March/April 2006 Annals of Family Medicine Tip Sheet

MARCH/APRIL 2006 ANNALS OF FAMILY MEDICINE TIP SHEET

NEW MOMS NEED MORE REST AND RECOVERY
A study in this issue finds that childbirth-related symptoms, particularly among women whose infants were delivered by cesarean section or who breastfeed, are present at five weeks postpartum. Telephone interviews were conducted five weeks postpartum with 716 women and found on average, women reported six postpartum symptoms, most frequently fatigue (64 percent), and never or rarely feeling refreshed after waking in the morning (50 percent). Other highly reported symptoms included breast discomfort (60 percent) and a decreased desire for sex (52 percent).

In this study, women who had delivered by cesarean section had significantly worse physical health than women who gave birth vaginally. When women were compared by delivery type, women with cesarean sections reported significantly decreased physical function and vitality, role limitations, and greater pain. These women were not completely recovered after five weeks, which the authors point out is just less than the six week period usually allotted for recovery from major surgery. This is likely due to the fact that these mothers were recovering both from childbirth and surgery, and also had infant care responsibilities. With cesarean deliveries reaching a record high of 26 percent of all births in 2002, the authors also assert there is a need by the medical community to reassess the growing practice of cesarean deliveries.

Additionally, the study finds that breastfeeding was significantly associated with more symptoms. Breastfeeding mothers experienced significantly more fatigue, breast symptoms, back and neck pain, more constipation and hemorrhoids, sweating and hot flashes, and less desire for sex than women not breastfeeding.

According to the authors, with many new mothers returning to work soon after childbirth, there is a need to reexamine and broaden the definition of postpartum health, particularly for employed women. They suggest the need for on-going support to the new mother, for efforts to reexamine the cesarean delivery rate, and promote ongoing rest and recovery for new mothers beyond the traditional postpartum period that is common in the United States.
Postpartum Health of Employed Mothers 5 Weeks After Childbirth
By Pat McGovern, Ph.D., et al

QUESTIONING THE EXTERNAL VALIDITY OF RANDOMIZED CONTROL TRIALS – THE GOLD STANDARD OF MEDICAL RESEARCH
A study by Fortin and colleagues, and an accompanying editorial by Starfield highlight the need to focus research on the realities of the types of patients who need care. Fortin et al show that most patients treated for hypertension in primary care have multiple chronic conditions, whereas the clinical trials and practice guidelines based on these trials often exclude patients with comorbidities. Specifically, they find that 89 to 100 percent of patients eligible for five randomly selected randomized control trials had multiple chronic conditions. The authors assert that while the exclusion of patients with comorbidities from randomized control trials might help ensure the internal validity of findings, it likewise compromises the findings' external validity by limiting their widespread applicability. The accompanying editorial by Starfield outlines action steps necessary to design clinical trials, alter the focus of primary health care and develop the basis for judging adequacy of evidence for judging the quality of care based on patient's problems rather than on specific diagnoses. She calls for a broader view of various aspects of health and their interactions in patients and populations.
Randomized Controlled Trials: Do They Have External Validity for Patients With Multiple Comorbidities?
By Martin Fortin, M.D., M.Sc., C.M.F.C, et al
Threads and Yarns: Weaving the Tapestry of Comorbidity
By Barbara Starfield, M.D., M.P.H.

OPIOID DEPENDENCE: A FAMILY PHYSICIAN'S PERSPECTIVE
With the crisis of opioid addiction in the United States growing at a rapid pace, a family physician from Belfast, Maine, reflects on his progress in overcoming personal biases about addicts and the use of buprenorphine, the office-based treatment for opioid dependence. The author acknowledges that this problem is no longer limited to inner-city neighborhoods; it has now infiltrated into the mill towns and fishing villages of his home state of Maine.

Until recently, the benefits and access to therapy for opioid dependence were limited. The approval of buprenorphine for office-based treatment now allows primary care physicians to provide care to patients with opioid addiction. The author provides personal testimony of his experience in treating one young woman who did not have the opportunity to be treated with buprenorphine and how that drove him to go through the process of obtaining a waiver from the FDA for the ability to prescribe this medication. Today, his practice offers a program for the treatment of opioid dependence. He writes about the gratification he finds in knowing he is part of the solution for the national narcotics crisis and not fueling it with poorly managed prescriptions.
Helping "Them": Our Role in Recovery From Opioid Dependence
David Loxterkamp, M.D.

ELECTRONIC HEALTH RECORDS IMPACT ON THE PATIENT-PHYSICIAN ENCOUNTER
Use of an electronic health records (EHR) by physicians in the exam room influences multiple cognitive and social aspects of encounters between physicians and their patients, and produces both intended and unintended consequences. This multimethod study identified 14 factors that shape how EHRs are perceived and used in medical practice: 1) spatial – effect of the physician presence and location of EHRs on interactions between physicians and patients; 2) relational – perceptions of physicians and patients about the EHR and how those perceptions affected its use; 3) educational –issues of developing physicians' proficiency with and improving patients' understandings about EHR use; and 4) structural – institutional and technological forces that influence how physicians perceived their use of an EHR.

