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July/August 2009 Annals of Family Medicine tip sheet

The Primary Care Paradox and the Need to Integrate Primary and Specialty Care to Improve the Quality of Healthcare
The third in a seven-part series of commentaries to understand health and healthcare

With the healthcare reform debate heating up in Washington, D.C., Annals of Family Medicine editor Kurt Stange, M.D., Ph.D., continues his seven-part series of commentaries designed to help make sense of the problems and opportunities we face for understanding and improving healthcare and health. The July/August issue of the Annals features the series' third installment, which explores the paradox of primary care the fact that when compared with specialty care, primary care is associated with poorer quality care for individual diseases, yet higher value health care at the level of the whole person, and better health, greater equity, lower costs and better quality of care at the level of populations.

Stange warns that current solutions to improving quality may do more harm than good if they focus more on diseases than on people because efforts to improve the parts (evidence-based care of specific diseases) may not necessarily improve the whole (the health of people and populations). He contends that our current system undervalues care at the level of the whole-person and community, resulting in adverse consequences for the cost, effectiveness and equity of health care. He calls for systems of care that foster the integration of generalist and specialist care both horizontally for individuals, communities and populations, and vertically for specific diseases.

The Paradox of Primary Care
By Kurt C. Stange, M.D., Ph.D.
Case Western Reserve University, Ohio

Chronic Disease Care Better in Community Health Centers and Practices with Nurse-Practitioners

Analyzing the impact of different primary care models and practice features on chronic disease management, researchers in Ontario, Canada found that chronic disease management was superior in community health centers and in practices where a nurse-practitioner was part of the health care team. The survey of 137 primary care practices in Ontario revealed that clinicians in community health centers found it easier than those in other models (fee-for-service, capitation and blended payment) to promote high-quality care, in part because of longer consultations and interprofessional collaboration. Specifically, community health centers scored 10-15 percent higher than the other practice models. Across all practices types, they found that nurse-practitioners had a positive effect, improving performance by 6 percent. By contrast, quality of care decreased with patient load (3 percent drop for each additional 1,000 patients) and in those practices with more than four full-time-equivalent family physicians (7 percent lower score). They conclude that these three critical factors the presence of a nurse practitioner, smaller practices and lower patient load were responsible for high-quality chronic disease care, not the particular practice model. Notably, they found no evidence that a practice's use of electronic medical records influenced the quality of chronic disease management. The researchers call for further research to examine whether current moves toward larger practices and greater patient-physician ratio may have unanticipated negative impacts on the quality of care.

Managing Chronic Disease in Ontario Primary Care: The Impact of Organizational Factors
By Grant M. Russell, M.B.B.S., F.R.A.C.G.P., M.F.M., Ph.D., et al
C.T. Lamont Primary Health Care Research Centre, Ontario, Canada

Researchers Debunk the Idea that Diabetes Increases Risk of Depression

Findings from a study out of Minnesota challenge the conventionally accepted view that diabetes substantially increases the risk of depression. Analyzing data on more than 17,000 patients with incident or prevalent diabetes, researchers find that when they controlled for the number of primary care visits, diabetic patients have little or no increased risk of a new depression diagnosis relative to patients without diabetes (0.95 odds ratio). They explain that when controlling only for age and sex, the data does indicate a significantly higher risk of a depression diagnosis (1.46 odds ratio); however, additional analyses clearly show that much of the purported association is likely attributable to the fact that diabetic patients have more frequent contact with the medical care system than patients without diabetes. They suggest that previous studies finding such an association may have inadequately adjusted for comorbidity or exposure to the medical system.

Does Diabetes Increase the Risk of Depression?
By Patrick J. O'Connor, M.D., M.P.H., et al
HealthPartners Research Foundation, Minnesota

Overweight and Obese Children Suffer More Musculoskeletal Problems

With the obesity epidemic in children spreading at an alarming rate, researchers in the Netherlands find that overweight and obese children experience musculoskeletal problems more often than normal-weight children. In a study of 2,459 children aged 2 to 17 years seen in Dutch family practices, researchers found that overweight and obese children aged 2 to 11 years were 1.86 times more likely to report musculoskeletal problems in daily life than did their normal-weight peers. Overweight and obese children aged 12 to 17 years were 1.69 times more likely to do so. Additionally, they found that overweight and obese children across both age-groups more frequently sought medical help for ankle and foot problems (1.92 odds ratio). Significantly, they also found that overweight and obese children older than 12 years more frequently sought help for problems with their lower extremities than did normal-weight children (1.92 odds ratio). The researchers hypothesize that a vicious cycle results wherein being overweight, having musculoskeletal problems and a low fitness level reinforce each other.

