July/August 2005 Annals of Family Medicine tip sheet

07/22/05

PERSONS CONSIDERED PREHYPERTENSIVE AT A GREATER RISK FOR CARDIOVASCULAR MORBIDITY
Prehypertension is associated with increased risk for cardiovascular disease, according to a study from researchers with the Medical University of South Carolina. These findings support the latest recommendations from the Joint National Commission on Prevention, Detection, Evaluation, and treatment of High Blood Pressure (JNC 7), which added prehypertension as a new risk category. The expert panel recommended lifestyle modifications for all prehypertensive people, defined as those with systolic blood pressure levels between 120 and 139 mm Hg, or diastolic blood pressure levels between 80 and 90 mm Hg.

Analyzing nationally-representative data with 18 years of follow-up, researchers found that people with prehypertension are 1.79 times as likely to have a major cardiovascular event than those with normal blood pressure. Even after adjustment for cardiovascular risk factors, researchers found that the relationship between prehypertension and cardiovascular disease persists with a 1.32 times greater risk of major cardiovascular event over normal blood pressure. The authors assert that these findings support recommendations for physicians to actively target lifestyle modifications and multiple risk reduction in their prehypertensive patients. Epidemiologic data from the 1999-2000 National Health and Nutrition Examination Survey estimates that 31 percent of the population is prehypertensive and more than 88 percent of these people have a least one major cardiovascular risk factor.

An accompanying editorial to this article considers the study's implications along with the recent recommendations of the JNC 7 for practicing physicians. The editorial asserts that given the risk associated with prehypertension and its increasing prevalence in practice, primary care physicians must think about how they practice when it comes to blood pressure and what might need to be done beyond clinical practices to work with patients on making healthy lifestyle changes.
Prehypertension and Cardiovascular Morbity
By Heather Liszka, M.D., et al
Prehypertension, Patient Outcomes, and the Knowledge Base of Family Medicine
By Lee Green, M.D., M.P.H.

HIGH USERS OF PRIMARY CARE ARE OVER-SERVICED BUT UNDERSERVED
Many persistently high users of primary care appear to be over-serviced but underserved, with underlying problems that can be better addressed by a non-medical approach. Analyzing outpatient visits of approximately 58,000 people to primary care physicians in a Midwestern city, the study finds that a small proportion of patients (2 percent) consume a large proportion of primary care visits (18 percent). Among these persistently high-use patients were a substantial number of patients with unstable chronic medical conditions who are candidates for disease management efforts. There also were a number of patients with illnesses involving both the mind and body who could benefit from psychosocial support. Nonmedical approaches, the authors assert, might better address these patients' underlying needs than our current medical system, which focuses on alleviating physical symptoms.
Predicting Persistently High Primary Care Use
By James M. Naessens, M.P.H., et al

USE OF ELECTRONIC MEDICAL RECORD HAS LITTLE IMPACT ON IMPROVED DIABETES QUALITY OF CARE
Analyzing data from a 5-year longitudinal study of 122 diabetic adults, researchers found that the use of electronic medical records (EMR) did not lead to improved clinical outcomes. While EMR use was associated with an increased frequency of testing for long-term blood glucose control and bad cholesterol levels, it did not improve glucose control among diabetic patients, which is a predictor of future risk of complications and increased health care costs. The data suggests that despite substantial cost and increasing technical sophistication of EMRs, EMR use failed to achieve desirable levels of clinical improvement. The authors assert that if EMRs are to fulfill their promise as care improvement tools, less disruptive implementation strategies and more sophisticated clinical decision support may be needed. Additionally, they suggest that using an EMR may help activate patients to be more involved in their own care. They conclude that in the absence of more advanced EMR capabilities, less expensive and less disruptive care-improvement strategies may improve chronic disease as effectively as EMRs.
Impact of an Electronic Medical Record on Diabetes Quality of Care
By Patrick J. O'Connor, M.D., M.P.H., et al

