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March/April 2011 Annals of Family Medicine tip sheet

North America's Largest Example of a Patient-Centered Medical Home Popular with Patients and Physicians

Rosser and colleagues detail the implementation of Ontario's Family Health Team Model, which serves nearly 2 million Ontarians, making it North America's largest example of a patient-centered medical home. Implemented in 2005, the Family Health Team model is based on multidisciplinary teams and an innovative incentive-based funding system. Preliminary observations suggest high satisfaction among patients, higher income and more gratification for primary care physicians, and trends for more medical students to select careers in family medicine. Popular demand, the authors note, is resulting in expansion from 170 FHTs today to 200 FHTs in the near future. They assert the model should be part of the solution for health system reform in both Canada and the United States.

Progress of Ontario's Family Health Team Model: A Patient-Centered Medical Home
By Walter W. Rosser, M.D., et al
Queen's University School of Medicine, Ontario, Canada

Novel, Patient-Friendly Approach to Detecting White-Coat Hypertension

Sitting for 30 minutes in a quiet room with automated serial blood pressure measurements is as useful in detecting white-coat hypertension as is standard 24-hour continuous home blood pressure monitoring, saving patients from being falsely labeled as hypertensive and the traditional costs and trouble of finding out. Using the same technology used for 24-hour blood pressure measurement, the authors analyzed data from 84 patients. They found a difference of less than 2 mm Hg, with a standard deviation of the difference of less than 10 mm Hg, for the systolic and diastolic blood pressures using the 30-minute method compared with the 24-hour method. They conclude the automated 30-minute blood pressure measurement technique is a valid, useful, office-based alternative to the more laborious 24-hour blood pressure monitoring, allowing physicians to overcome problems such as observer bias and the white-coat effect, while saving patients from the hassle of 24-hour monitoring.

Novel Approach to Office Blood Pressure Measurement: 30-Minute Office Blood Pressure vs Daytime Ambulatory Blood Pressure
By Mark C. van der Wel, M.D., M.Sc., et al
Radboud University Nijmegen Medical Centre, The Netherlands

Predictors of Depression Among Diabetic Patients

Examining risk factors associated with the development of major depressive disorder among 338 adult patients with type 2 diabetes, researchers found prior MDD and negative affect were the primary predictors of subsequent MDD. When stratified by negative affect, negative life events, elevated body mass index and poor control of glycated hemoglobin also predicted MDD. The authors assert that negative life events and patients' disease-related concerns are important when understanding what predicts subsequent MDD, and they conclude these variables combine to yield the negative emotional symptoms that predict MDD over time. They suggest that when patients have moderate levels of increased depressive symptoms, it may be helpful to inquire about other life stressors and chronic disease management. Devoting attention to the contextual stressors that occur in patients' lives and providing appropriate interventions that might help reduce the negative impact of these stressors may have a positive impact on both their emotional status and their disease management.

Patients With Type 2 Diabetes at Risk for Major Depressive Disorder Over Time
By Diana M. Naranjo, Ph.D., et al
University of California, San Francisco

Self-Removal of Earwax a Cost-Effective Alternative to Removal by Health Care Professionals

Given the significant health cost associated with the irrigation of ears to remove earwax in primary care and the relative ease of self-treatment at home with drops and self-irrigation using a bulb syringe, researchers evaluated the impact on health service utilization of the latter in the United Kingdom. Of the 237 patients studied, researchers found that of patients presenting with ears blocked with wax and subsequently cleared, those originally given a bulb syringe for self-use had about one-half the rate of irrigation consultations of those treated in the clinic for irrigation in the following two years. Specifically, in the 2-year follow-up period, 73 percent of control group patients returned to the clinic with episodes of earwax versus 60 percent of patients in the intervention group. The average number of consultations for earwax was 1.15 among control group participants versus 0.64 for intervention group patients, a difference of 0.50 consultations and an estimated 79 percent higher consultation rate for the control group. The authors conclude that self-treatment with drops and self-irrigation may offer a feasible alternative to routine attendance with a clinician, saving patients the time and cost involved in clinic visits. They estimate that encouraging the initial use of bulb syringes could, in the following two years, potentially reduce the number of clinic irrigations by around 0.9 million in the United Kingdom.