Musculoskeletal Problems in Overweight and Obese Children
By Marjolein Krul, M.D., et al
Erasmus MC University Medical Center, Rotterdam, The Netherlands

Status of Virginia Family Medicine Practices' Adoption of the Patient-Centered Medical Home Model of Healthcare

Amidst the growing movement to transform primary care practices around the widely accepted patient-centered medical home model of care, which is designed to improve access, quality, and business functionality, researchers from Virginia Commonwealth University assess the rate of adoption of the model's components in a sample of Virginia family medicine practices. They find that while most of the 342 practices include some components of the model, full implementation is low (1 percent). Specifically, most practices reported use of continuity-of-care processes (87 percent) and clinical guidelines (77 percent). Fewer reported use of patient surveys (48 percent), electronic medical records for internal coordination (38 percent), community linkages for care (31 percent) and clinical performance measurement (28 percent). A small number reported patient registries for multiple diseases (19 percent). They conclude that family medicine practices, particularly smaller practices, are challenged with aspects of the model that require considerable financial and knowledge resources, such as electronic medical records and performance measurement. They assert that because small practices represent such an important component of our healthcare delivery system, policy makers need to consider the challenges they face and should develop specific policies to support them in developing efficient and effective models of care.

Elements of the Patient-Centered Medical Home in Family Practices in Virginia
By Debora Goetz Goldberg, Ph.D., M.H.A., M.B.A. and Anton J. Kuzel, M.D. and M.H.P.E.
Virginia Commonwealth University, Richmond

Medical Students' Expanded View of Physicianhood: An Analysis of Personal Mission Statements

In a glimpse at the professional aspirations, commitments and values medical students consider in developing their own professional identities, researchers from the University of California offer a thematic analysis of individual mission statements written by medical students from 10 U.S. medical schools. They identify three primary themes that emerged professional skills, personal qualities and scope of professional practices. Unlike classic oaths and contemporary professionalism statements, they point out that these students offer an expanded view of physicianhood that includes such elements as dealing with fears, personal-professional balance, love, nonhierarchical relationships, self-care, healing, and awe. While recognizing the primacy of the patient, today's students appear to be presenting a more matured perspective, recognizing their ties to their own families and the need for balance and a supportive community, as well as the forethought to maintain personal wholeness and deal with negative aspects of training. The authors conclude that medical school curricula may require adaptation to support the personal aspirations of those now entering the profession.

Promise of Professionalism: Personal Mission Statements Among a National Cohort of Medical Students
By Michael W. Rabow, M.D., et al
University of California, San Francisco

Why Current Asthma Guidelines (and Others) Fall Short and Suggestions for Change

Using the National Heart, Lung and Blood Institute's new expert panel report on the management of asthma as an example, David L. Hahn, M.D., M.S. concludes that asthma guidelines, like most other evidence-based guidelines, are limited by a flawed evidence-grading system. He asserts that guidelines could be enhanced by more attention to applicable patient populations, patient-oriented outcomes and shared decision making.

Importance of Evidence Grading for Guideline Implementation: The Example of Asthma
By David L. Hahn, M.D., M.S.
University of Wisconsin School of Medicine and Public Health, Wisconsin

Peer-Led Self-Management Training for Chronic Illnesses Not Cost-Effective

Findings from a randomized controlled trial of 415 patients with one or more chronic diseases question the cost-effectiveness of peer-led self-management training for improving chronic illness outcomes, despite previous studies suggesting such interventions have potential to enhance self-efficacy. In this study, compared with usual care, a chronic disease self-management program delivered in the home led to significantly higher illness self-management efficacy at six weeks and at six months but not at one year. Neither the in-home program or a similar program delivered by phone had significant effects on the primary outcomes of overall mental and physical health status or on other secondary study outcomes, including health care utilization. These findings do not encourage a systematic implementation of phone- or home-based methods of peer-led self-management.

Home-Based, Peer-Led Chronic Illness Self-Management Training: Findings From a 1-Year Randomized Controlled Trial
By Anthony Jerant, M.D., et al
University of California, Davis

Poor Management of Test Results in Family Medicine Offices

Given the frequency with which primary care physicians order tests on patients, this study notes a disturbing lack of consistency in test results management among four Ohio family medicine practices studied. Specifically, no office consistently had or adhered to office-wide results management practices, and only two offices had written protocols or procedures. Whereas most patients surveyed acknowledged receiving their test results (87-100 percent), a far smaller proportion of patient charts documented patient notification (58-85 percent), clinician response to the result (47-84 percent), and follow-up for abnormal results (28-55 percent). The authors note that an office's level of safety awareness and appropriate adoption of technology are important factors in achieving high-quality results management and designing systems that can lead to higher quality care.

Management of Test Results in Family Medicine Offices
By Nancy C. Elder, M.D., et al
University of Cincinnati, Ohio

Defining Comorbidity

Given the increasing prevalence of patients with multiple co-existing chronic conditions in the United States about 80 percent of Medicare spending is devoted to patients with four or more chronic conditions Valderas and colleagues attempt to better define comorbidity and its related constructs. They assert that more precise terminology would lead to improved research in the areas of clinical care, epidemiology and health services planning and financing.

Defining Comorbidity: Implications for Understanding Health and Health Services
By Jose M. Valderas, M.D., Ph.D., M.P.H., et al
The University of Manchester, United Kingdom


Contact: Angela Sharma
American Academy of Family Physicians

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