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July/August 2008 Annals of Family Medicine tip sheet

Innovative North Carolina Program Improves Patient Care and Saves an Estimated $160 Million in Medicaid Costs Annually

Community physicians in North Carolina may have found a way to narrow the gap between rising health care costs and declining health outcomes. In this special report, the authors describe how an innovative system of community health networks led by local primary care physicians is improving quality of care and saving the state at least $160 million in Medicaid costs annually.

The program, Community Care of North Carolina (CCNC), includes about 1,200 primary care practices across North Carolina, which manage the care of about 750,000 Medicaid patients roughly 80 percent of the state Medicaid population or almost 10 percent of the North Carolina population.

As described, this payer-practice collaboration offers a modified version of the "medical home" concept where patients are assigned to a primary care home that provides comprehensive longitudinal care, where case managers provide wrap-around services, where practice-specific data are used to improve care, where patients learn from each other and where community partners support care.

Conservative modeling indicates CCNC saved the state of North Carolina $60 million in fiscal year 2003. By 2006 just eight years after the program was implemented savings had increased to $161 million annually, with more liberal modeling putting the cost savings at more than $300 million annually by 2006. The largest savings were achieved in emergency department utilization (23 percent less than projected), outpatient care (25 percent less than projected) and pharmacy costs (11 percent less than projected).

Beyond saving money, CCNC has also improved quality of care, as illustrated by increased asthma control, one of the program's first initiatives. Two years after implementation, chart audits showed a 16 percent increase in asthma staging, and 90 percent of staged patients were on appropriate preventive medications. Emergency department visits for CCNC children with asthma decreased by 8 percent during the first year of the program. Hospitalization rates for the same group during this time decreased by 34 percent, and rates have been sustained at these lower levels.

The authors assert that CCNC has moved beyond the demonstration phase to prove that this model can be scaled and implemented across an entire state by practicing physicians in busy outpatient practices. They conclude it is a model of care that could be implemented across the country.

In an accompanying editorial, Thomas Bodenheimer, M.D., draws seven lessons from North Carolina's experience and urges the medical community and leaders concerned with the cost and quality of care to consider more widespread implementation of similar models across the country.

Community Care of North Carolina: Improving Care Through Community Health Networks
By Beat D. Steiner, M.D., M.P.H., et al

North Carolina Medicaid: A Fruitful Payer-Practice Collaboration
By Thomas Bodenheimer, M.D.

When It Comes to Cardiovascular Disease Risk, It Pays to Be Optimistic If You're a Man

Men who rate their 5-year risk of having a stroke or heart attack as "low" go on to have a lower-than-expected rate of death from cardiovascular disease (CVD) in the subsequent 15 years. Interestingly, researchers didn't find such an optimistic bias among women. Analyzing data from 2,816 adults, researchers found that men who rated their cardiovascular disease risk to be lower than men of their same age had nearly a three times lower incidence of CVD-related mortality compared with all others. Among women, they observed no association. The researchers conclude that holding optimistic perceptions of health risk leads to advantages, at least among men, and physicians need to be aware of the underpinnings of optimistically-biased risk perception when communicating risk to patients.

Self-Rated Cardiovascular Risk and 15-Year Cardiovascular Mortality
By Robert Gramling, M.D., D.Sc., et al

Integrating Depression and Hypertension Treatment Improves Outcomes

Integrating depression treatment into care for high blood pressure improves blood pressure control, depression outcomes, and adherence to antidepressant and antihypertensive medications among older patients. In a study of 64 patients aged 50 to 80 years with a combination of depression and hypertension, researchers found that at six weeks' follow-up, those who received integrated care for their conditions had fewer depressive symptoms (9.9 vs. 19.3), lower systolic blood pressure (127.3 mm Hg vs. 141.3 mm Hg), and lower diastolic blood pressure (75.8 mm Hg vs. 85.0 mm Hg) compared with participants who received usual care. Moreover, compared with the usual care group, the proportion of patients in the intervention group who had 80 percent or greater adherence to an antidepressant medication (71.9 percent vs. 31.3 percent) and to an antihypertensive medication (78.1 percent vs. 31.3 percent) was greater at six weeks' follow-up. The findings of this relatively brief pilot trial support the integration of depression treatment with chronic medical conditions. The authors call for further research to evaluate this intervention in a larger, more representative sample with longer periods of follow-up.

Integration of Depression and Hypertension Treatment: A Pilot, Randomized Controlled Trial
By Hillary R. Bogner, M.D., M.S.C.E., and Heather F. de Vries, M.S.P.H.

