as well as victims - believed physicians should ask, agreeing that questioning was part of the family physicians' job. In open-ended questioning, respondents indicated that they wanted physicians to ask about family conflict, listen to their stories, and provide information and appropriate referrals.
Patients' Advice to Physicians About Intervening in Family Conflict
By Sandra K. Burge, Ph.D., et al

SPECIAL ONLINE SUPPLEMENT: "CONTEMPORARY CHALLENGES FOR PRACTICE-BASED RESEARCH NETWORKS"
The May/June 2005 issue of Annals features an online supplement on practice-based research methods. Sponsored by the Primary Care Center of the Agency for Research and Quality, the supplement provides ideas and tools for furthering the development of the practice-based research networks that are a crucial engine for primary care research.

OTHER STUDIES IN THIS ISSUE:

U.S. PREVENTIVE SERVICES TASK FORCE UPDATES GONORRHEA SCREENING RECOMMENDATION
In an updated recommendation statement, the U.S. Preventive Services Task Force recommends screening high-risk women for gonorrhea infection but finds insufficient evidence to recommend for or against screening for high-risk men. The Task Force finds that harms outweigh the benefit of screening low-risk men and women but finds strong evidence to support neonatal ocular prophylactic medication. The Task Force recommends screening high-risk pregnant women and finds insufficient evidence to recommend for or against screening normal risk pregnant women.
Screening for Gonorrhea: Recommendation Statement
U.S. Preventive Services Task Force

QUALITY IMPROVEMENT COLLABORATIVE IN ASTHMA CARE IMPROVED PROCESSES BUT NOT HEALTH OUTCOMES OF ASTHMATIC ADULTS
In the first controlled evaluation of an Institute for Healthcare Improvement Breakthrough Series Collaborative for asthma care, researchers found that the intervention improved patient self-management practices (attending educational sessions, having a written action plan, setting goals, monitoring peak flow rates, and using long-term asthma medications), but had no effect on health-related outcomes (quality of life, number of bed days caused by asthma-related illness, and acute care service use).
Evaluation of a Quality Improvement Collaborative in Asthma Care: Does it Improve Processes and Outcomes of Care?
By Matthias Schonlau, Ph.D., et al

MULTILEVEL ANALYSIS FINDS NO ASSOCIATION BETWEEN PHYSICIANS' INTERPERSONAL STYLE AND PATIENTS' HEALTH OUTCOMES
The relationship between physicians' interpersonal style and patient health outcomes appears to have been well established in previous research. Franks and colleagues find, however, that this association disappears when more sophisticated multilevel modeling techniques are used. They conclude that multilevel analyses will be necessary to tease out the components of physician behaviors that contribute to better patient outcomes.
Are Patients' Ratings of their Physicians Related to Health Outcomes?
By Peter Franks, M.D., et al

AN ATTEMPT TO DEFINE "HEALING"
In an effort to clarify the meaning of healing, Egnew analyzed in-depth interviews with several well-known physicians about their perceptions of healing. Highly personal themes of wholeness, narrative and spirituality contribute to the author's operational definition of healing as the personal experience of the transcendence of suffering.
The Meaning of Healing: Transcending Suffering
By Thomas R. Egnew, Ed.D., L.C.S.W.

EVIDENCE VS. EXPERIENCE: TWO APPROACHES TO CLINICAL DECISION MAKING
An essay explores generational differences among physicians in the use of evidence rather than experience as the basis for clinical decisions. The Irreverent Nature of Evidence
By Zachary Flake, M.D.

Source: Eurekalert & others

Last reviewed: By John M. Grohol, Psy.D. on 21 Feb 2009
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