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May/June 2012 Annals of Family Medicine tip sheet

Reinvigorating the 1967 Folsom Report's 'Communities of Solution' to Address Today's Fragmented U.S. Health Care System

In the wake of federal efforts to reform the U.S. health care system, a group of rising family medicine leaders call for a reinvigoration of community-centered health systems, as originally outlined in the landmark 1967 Folsom Report. They contend the vision of the original Folsom commission could not be more pertinent to America's current pressing needs. The group revitalizes and modernizes the Folsom Report's blueprint, offering an updated series of 13 grand challenges to facilitate a vision for nationwide integrated patient-centered community health services. The renewal of the Report's "Community of Solution" concept serves as the anchor point for improving overall health and decreasing health costs. Other key lessons drawn from the original report include the integration of public health and clinical care and the importance of local decision making. It is the group's hope that these updated challenges might serve as a springboard for health care professionals, public health organizations, community groups and policy makers to take concrete steps to reengage at the community level.

Communities of Solution: The Folsom Report Revisited

By The Folsom Group

American Board of Family Medicine Young Leaders Advisory Group

Nasal Steroids Offer Small Therapeutic Benefit for Sinus Infection Sufferers

As evidence and clinical policy recommendations move away from antibiotic use for acute sinusitis, a systematic review and meta-analysis finds a therapeutic benefit from intranasal corticosteroidsbut the effect is small and not apparent until two to three weeks. Analyzing six studies with a total of 2,495 patients, researchers found intranasal corticosteroids resulted in a small increase in the resolution or improvement of symptoms at days 14 to 21, with the most consistently significant benefits being relief of face pain and congestion. The effect was most marked when patients were given longer durations of treatment (21 days) and higher doses of medication. In their analysis, the researchers found that whereas 66 percent of patients would experience improvement or resolution of symptoms at 14 to 21 days using a placebo, an additional 7 percent of patients would achieve this outcome with corticosteroids, equating to a number needed to treat of 13. This clinical benefit, the authors note, must be set against the potential harms of medication and cost implications. They call for additional research comparing intranasal corticosteroids with placebo in the absence of antibiotics to clarify the time-course of clinical benefit and the impact on work and quality of life.

In an accompanying editorial, a family physician argues nasal steroids are not the answer for most patients. Most patients, he asserts, want to get better in a few days, not three weeks. Furthermore, he argues, the symptom relief offered by nasal steroids is minimal, and the cost is high relative to other over-the-counter drugs, like pseudoephedrine and ibuprofen, that offer similar relief at a fraction of the cost. He concludes instead of writing a prescription, treatment should focus on symptom relief.

Intranasal Corticosteroids in Management of Acute SinusitisA Systematic Review and Meta-Analysis

By Gail Hayward, MBBChir, DPhil, et al

Oxford University, England

Intranasal Steroids for Acute Sinusitis?

By John Hickner, MD, MSc

Case Western Reserve School of Medicine, Cleveland

Study: Electronic Health Record Use Does Not Lead to Better Diabetes Care

Even after the potentially disruptive phase of initial electronic health record implementation, quality improvements may remain elusive. Analyzing data over three years for 798 diabetic patients at 16 EHR-using and 26 non‒EHR-using practices, researchers found EHR use was not associated with better adherence to care guidelines or a more rapid improvement in adherence. In fact, patients in practices that did not use an EHR were more likely than those in practices that used an EHR to meet outcome targets for hemoglobin A1c, low-density lipoprotein cholesterol and blood pressure at the 2-year follow-up. The authors conclude that achieving truly meaningful use of EHR technology will require more than time and experience; it will require recognition that until population health is improved, use does not equal success. They assert practices will need assistance with implementation and achieving successful use to improve care and population health outcomes, especially with regard to redesigning work processes to make the best use of these new technologies by all members of the primary care delivery team.

Typical Electronic Health Record Use in Primary Care Practices and the Quality of Diabetes Care

By Jesse C. Crosson, PhD, et al

UMDNJ - Robert Wood Johnson Medical School, New Jersey

Paying Patients for Performance: A Novel Twist on Quality Improvement

In a novel proposal, a family physician proposes paying patients for performance by rewarding them for achieving evidence-based health goals. Citing preliminary studies showing traditional pay-for-performance programs come up short despite considerable investment of resources, Joanne Wu, MD, MPH, suggests that offering direct incentives, such as discounts toward co-payments, procedures and medications, to patients for reaching health goals, has the potential to foster a stronger partnership between doctors and patients and improve health outcomes. The current system, which places all the responsibility and reward of quality of care on physicians, she asserts, perpetuates a paternalistic approach that is neither cost-effective nor sustainable. She concludes that patients deserve a greater role in improving their wellness and reaping the rewards from it.

An accompanying editorial supports the concept of reinforcing positive behavior but argues that the literature on incentives does not yet justify such a proposal. In the editorial, Bruce Christiansen, PhD, asserts the size of incentive needed for meaningful behavior change has implications for both feasibility and cost-effectiveness. He concludes because there is a strong relation between the size of the incentive and the degree of behavior change, it seems unlikely that sufficient resources would be available to change the major, refractory behaviors that undermine health.

Rewarding Healthy BehaviorsPay Patients for Performance

By Joanne Wu, MD, MPH

Northwest Primary Care, Portland, Oregon

What Does It Cost to Change Behavior?