Two Factors Highly Predictive of Youth Smoking

Sixth graders' answers to two questions "Do you have friends who smoke?" and "Would it be easy for you to get a cigarette?" predict becoming a regular smoker by the tenth grade. In this prospective study of 1,195 Massachusetts students, researchers found the perception that cigarettes were easy to obtain increased the risk for smoking initiation and regular tobacco use among respondents. Having peers who smoke increased the impact of perceived accessibility. The authors conclude that youths who have peer smokers and perceive easy access may be at high risk for higher levels of smoking and may warrant greater attention in clinical and public health settings. They recommend clinicians routinely ask youths about their perceptions of the accessibility of tobacco and exposure to peer smokers.

Perceived Accessibility as a Predictor of Youth Smoking
By Chyke A. Doubeni, M.D., M.P.H., et al


Why Hospital Care is Vital to the Future of Family Medicine, One Physician's Reflection

A family physician reflects about her place within the complex hospital ecosystem, questioning whether, with the advent of hospitalists, she still needs to be directly involved in her patients' hospital care. She concludes that when family physicians opt out of hospital practice, they lose their voice and thus risk their own extinction.

Dinosaurs, Hospital Ecosystems, and the Future of Family Medicine
By Cherie Glazner, M.D., M.S.P.H.

Exploring and Measuring the Social Construct of Healing

This issue features a cluster of three articles on healing. Analyzing focus group discussions with 28 patients and 56 clinicians, Hsu and colleagues found remarkable concurrence among the participants in the definition of healing: "Healing is a dynamic process of recovering from trauma or illness by working toward realistic goals, restoring function, and regaining a personal sense of balance and peace. Healing is a multidimensional process with physical, emotional and spiritual dimensions." The shared vision emphasizes the key themes of wholeness, recovery, balance, communication and relationships.

In a second article, Scott and co-investigators explored the healing relationship through in-depth interviews with six exemplar primary care physician-healers and 23 patients who had experienced healing relationships. Like Hsu and colleagues, Scott et al found that patients and clinicians had a common understanding of the nature of healing, which they defined as transcendence of suffering. Their conceptual model of healing relationships is characterized by a nonjudgmental emotional bond, the clinicians' conscious use of power for the patient's benefit, a commitment to caring for patients over time, hope and a sense of being known.

Meza and Fahoome, finding similar constructs in the literature of healing, propose one of the first quantitative tools to measure healing. Termed the Self-Integration Scale v 2.1, this valid and reliable measurement scale for attributes of healing provides researchers with a means to study new areas of humanistic health care.

Healing in Primary Care: A Vision Shared by Patients, Physicians, Nurses and Clinical Staff
By Clarissa Hsu, Ph.D., et al

Understanding Healing Relationships in Primary Care
By John G. Scott, M.D., Ph.D., et al

The Development of an Instrument for Measuring Healing
By James Peter Meza, M.D., M.S.A. and Gail Fahoome, Ph.D., et al

Family Physicians Lack Evidence-Based Information About Chronic Fatigue Syndrome

Interviews with 24 patients and 14 family physicians in the United Kingdom revealed that family physicians feel unprepared by their medical training and continuing education to diagnose and manage chronic fatigue syndrome, and, as a result, end up seeking nonclinical evidence through the media, observations of patients outside the office, and, most powerfully, through personal experience. Interviews with patients indicated patients are aware of the physicians' limited understanding of the condition and sometimes feel their concerns are dismissed.

Using Multiple Sources of Knowledge to Reach Clinical Understanding of Chronic Fatigue Syndrome
By Carolyn A. Chew-Graham, M.D., F.R.C.G.P., et al

Prevalence of Skin Diseases Seen by Family Physicians in the Netherlands

Analyzing a disease registry for approximately 12,000 patients in the Netherlands, researchers found that skin diseases accounted for 12.4 percent of all diseases seen by a network of family physicians. Regarding the use of medical care, data indicated that more than 80 percent of the patients had contacted their family physician for their skin disease during the previous year, 18 percent had contacted a medical specialist, and 5 percent had consulted an alternative health care clinician. Overall, patients who reported more severe disease and lower quality of life sought more treatment.

Skin Diseases in Family Medicine: Prevalence and Health Care Use
By Elisabeth W.M. Verhoeven, M.Sc., et al

Criteria for Good Qualitative Research

A content analysis of nearly 65 journal articles, books and book chapters that address the standards of good qualitative research in health care revealed seven evaluative criteria for this type of research: (1) carrying out ethical research; (2) importance of the research; (3) clarity and coherence of the research report; (4) use of appropriate and rigorous methods; (5) importance of reflexivity or attending to researcher bias; (6) importance of establishing validity or credibility; and (7) importance of verification or reliability.

Evaluative Criteria for Qualitative Research in Health Care: Controversies and Recommendations
By Deborah J. Cohen, Ph.D. and Benjamin F. Crabtree, Ph.D., et


Contact: Angela Sharma
American Academy of Family Physicians

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