Randomized Trial of Bulb Syringes for Earwax: Impact on Health Service Utilization
By Richard Coppin, B.Med.Sci., B.M., B.S., D.R.C.O.G., et al
The Surgery, Overton, United Kingdom

Women With Intellectual Disabilities Feel Inadequately Prepared for and Upset by Mammography

Women with intellectual disabilities perceive mammography differently from women in the general population, and their perception is shaped by inadequate knowledge, anxiety and inadequate preparation. In-depth interviews with 27 intellectually disabled women revealed that women with intellectual disabilities feel poorly prepared for the procedure, not understanding its purpose or what to expect during the test. The latter was particularly upsetting to those interviewed and contributed to their negative perceptions of mammography. Participants reported feeling singled out for being unprepared, despite their desire to have at least one mammogram like other women their age. The authors assert that women with intellectual disabilities need more time and explanation to understand and process elements of the experience; and they want to be perceived as competent, not disabled, which compounds the anxiety of unfamiliar situations. Increasing patients' familiarity with the test, they conclude, may facilitate their ability to complete mammography successfully and to return for subsequent screenings. Based on their findings, the authors offer several recommendations for preparing intellectually disabled women for mammography, including allowing for extra time during the appointment so medical providers can describe the procedure, including details about where it occurs, how long it takes, what the experience will be like, as well as a brief explanation of why it is necessary.

'It's Easier Said Than Done': Perspectives on Mammography From Women With Intellectual Disabilities
By Joanne E. Wilkinson, M.D., M.Sc., et al
Boston University School of Medicine

Patients Want Doctors' Opinions on Preventive Cardiovascular Meds

Examining patient preferences for how doctors communicate the benefits of preventive cardiovascular medication, researchers found patients prefer a doctor give his or her opinion about the medication rather than explain the risks using numbers or pictures. Moreover, researchers found patients prefer visual depictions to words. Specifically, the study of 934 patients in Auckland, New Zealand, found 62 percent preferred to know what their doctor thinks about the medication, and 55 percent preferred pictorial presentations to numbers, with a people or bar chart being equally favored. Notably, irrespective of education, numeracy score, socioeconomic status, or actual cardiovascular risk, patients showed a strong preference for relative risk as a means of encouraging them to take preventive medication. The findings, the authors conclude, show that patients' willingness to take preventive cardiovascular medication depends more on the mode of communication of treatment benefit than on their short-term cardiovascular disease risk score or their level of concern about a future cardiovascular event. Moreover, it is not possible to predict which mode of communication is preferred by individual patients. As such, they recommend clinicians routinely use several modes and formats to communicate risk, flexibly matching information to the needs of individuals.

Patients' Preferences for Ways to Communicate Benefits of Cardiovascular Medication
By Felicity Goodyear-Smith, M.B., Ch.B., M.G.P., et al
University of Auckland, New Zealand

Report: Mixed Progress in Healthy People 2010 Arthritis Management Objectives

In an analysis updating national progress toward targets for three Healthy People 2010 objectives for arthritis management, researchers found significant progress has been made by clinicians for weight loss counseling of overweight and obese adults with arthritis, but not for two other arthritis management objectives. Analyzing national data sets, researchers found that the proportion of overweight and obese adults with doctor-diagnosed arthritis who were counseled by their clinicians to lose weight to lessen their symptoms increased significantly from 35 percent in 2002 to 41 percent in 2006, just shy of the 2010 target of 46 percent. There was no change, however, in the proportion of adults with arthritis who had ever taken a self-management education class (approximately 11 percent), or who had been counseled to engage in physical activity (approximately 52 percent), whose targets for 2010 are 13 percent and 67 percent, respectively. The authors assert that the lack of progress for physical activity counseling and arthritis education is discouraging because self-management skills, including regular physical activity, are essential to reducing arthritis pain and disability and improving quality of life. They call for additional research to fully understand the obstacles and barriers faced by primary care physicians in meeting these two objectives.