The author's assert that seen from the perspective of examination room encounters between physicians and patients, the EHR becomes much like a third party to a conversation. They conclude it would be a mistake to believe that the effects of EHRs will be automatically and universally positive, and that those using EHRs thoughtfully consider their use of this medical technology with patients in order to maximize its therapeutic effectiveness.
Physicians, Patients, and the Electronic Health Record: An Ethnographic Analysis
By William Ventres, M.D., M.A., et al

OTHER STUDIES IN THIS ISSUE:

A CALL FOR COLLABORATION AMONG PRIMARY CARE SPECIALTIES
An essay by five Robert Wood Johnson Foundation Generalist Scholars and a member of their National Advisory Committee calls for active collaboration among generalist disciplines. The authors assert that a lack of collaboration between the academic generalist disciplines – pediatrics, internal medicine and family medicine – which form the sources of the primary care physician workforce – may be hampering each disciplines' efforts and futures because they are competing with each other for patients, trainees and resources. Interspecialty collaboration, they suggest, is likely to lead to a greater focus on the critical role of primary care in the changing health care system to meet patient and population needs, rather than focus on meeting the needs of physicians. They also point out other advantages to collaboration, including enhanced opportunities for trainees, more meaningful primary care research, powerful advocacy and improved patient care.
Facilitating Collaboration Among Academic Generalist Disciplines: A Call to Action
Jean S. Kutner, M.D., M.S.P.H., et al

PRACTICE-SPONSORED WEB SITES ARE EFFECTIVE TOOLS FOR PHYSICIANS
Woolf and colleagues find that the use of a practice-sponsored patient education Web site can be an effective tool to encourage patients to pursue healthy behaviors but that it also has challenges in implementation and fostering use. They conclude that Web sites enable the practice to extend educational outreach beyond the time and place of the clinical encounter, empowering patients with convenient access to the most appropriate information when they need it.
A Practice-Sponsored Web Site to Help Patients Pursue Healthy Behaviors: An ACORN Study
By Steven H. Woolf, M.D., M.P.H., et al

COMMON CAUSE OF INFECTION PREVALENT AMONG U.S. POPULATION
Staphylococcus aureus is a common cause of invasive infection, often found in hospitals and other institutional settings. A study of a nationally representative sample finds more than 2.2 million people carry methicillin-resistant S aureus (MRSA), a drug-resistant strain. Additionally, it finds the prevalence of colonization of S aureus involves an estimated 86.9 million people, or nearly one third of the population. The authors assert this indicates a need for vigilance in infection control procedures and avoidance of unnecessary antibiotics.
Nasal Carriage of Staphylococcus aureus and Methicillin-Resistant S aureus in the United States, 2001-2002
By Arch G. Mainous III, Ph.D., et al

ATTRIBUTES OF AN EXEMPLARY PRACTICE
This case study of an exemplary 15 physician family medicine group finds they score highly on multiple quality measures that include chronic disease care and prevention. The authors identify 12 attributes of this practice that appear to be associated with good care quality, including patient-centeredness, strong support for the physician-patient relationship, a team approach to care, and transparent, data-based, accountable systems. They assert these attributes and others identified in the study are replicable for other practices looking to achieve excellent quality of care.
Transforming Medical Care: Case Study of an Exemplary, Small Medical Group
By Leif I. Solberg, M.D., et al

PROVEN DECISION AID SHOWS NO IMPACT ON TRIAGE OR DIAGNOSTIC ACCURACY IN RURAL HOSPITALS
The use of the Acute Cardiac Ischemia Time-Insensitive Predictive Instrument (ACI-TIPI), which assists in the diagnosis of acute cardiac ischemia, had no statistically significant impact on triage or diagnostic accuracy among patients with chest pain at emergency departments in 10 rural hospitals. In this randomized controlled trial, the average diagnostic accuracy was not statistically different when ACI-TIPI was used (86.8 percent ACI-TIPI off vs. 89.0 percent ACI-TIPI on).
Triage and Diagnosis of Chest Pain in Rural Hospitals: Implementation of the ACI-TIPI in the High Plains Research Network
By John M. Westfall, M.D., M.P.H., et al

PATIENTS RECEIVE MORE COMPREHENSIVE CARE WHEN THEY SEE THEIR FAMILY PHYSICIAN FOR OCCUPATIONAL INJURIES
In a study of a nationally representative sample of patients seen for work-related conditions, researchers found that the majority of visits to family physicians involved patients seeing their regular primary care doctor. Possibly for this reason, at these visits, patients were more likely to have their blood pressure taken, receive diagnostic and screening services, and be prescribed or administered prescription drugs, compared with patients seeing other types of physicians. The author's suggest that these findings may be useful for establishing benchmarks to help family physicians assess the extent and type of services currently provided for work-related conditions, relative to national norms.
Services Provided by Family Physicians for Patients With Occupational Injuries and Illness
By Jong Uk Won, M.D., Dr.P.H., et al

PRIMARY CARE ORIENTATION LINKED TO CHRONIC CARE MANAGEMENT
Physician organizations that have adopted six core attributes of primary care, representing comprehensive health service delivery and a commitment to overall patient health, appear to use more chronic care management practices finds this study of 957 physician organizations. The authors suggest that these findings support the need for a primary care home to strengthen management of chronic care illness.
The Effect of Primary Health Care Orientation on Chronic Care Management
By Julie A. Schmittdiel, Ph.D., et al

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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. Annals is sponsored by six 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 and the North American Primary Care Research Group. 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.


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