September/October Annals of Family Medicine tip sheetDuring the recent economic downturn, Medicaid programs in all 50 states implemented cost-saving strategies including benefit reductions, cost-sharing and tightened administrative rules. These cost-saving strategies have significant adverse impact on health care access and utilization among Medicaid beneficiaries concludes this study of 2,783 adults in the Oregon Health Plan. Importantly, the impact was felt by these patients within the first 10 months of these changes being made.
Medicaid program reductions resulted in 31 percent of enrolled adults losing coverage and 15 percent reporting disrupted coverage. Furthermore, 67 percent of those who lost coverage reported unmet health care needs, compared with 40 percent of those with disrupted coverage and 28 percent of those with stable coverage. The authors assert that as many states continue to struggle with financing their Medicaid programs and the federal budget proposes deep cuts in Medicaid funding, these findings give rise to a serious discussion about the potentially negative impacts of policy options that include increasing cost sharing or limiting enrollment in Medicaid programs. Short-Term Impacts of Coverage Loss in Medicaid Population: Early Results from a Prospective Cohort Study of the Oregon Health Plan By Matthew J. Carlson, Ph.D., et al
INSURANCE STATUS AFFECTS PHYSICIAN'S DECISIONS ON CLINICAL CARE
Physicians incorporate patients' insurance status into their clinical decision making and frequently alter their clinical management as a result. This study of 25 physicians in Washington, D.C., finds that in a single day of reporting, 88 percent of participating physicians reported making at least one change in clinical management as a result of a patient's insurance status. The physicians reported considering their patient's insurance status in nearly half of all visits and making changes in over one quarter of visits. Of the 409 physician-patient encounters in the sample, physicians discussed insurance issues with patients during 62 percent of visits during which they made a change in management due to insurance status. The authors suggest that additional research is needed to understand the effect of these changes on patient health and to assist both doctors and patients in maximizing the quality of care delivered within the constraints of the current insurance system. Primary Care Physicians' Perceptions of the Effect of Insurance Status on Clinical Decision Making By David S. Meyers, M.D., et al
RENEWING THE HEALTH CARE REFORM DEBATE
An accompanying editorial to the previous two studies argues that the health care situation in the United States is in many ways worse than twenty years ago. The authors call for renewed efforts to reform health care in light of the increasing numbers of the uninsured, decreased charity care and poor quality health care. In particular, they call upon physicians and public health professionals to work toward improving access to health and public health as well as access to care and the health care system. History and Renewing the Health Care Reform Debate By Kathryn Pitkin Derose, Ph.D., M.P.H., et al
FAMILY MEDICINE DEPARTMENTS CAN HELP RENEW ACADEMIC HEALTH CENTERS
A special supplement to the September/October issue highlights that departments of family medicine are uniquely positioned to play a leadership role in the revitalization of academic health centers (AHCs) to ensure they remain relevant to society's most pressing needs. The supplement features five case studies and accompanying commentaries from deans and other leaders of academic medicine that showcase best practices from five AHCs in five key areas: 1) ambulatory and primary care 2) indigent care 3) education in community and international settings 4) workforce policy and practice and 5) translational research. The case studies demonstrate how departments of family medicine have contributed to and provided leadership in the necessary transformation of AHCs.
The authors assert that family medicine, with its expertise in ambulatory care, systems of care and community-oriented education and research, can help lead in changing the direction of AHCs. The nation's 126 academic health centers (AHCs), which train a considerable portion of today's health care professionals, conduct important research and provide substantial amounts of clinical care, especially to underserved and uninsured populations, are falling short of their responsibilities amid a changing health care landscape. This supplement is an effort of the Association of Departments of Family Medicine (ADFM), in collaboration with six family medicine organizations. Shaping the Future of Academic Health Centers: The Role of Family Medicine Faculty and Departments By Warren P. Newton, M.D., M.P.H., et al
UNDIAGNOSED DIABETES CAN HAVE DETRIMENTAL CONSEQUENCES
Among people with undiagnosed diabetes, 27 percent have nephropathy and 22 percent have neuropathy. Both of these conditions occur at more than twice the rate of people without diabetes. This look at nationally-representative data of adults older than 40 years adds to the accumulating literature documenting that undiagnosed diabetes is not a benign condition and represents a significant public health concern. With nearly 5 million adults in the U.S. suffering from undiagnosed diabetes, the authors assert these findings may influence policies about early screening for diabetes. They recommend more aggressive use of screening based on risk stratification for diabetes is in order and should be appropriately reimbursed. Evidence of Nephropathy, Peripheral Neuropathy in United States Adults with Undiagnosed Diabetes By Richelle J. Koopman, M.D., M.S., et al
OTHER STUDIES IN THIS ISSUE
NIGHT SWEATS ASSOCIATED WITH OTHER SLEEP DISTURBANCES
Nights sweats very common and associated with a number of other sleep disturbances finds this study of patients in 10 primary care physicians' offices. Of the 363 patients interviewed, 34 percent reported night sweats, half of whom reported saturating their bed clothes. Night sweats were associated with daytime tiredness, waking up with a bitter taste in the mouth, legs jerking during sleep and waking with pain in the night. These findings, the authors assert, may begin to identify a syndrome of coexisting sleep problems and physicians should consider asking about sleep quality and sleep-related symptoms when patients report night sweats. Associations Between Night Sweats and Other Sleep Disturbances: An OKPRN Study By James W. Mold, M.D., M.P.H., et al