CONTINUITY OF CARE HIGHLY VALUED BY FAMILY PHYSICIANS IN THREE COUNTRIES
A cross-national survey of 1,523 family physicians and general practitioners in England and Wales, the United States, and the Netherlands, found family physicians place a high value on maintaining the patient-physician relationship through personal continuity. This was apparent even in strikingly different health care systems with different patient expectations and cultural influences. Doctors in all three countries felt strongly that personal continuity of care remained an important aspect of good quality care to their patients. Interestingly, personal continuity of care was valued most by family physicians from the United States, even though (or perhaps because) the current U.S. health care system makes it difficult to maintain personal continuity.
Continuity of Care: Is the Personal Doctor Still Important? A Survey of General Practitioners and Family Physicians in England and Wales, United States, and the Netherlands
By Tim Stokes, Ph.D., M.P.H., M.B.Ch.B., et al

PATIENTS TREATED WITH DIGNITY REPORT HIGHER SATISFACTION, TREATMENT ADHERENCE, AND RECEIPT OF PREVENTIVE CARE
Patients who are treated with dignity and who are involved in decisions about their health care treatment report higher levels of satisfaction, adherence to treatment, and receipt of optimal preventive services. Analyzing data on 6,722 adults from the Commonwealth Fund 2001 Health Care Quality Survey, researchers found that the probability of reporting a high level of satisfaction was higher for those treated with than not treated with dignity and for those involved in, versus not involved in, decision-making. Being involved in decisions was significantly associated with adherence for whites, whereas being treated with dignity was significantly associated with adherence for racial/ethnic minorities. The authors assert that these results emphasize the importance for physicians to not only involve their patients in decisions but to also treat them with dignity.
Do Patients Treated With Dignity Report Higher Satisfaction, Adherence, and Receipt of Preventive Care?
By Mary Catherine Beach, M.D., M.P.H., et al

PRESCRIPTION FOR HEALTH PROGRAM IDENTIFIES STRATEGIES FOR PROMOTING HEALTHY PATIENT BEHAVIORS
In a supplement to the July/August issue, the Robert Wood Johnson Foundation's 5-year, $9 million Prescription for Health initiative reports its early findings. The program aims to identify, test and evaluate the feasibility of practical, evidence-based tools and techniques for improving the delivery and effectiveness of health behavior change strategies in real primary care practices. In 4 synthesis analyses, the supplement reports over-arching lessons learned from a first round of funding that enabled primary care practices to develop and test some of their best practical ideas about how to help people avoid and change unhealthy behaviors and adopt and maintain healthier lives. Lessons learned by 16 practice-based research networks are depicted in brief peer-reviewed articles. The Prescription for Health program was a joint effort of the Robert Wood Johnson Foundation, the Agency for Healthcare Research and Quality and the nation's practice-based research networks.
Robert Wood Johnson Foundation with support from the Agency for Healthcare Research and Quality. Prescription for health: changing primary care practice to foster healthy behaviors.
Supplement to the July/August 2005 issue of the Annals of Family Medicine

OTHER STUDIES IN THIS ISSUE:

SUCCESSFUL ELECTRONIC MEDICAL RECORD SYSTEMS REQUIRE THOUGHTFUL IMPLEMENTATION
Implementing an electronic medical record (EMR) system in a medical practice without proper communication, decision-making processes and methods for addressing conflicts can limit the overall effectiveness the EMR may have in improving quality of care and productivity within the practice. A qualitative case study of a private family medicine practice that had recently purchased and implemented an EMR showed that dysfunctional communication patterns, the distribution of decision-making power and internal conflicts limited the effective implementation and use of the EMR. In this practice, use of the EMR offered little or no improvement over use of paper charts.
Implementing An Electronic Medical Record in a Family Medicine Practice: Communication, Decision-Making, and Conflict
By Jesse C. Crosson, Ph.D., et al