Healthy People 2010 Arthritis Management Objectives: Monitoring Education and Clinician Counseling for Weight Loss and Exercise
By Barbara T. Do, M.S.P.H., et al
Centers for Disease Control and Prevention, Atlanta, Ga.

First Measure of Physician Trust in the Patient

Although several measures of patient trust in the physician have been previously published, this study details the development and validation of the first measure of physician trust in the patient. Developed as part of a community-based study of prescription opioid use for chronic pain in HIV-infected patients, the final 12-item scale demonstrated high internal consistency, a distinct 2-factor pattern, and both convergent and discriminant validity. The final measure, which is consistent with the limited published qualitative work on physician trust of patients, includes items asking about expectations that patients will behave in ways that fulfill their roles in providing accurate and complete histories, asking questions, following a treatment plan, and following up. It also includes respecting the physician's boundaries, and not manipulating the relationship for personal gain. The authors assert that the new measure will provide a better understanding of the relationship between mutual trust and processes and outcomes of care leading to improvements in quality care and both patient and physician satisfaction.

Physician Trust in the Patient: Development and Validation of a New Measure
By David H. Thom, M.D., Ph.D., et al
University of California, San Francisco

Oral Prednisolone Test Not Useful for Diagnosing Chronic Obstructive Pulmonary Disease

Sometimes doctors use the patient's response to a short course of oral prednisolone test to diagnose chronic obstructive pulmonary disorders. These researchers found that while a response to oral prednisolone was suggestive of COPD, it added no diagnostic value to more easily obtainable information. Of 233 patients complaining of cough who were given a 14-day test treatment with oral prednisolone, researchers found those who responded to the treatment were more likely to have chronic obstructive pulmonary disease (23 percent) than asthma (4 percent). After adjusting for age, sex and smoking status, however, the association between prednisolone and COPD was no longer statistically significant; hence, the researchers conclude the oral prednisolone test had no relevant value for diagnosing or excluding COPD in addition to more easily obtainable diagnostic information. In light of the unwillingness of many patients to undergo the prednisolone test, the authors recommend against using this test in the diagnostic workup when COPD is suspected.

Diagnostic Value of Oral Prednisolone Test for Chronic Obstructive Pulmonary Disorders
By Berna D. L. Broekhuizen, M.D., et al
University Medical Center Utrecht, The Netherlands

Literature Review Identifies Instruments for Measuring Patient-Centered Care

A systematic literature review finds 13 instruments for measuring patients' perceptions of patient-centered care, a central value in modern medicine. Two of the 13 instruments identified by the researchers are dedicated to patient-centered care, but the authors point out they are visit-based, limiting their applicability for the study of care processes over time, such as chronic illness management. The eleven remaining instruments provide only partial coverage of the concept.

Measuring Patients' Perceptions of Patient-Centered Care: A Systematic Review of Tools for Family Medicine
By Catherine Hudon, M.D., M.Sc., C.F.P.C., et al
Universit de Sherbrooke, Quebc, Canada

Call for New Measures of Patient-Centered Care

An editorial by researchers out of the University of Rochester takes a closer look at the concept of "patient-centered care," now prominently positioned on the political agenda and widely used in the lexicons of health care institutions, planners and policy leaders. They call for the development of new measures that include the perspectives of all relevant stakeholders patients, their families, clinicians and health systems to capture all the important aspects of patient-centered care and ensure it is being achieved.

The Values and Value of Patient-Centered Care
By Ronald M. Epstein, M.D., and Richard L. Street, Jr., Ph.D.
University of Rochester, New York


Contact: Angela Sharma
American Academy of Family Physicians

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