By Bruce A. Christiansen, PhD

University of Wisconsin, Madison

Major UK Pay-for-Performance Program Has Limited Effect on Health Inequalities

Pay-for-performance schemes have been touted as a route to reducing health care disparities, yet this analysis of the Quality and Outcomes Framework, a major pay-for-performance program in the United Kingdom, finds the introduction of the program had no effect on health care inequalities in the practices studied. Analyzing outcomes data on diabetes patients registered with 29 practices in London, researchers found the introduction of the pay-for-performance scheme was associated with initial accelerated improvements in systolic blood pressure in white and black patients, but these improvements were sustained in only black patients. Initial improvements in diastolic blood pressure in white patients and in cholesterol levels in black and white patients were not sustained after QOF was introduced. There was no beneficial impact of QOF on HbA1c levels in any ethnic group. Furthermore, the authors note existing disparities in risk factor control remained largely intact at the end of the study period. The authors conclude that targeted quality improvement strategies may be required to address disparities in chronic disease management. Designers of pay-for-performance schemes, they assert, should consider incorporating targeted incentives to address the persistence of disparities.

Effect of a UK Pay-for-Performance Program on Ethnic Disparities in Diabetes Outcomes: Interrupted Time Series Analysis

By Riyadh Alshamsan, MSc, et al

Imperial College London

Pedometer-based Green Prescriptions Increase Physical Activity in Older Adults

A pedometer-based "Green Prescription" a recommendation for physical activity with pedometer monitoring results in a greater increase in leisure walking activity among older adults than green prescriptions that rely only on time-based goals. Comparing the effectiveness of the two physical activity prescriptions in 330 older adults with low levels of physical activity, researchers found leisure walking increased by 50 minutes per week among the pedometer-based green prescription group compared with 28 minutes per week among the standard Green Prescription group. For both groups, there were significant increases in physical activity that were largely maintained throughout the 12-month study period. BMI did not change in either group, but significant improvements in blood pressure (10 mm Hg systolic and 4.5 mm Hg diastolic) were observed for both groups without any difference between them. The authors hypothesize pedometers likely improve the efficacy of the activity prescription by providing regular objective monitoring and feedback to assist motivation. The findings of this study combined with the cost-effectiveness of the intervention, the authors conclude, should encourage health funding agencies to consider the use of such approaches to improve activity levels.

Healthy Steps Trial: Pedometer-Based Advice and Physical Activity for Low-Active Older Adults

By Gregory S. Kolt, PhD, et al

University of Western Sydney, Australia

Nonprofessional Home Coaching Improves Blood Pressure Control

Blood pressure control in low-income minority patients can be improved by teaching patients to monitor their blood pressure at home and having nonprofessional health coaches assist patients by counseling them on medication adherence. Monitoring the change in systolic blood pressure over 6 months in 237 patients randomized to receive in-home health coaching with or without in-home adjustment of their antihypertensive medications, researchers found both arms had significant reductions in systolic blood pressure (mean 22 mm Hg decrease), as well as a decrease in the number of primary care visits from 3.5 in the 6 months before the study to 2.6 in the 6-month study period and 2.4 in the 6 months after the study. The more coaching encounters patients had, the greater their reduction in blood pressure. As less than one-fifth of patients in the home titration arm actually undertook an adjustment of their antihypertensive medication at home, the feasibility of home titration still remains uncertain. The authors conclude that because blood pressure control was improved using minimally trained nonprofessional staff, this intervention holds promise for improving hypertension control without increasing demand on physician time.

Health Coaching to Improve Hypertension Treatment in a Low-Income, Minority Population

By Thomas Bodenheimer, MD, et al

University of California, San Francisco

Family Physician Reflects on Why He Loves His Work

In an essay, a family physician in El Salvador reflects on the personal joys family medicine has brought him, touching on six themes that continue to rejuvenate his practice: love, faith, mystery, place, dance and medicine. By examining the emotional and psychological dimensions of these themes, he offers a path by which other family physicians may be able to find sustenance and joy in their daily work.

The Joy of Family Practice

By William Ventres, MD, MA

University of El Salvador School of Medicine, San Salvador

Lebanese Women Welcome Health Care System Involvement in Addressing Domestic Violence

Even in conservative societies such as Lebanon, addressing domestic violence through the health care system may be socially acceptable and not offensive to women. Although Arab women are generally expected to balance their needs and well-being against preservation of family reputation and loyalty to one's husband, the 72 Lebanese women who participated in this qualitative study encouraged involvement of the health care system in the management of domestic violence and considered it to be a socially accepted way to break the silence. Participants described characteristics of health professionals that would be conducive to disclosure, including open-mindedness, good listening skills, a caring and unhurried demeanor and respect for confidentiality. The participants did not, however, believe the health care system alone could reduce or end domestic violence, and recommended mass media and community awareness campaigns focusing on family relationships to change knowledge, attitudes, beliefs and social norms.

Involving the Health Care System in Domestic Violence: What Women Want

By Jinan Usta, MD, MPH, et al

American University of Beirut, Lebanon

Researchers Offer Estimates of Intraclass Correlation Coefficients to Aid Practice-Based Investigators

Thompson and colleagues provide information on clustering data from more than 5,000 patients in 61 practices in eight practice-based research networks across the United States obtained from the Prescription for Health program sponsored by the Robert Wood Johnson Fund. The details of these intraclass correlation coefficients across multiple patient characteristics, practices and networks will be of use to practice-based researchers in planning studies to ensure adequate statistical power.

Intraclass Correlation Coefficients Typical of Cluster-Randomized Studies: Estimates From the Robert Wood Johnson Prescription for Health Projects

By David M. Thompson, PhD, et al

University of Oklahoma Health Sciences Center, Oklahoma City

Contact: Angela Sharma
American Academy of Family Physicians

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