PSYCHOLOGICAL DISTRESS IS MORE SEVERE IN PATIENTS WITH MULTIPLE AND SEVERE CHRONIC ILLNESS
Psychological distress increases with multimorbidity when severity of the disease is accounted for finds this study of 238 patients from 21 family physician practices. The estimated risk of psychological distress increased almost five times for those patients with the highest burden of disease. The authors recommend that clinicians should be aware of the possible presence of psychological distress in patients with multiple and severe chronic illness, and mental health professionals should consider the effects of physical illness in patients with psychiatric symptoms. Psychological Distress and Multimorbidity in Primary Care By Martin Fortin, M.D., M.Sc., et al
PARADOXES AFFECT PHYSICIANS DECISIONS IN REPORTING ELDER ABUSE
Despite mandatory reporting laws for elder abuse, physicians have low rates of reporting the abuse. This qualitative study of 20 primary care physicians revealed three paradoxes expressed by physicians about the mandatory reporting of elder abuse. Of the physicians surveyed, 50 percent were concerned about the contradictory effects of reporting elder abuse on patient rapport – potentially helping the patient but potentially damaging the patient's trust in the physician – and felt it both increased and decreased the likelihood of reporting. These paradoxes appear to be primarily hidden or unconscious, yet they influence the conscious decision process of whether or not to report. The authors suggest that these paradoxes and alternative modes of managing paradoxes are important issues to address in educational and training programs for physicians. Mandatory Reporting of Elder Abuse: Between a Rock and a Hard Place By Michael A. Rodriguez, M.D., M.Ph., et al
FAMILY MEDICINE RESEARCH HAS ROOM FOR GROWTH
National Institutes of Health (NIH) funding is a major source of funding for medical schools conducting medical research. This analysis of NIH awards to departments of family medicine in 2003 finds the 17 investigator-initiated (R01) awards to family physicians represented only 0.055 percent of the 30,886 R01 grants awarded that year. The majority of NIH awards to family medicine departments went to principal investigators in noncore organizational components, where most physicians PIs were not family physicians. The authors state that these findings reinforce the critical importance of increasing the research capacity in family medicine. NIH Funding in Family Medicine: An Analysis of 2003 Awards By Howard K. Rabinowitz, M.D., et al
PATIENT-PHYSICIAN RELATIONSHIP PLAYS ROLE IN DISCUSSING PROS AND CONS OF PSA TESTING
An examination of nationally representative data finds that 63 percent of men have discussion with their physician of the pros and cons of prostate-specific antigen (PSA) before testing. Analysis of data from 2,184 men over the age of 50 years finds that these discussions are more likely to occur among African American men, those with a usual source of care and when physicians initiate the testing. The authors suggest that characteristics of the patient-physician relationship are more central to the discussion of risks and benefits than patient attributes. U.S. Men Discussing Prostate-Specific Antigen Tests With a Physician By Stephanie L. McFall, Ph.D., et al
IN-HOSPITAL MEDICAL INJURIES ARE INFLATED WHEN CO-MORBIDITY IS NOT
Estimates of in-hospital medical injuries are inflated if comorbidity is not accounted for concludes this study. Using a sophisticated surveillance system, 562,317 acute care hospital discharges were evaluated and 13.8 percent (77,666) were associated with at least one medical injury. Patients who sustained a medical injury were more likely to be older, have a higher comorbidity index and experience a longer length of stay and greater number of procedures. The authors assert these findings suggest the number of deaths directly attributable to medical injury may not be as high as previous estimates. They state these findings have implications for the care family physicians provide for hospitalized patients and for the advice they provide their patients who are concerned about the risks of hospitalization. Excess Mortality Due to Medical Injury By Linda N. Meurer, M.D., M.P.H., et al
METHODOLOGICAL THINK TANKS ARE USEFUL
A 10-year review of outcomes of a methodological think tank held at a primary care research meeting finds that methodological think tanks are successful in fostering funded research. Findings include three lessons learned: 1) the importance of careful selection of participating methodologists, 2) all think tank communities of inquiry must go through four stages of development from "pseudocommunity" to "community" and 3) the critical importance of listening by the investigator. The authors assert that researchers and academic departments can use this process locally to develop innovative research designs. Creating Innovative Research Designs: The 10-Year Methodological Think Tank Case Study By David Katrendahl, M.D., M.A., et al
THEORIES OF KNOWLEDGE ARE USEFUL FOR PHYSICIANS
Three theories of knowledge are used when family physicians listen, reflect and diagnose finds this theory analysis. The author suggests that by recognizing these ways of thinking, physicians can use this knowledge as a practical guide for clinical practice, inquiry and learning. General Medical Practioners Need to be Aware of the Theories on Which Our Work Depends By Paul Thomas, F.R.C.G.P., M.D.
FAMILY MEDICINE'S IDENTITY: BEING GENERALISTS IN A SPECIALIST CULTURE
This essay by a senior family medicine educator is a reflection of family medicine's history and pitfalls and its future potential. The author describes conflicting views of the content, boundaries and identity that have characterized American family medicine. Family Medicine's Identity: Being Generalists in a Specialist Culture? By Howard F. Stein, Ph.D.
A family physician reflects on the multiple meanings of "Sí, Doctora" when working with Spanish speaking patients. The author finds from experience with patients and a Spanish speaking friend that "yes" is not always an indicator of agreement or comprehension. She concludes that when a patient says "Sí, Doctora", the physician must probe with more questions and listen hard to the answers. Sí, Doctora By Lucy M. Candib, M.D.
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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