SHOW OF EMOTION AND SHARING OF PERSONAL EXPERIENCES BY A PHYSICIAN MAY BENEFIT THE PATIENT
A qualitative study of nine physicians finds that a spontaneous show of emotions from a physician may help the patient, and that personal disclosure and the sharing personal experiences may lead to constructive interactions.
The Doctor Who Cried: A Qualitative Study About the Doctor's Vulnerability
By Kirsti Malterud, M.D. Ph.D., et al

PERCEPTIONS OF PRIMARY CARE HIGH-USERS DIFFER FROM THAT OF PRIMARY CARE PHYSICIANS
The criteria held by family doctors and researchers regarding the appropriate rate of consultations in primary care may not be shared by patients who make frequent office visits. These patients want their family physician to acknowledge their symptoms and provide reassurance. Moreover, their expectations of their physician visits were complex and included the presentation of old and new symptoms implicitly anchored in the framework of an illness.
Stories from Frequent Attenders: A Qualitative Study in Primary Care
By Paula Hodgson, et al

STUDY EXAMINES PHYSICIAN TRUST AMONG JAPANESE-AMERICAN AND JAPANESE PATIENTS
In this cross-national study of nearly 1,000 Japanese and Japanese-American patients, researchers found that decreased patient desire for autonomy, being married, greater religiosity and a physician-patient relationship of longer duration were associated with greater trust in one's physician. Overall, English-speaking Japanese-American participants and Japanese-speaking Japanese-American participants reported more trust than Japanese respondents living in Japan. Among Japanese Americans, more acculturated respondents reported more trust, and Japanese physicians were trusted more than physicians of another ethnicity.
Trust in One's Physician: The Role of Ethnic Match, Autonomy, Acculturation, and Religiosity Among Japanese and Japanese Americans
By Derjung M. Tarn, M.D., M.S, et al

STUDY IDENTIFIES FEATURES THAT SUPPORT INNOVATION AND ORGANIZATIONAL CAPACITY IN PRIMARY CARE GROUPS
In a study of four fledgling Primary Care Organizations in the United Kingdom, researchers identified five features associated with increased organizational capacity for innovation: 1) clear structures and vision for corporate and clinical governance, 2) opportunity for people to learn at all organizational levels, 3) both clinicians and managers in leadership roles that encourage participation, 4) the right timing for adapting initiative, and 5) external facilitation that allow people to make sense of their experiences. A whole system participatory action research model that enabled people from different backgrounds to make sense of diverse research insights, was used to identify these features. The authors assert that this approach has great potential to foster innovation and capacity building in health care.
Increasing Capacity for Innovation In Bureaucratic Primary Care Organizations - A Whole System Participatory Action Research Project
By Paul Thomas, F.R.C.G.P., M.D., et al

LITTLE SHOULD BE LEFT TO CHANCE IN TEAM-BASED QUALITATIVE RESEARCH
To improve team-based qualitative research, systematic methods, processes and documentation are required. Drawing upon a decade of experience working on teams and through trials of tools and techniques, expert consultation and literature review, the authors conclude that in a team setting, little should be left to chance. The goal should be to foster team processes for efficient, rigorous and thoughtful analysis.
Enhance Your Team-Based Qualitative Research
By Douglas Fernald, M.A., et al

A PHYSICIAN WRITER FINDS TIME TO WRITE
An experienced physician writer ponders different strategies for finding time to write. As the author examines how busy people find the time to write, three types of writers are identified: deck clearers, wedgers and schedulers.
Making Time to Write?
By Lucy M. Candib, M.D.

ON THIS DAY OF MOTHERS AND SONS
A physician reflects on a difficult day when she was faced with telling a pregnant mother that her unborn baby had passed away in her womb. The author recalls the irony of this as she herself was celebrating the eighth birthday of her own son that same day.
On This Day of Mothers and Sons
By Sara G. Shields, M.S., M.S.

Source: Eurekalert & others

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