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March/April 2010 Annals of Family Medicine tip sheet

Convenience of Retail Health Clinics Attractive to Patients

The time and cost savings offered by retail clinics are attractive to patients, and they are likely to seek care for minor illnesses there given sufficient cost savings, according to a telephone survey of nearly 500 adults. When researchers presented respondents with two hypothetical acute illness scenarios (urinary tract infection and influenza), they found that though respondents preferred to receive care from a physician at a private office, pay less and receive care on the same day, given sufficient cost savings, respondents would be open to other options. In the first study to quantify the relative importance of and utility of the main attributes of retail health clinics, researchers found that all else equal, a cost savings of $82.12 would be required for respondents to wait one day or more for an appointment and $31.42 to seek care at a retail clinic. With these findings indicating that wait time is the most important factor in patients' care-seeking decisions, researchers conclude that primary care practices, especially those in competitive markets, are likely to derive greater competitive advantage by addressing patient convenience features such as same-day scheduling, walk-in clinics and extended hours.
Physician Office vs Retail Clinic: Patient Preferences in Care Seeking for Minor Illnesses
By Arif Ahmed, Ph.D., and Jack Fincham, Ph.D.,University of Missouri Kansas City

High-touch, Not High-tech More Highly Correlated with Preventive Services Delivery

Despite widespread attention and endorsement of the patient-centered medical home as the future of primary care practice, there has been limited research evaluating the effectiveness of the model's principles. In this analysis of data from 568 patients from 24 New Jersey primary care offices, researchers from the Robert Wood Johnson Medical School find that relationship-centered aspects of the PCMH are more highly correlated with the delivery of preventive services than are information technology capabilities. Specifically, they found that having a greater number of visits and a well visit in the past five years had the greatest impact on the number of preventive services received. Additionally, seeing the same doctor and having a referral system to link patients to community programs were significantly associated with higher rates of preventive services. The only high-tech indicator that was significantly associated with receipt of preventive services was use of clinical decision support tools. The researchers point out that existing PCMH pilot projects and recognition and certification programs place greater emphasis on high-tech rather than high-touch, relationship-centered principles. They warn that by not adequately measuring and emphasizing key PCMH principles, particularly the core primary care attributes, these projects risk generating null results, which may lead to premature abandonment of the concept by major payors.
Principles of the Patient-Centered Medical Home and Preventive Services Delivery
By Jeanne M. Ferrante, M.D., M.P.H., et al, Robert Wood Johnson Medical School, New Jersey

Unexplained Gastrointestinal Symptoms Prevalent in Abused Children

Researchers from the University of North Carolina document a high prevalence of unexplained abdominal pain and nausea/vomiting among children who have been abused. Analyzing data on 845 children aged 4 to 12 years enrolled in the Longitudinal Studies of Child Abuse and Neglect, they find sexual abuse preceded or coincided with abdominal pain in 91 percent of cases, suggesting that the pain may be a consequence of childhood abuse. Moreover, youth recall of ever having been psychologically, physically or sexually abused was significantly associated with both abdominal pain and nausea/vomiting (odds ratio 1.5 to 2.1). Psychological distress partially mediated the relation between maltreatment and gastrointestinal symptoms, a finding that coincides with the literature showing increased psychological distress and dysregulation in the hypothalamic-pituitary-adrenal axis among those who are abused as a child. The researchers conclude that physicians should inquire about physical or sexual abuse when young patients complain about unexplained gastrointestinal symptoms.
Unexplained Gastrointestinal Symptoms After Abuse in a Prospective Study of Children at Risk for Abuse or Neglect
By Miranda A.L. van Tilburg, Ph.D., et al, University of North Carolina, Chapel Hill

In-office C-Reactive Protein Testing May Help Physicians More Appropriately Prescribe Antibiotics for Respiratory Tract Infections

Point-of-care C-reactive protein (CRP) testing to identify inflammation or infection in the body may help clinicians determine which patients will benefit from antibiotic treatment and thereby reduce unnecessary antibiotic prescribing. Evaluating the effectiveness of CRP point-of-care testing in 258 patients with acute lower respiratory tract and sinus infections, researchers found that those patients in the CRP-assisted group used fewer antibiotics than control patients after the initial consultation (43 vs. 57 percent). The difference remained significant during the 28-day follow-up (53 vs. 65 percent). Moreover, in the CRP-assisted group, delayed prescriptions, or prescriptions written under the condition that they are not used immediately but only if symptoms persist, were filled only in a minority of cases (23 percent) vs. 72 percent in the control group. Additionally, the researchers found that patient satisfaction with care was higher when CRP was used during the office visit. The authors conclude that a CRP test is both accurate and cost-effective and adds incremental information to what physicians can obtain from medical history and physical examination. It may be a useful tool for decreasing antibiotic use and increasing patient satisfaction without compromising patient recovery. Point-of-Care C-Reactive Protein Testing and Antibiotic Prescribing for Respiratory Tract Infections: A Randomized Controlled Trial
By Jochen Cals, M.D., M.Sc., et al, Maastricht University, The Netherlands
Orion Diagnostica, manufacturer of QuikRead point-of-care C-reactive protein devices, funded this study.

Informed Decision Making Changes Colorectal Cancer-Screening Test Preferences

Once patients learn more about the different colorectal cancer-screening tests, their test preferences change. Analyzing the preferences of 168 patients, researchers found that patients were clear about the test attributes they preferhigh test accuracy, amount of colon examined, strong scientific evidence for efficacy, minimum discomfort and low risk of complicationsbut they point out no single test has these attributes. When asked to consider the relative importance of 13 different test attributes together, patients said test accuracy, scientific evidence, and the amount of colon examined were most important for decision making. When asked which test they would prefer (fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, or double-contrast barium enema), initially the modal choice was fecal occult blood testing (59 percent), however, after reading detailed descriptions of each test and considering the different attributes, colonoscopy was the modal choice (54 percent). Given that preferences were varied across individuals and were not predictable, the authors conclude that clinicians should discuss the full array of available colorectal cancer-screening tests with all patients, focusing discussions on describing characteristics related to accuracy rather than process because accuracy is what patients identify as most important for decision making.
Informed Decision Making Changes Test Preferences for Colorectal Cancer Screening in a Diverse Population
By Navkiran K. Shokar, M.D., M.P.H., et al, University of Texas Medical Branch, Galveston

Brief Checklist Accurately Screens for Four Common Psychiatric Illnesses

A one-page, 27-item checklist that can be completed in a few minutes accurately indicates whether a patient has any of four common psychiatric illnesses, including major depression, bipolar disorder, anxiety disorder and post-traumatic stress disorder. Testing showed the My Mood Monitor, or M-3 checklist, was as accurate as that of currently used single-disorder screening instruments. Specifically, testing on 647 patients indicated the different disorder modules had sensitivities between 82 and 88 percent and specificities between 70 and 80 percent. The authors point out that many patients suffer from one condition, and those who do get help are often misdiagnosed. For these millions of people, they conclude, the M-3 screen may be a tremendously valuable resource. Because it combines screens for four different conditions into a one-page tool, the M-3 represents a huge improvement over existing mental health screeners that are limited by the number of disorders assessed.
Feasibility and Diagnostic Validity of the M-3 Checklist: A Brief, Self-Rated Screen for Depressive, Bipolar, Anxiety, and Posttraumatic Stress Disorders in Primary Care
By Bradley N. Gaynes, M.D., M.P.H., et al, University of North Carolina School of Medicine, Chapel Hill

Fostering Shared Moral Purpose to Advance Health

The last in a seven-part series of commentaries to understand health and health care With the March/April issue, Annals of Family Medicine editor Kurt Stange, M.D., Ph.D., concludes his seven-part series of commentaries designed to help make sense of the problems and opportunities we face for understanding and fostering health and high-value health care. The series' final installment explores how individuals and organizations can develop moral authority to advocate and advance health for people, communities and the population. Stange asserts that medicine's moral authority and shared moral purpose has declined as health professionals have placed an increasing emphasis on delivering commodities of technology-driven and narrowly focused health care rather than promoting health and healing. He calls on individuals and organizations to take up the hard, multi-level work of redesigning, transforming and reinventing health care so that it promotes health and healing in the information age.
Power to Advocate for Health
By Kurt C. Stange, M.D., Ph.D., Case Western Reserve University, Ohio

A New Model for Caring for Patients With Multiple Chronic Conditions

Researchers propose a primary care practice model for caring for patients with multiple chronic illnesses. Recognizing the challenges inherent for caring for these patients, the researchers describe a model based on ongoing learning and continual evaluation in which practices form open, constructive communities of practice in which they define common goals and concrete care plans and engage in reflective cased-based learning and practice. The model is based on (1) the importance of relationships among clinicians in delivering effective patient-centered care and (2) the flexibility gained in an environment of constant assessment and case-based learning.
Learning and Caring in Communities of Practice: Using Relationships and Collective Learning to Improve Primary Care for Patients with Multimorbidity
By Hassan Soubhi, M.D., Ph.D., et al, University of Sherbrooke, Quebec

Program to Increase Patient Communication Shows No Effect

The widely promoted Ask Me 3 (AM3) program, which encourages patients to ask three specific questions during the office visit with the goal of improving understanding and adherence to treatment recommendations, showed no effect on either questioning by patients or adherence to advice in this study of 834 patients. The authors suggest the findings may be misleading because the program was tested in a patient population in which asking questions already occurred at a high rate and in which levels of adherence were already fairly high. It would be difficult, they assert, for any intervention to improve question asking or adherence among patients with such high baseline rates of question-asking and prescription filling. They conclude it is possible that AM3 might be more effective among patients with lower health literacy levels and educational attainment.
Patient Question-Asking Behavior During Primary Care Visits: A Report from the AAFP National Research Network
By James M. Galliher, Ph.D., et al, American Academy of Family Physicians National Research Network, Kansas


Contact: Angela Sharma
American Academy of Family Physicians

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