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September/October 2007 Annals of Family Medicine tip sheet

Patients Seeking Care for Urgent Health Problems Report Highest Satisfaction When Seen by Their Own Family Physician; Satisfaction Lowest at Walk-in Clinics

Patient satisfaction with after-hours care for an urgent problem is higher if provided by their own family physician or their physicians after-hours clinic, compared with a walk-in clinic, the emergency department and telephone health advisory services. According to a survey of 1,227 patients from 36 practices in Thunder Bay, Ontario, who were asked to rate their satisfaction on a 7-point scale, patients reported highest satisfaction when care was received from their own family physician (6.1) followed by an after-hours clinic affiliated with their physician (5.6). Those who obtained care at a walk-in clinic or who used more than one service reported the lowest satisfaction rating (4.7).

As health systems emphasize improved access and continuity for patients, this study can inform the proliferation new models of care. The authors suggest that these findings support increasing financial and human resources to enhance access to practice-based primary care services.

Patient Satisfaction With Care for Urgent Health Problems: A Survey of Family Practice Patients
By Michelle Howard, M.Sc., Ph.D., et al

Anger and Psychological Stress Play a Role in the Development of Coronary Heart Disease in Prehypertensive Middle-Aged Adults

Prehypertensive middle-aged men who have high levels of trait anger a tendency to experience anger across a range of situations are at increased risk of progressing to hypertension and developing coronary heart disease, according to a secondary analysis of a large population-based study. The analysis of 2,334 men and women aged 45-64 years also found that long-term stress is associated with increased risk of coronary heart disease in both men and women.

Specifically, researchers found that men with high trait anger scores had 1.7 times greater odds for developing hypertension than those with low or moderate scores, and high trait anger scores were associated with a 90 percent increase in the risk of progression to coronary heart disease in prehypertensive men. Moreover, both men and women with high levels of long-term psychological stress had 1.68 times greater odds for developing coronary heart disease than those with low or moderate stress.

The authors suggest that treatment of anger and psychological stress may have a beneficial effect on slowing progression of prehypertension to hypertension and coronary heart disease.

Psychosocial Factors and Progression From Prehypertension to Hypertension or Coronary Heart Disease
By Marty Player, M.D., et al

Primary Care Physicians Unlikely to Broach the Topic of Suicide with Depressed Patients

Though the primary care setting presents an excellent venue for detection of and early intervention for suicide risk up to 75 percent of people who commit suicide have seen a primary care clinician in the previous 30 days this study finds that primary care physicians do not consistently inquire about suicidality. In a study of 152 physicians, suicide was explored in only 36 percent of 298 encounters with patient actors who portrayed depressive symptoms. Notably, exploration was more common when the patient portrayed major depression (versus adjustment disorder) and when they made a request for antidepressant medication. The latter finding was especially true when general (as opposed to brand name) antidepressant medication requests were made. Exploration was also more common in academic settings and among physicians who have had a personal experience with depression (whether in themselves, family members or close friends).

The authors conclude that their findings suggest that one approach to improving the rate of physician recognition of suicidal thinking in depressed patients is through advertising or public service messaging that prompts patients to ask for help to treat depression without encouraging them to request specific antidepressant medications.

Lets Not Talk About It: Suicide Inquiry in Primary Care
By Peter Franks, M.D., et al

A Novel Solution for Extending the 15-Minute Physician Visit: The Teamlet Model of Care

In the first of two essays in this issue to explore innovative staffing models, Bodenheimer and Laing assert that the 15-minute physician visit must be eliminated as the central institution of primary care. They propose it be replaced by a teamlet (little team) model, which has two central features: (1) the patient encounter involves two caregivers a clinician (physician, nurse-practitioner or physicians assistant) and a health coach rather than only the clinician; and (2) the 15-minute visit is expanded to include a previsit by the coach, a visit by the clinician together with the coach, a postvisit by the coach and between-visit care by the coach.

Bodenheimer and Laing argue that the teamlet model is a blueprint for addressing some of the serious problems facing primary care: inadequate visit time to provide all recommended acute, chronic and preventive care; physician and patient dissatisfaction in the rushed atmosphere of many visits; and the inadequate quality of care provided by stressed primary practices. Currently, pilot projects are underway to test the feasibility of this model of care.

The Teamlet Model of Primary Care
By Thomas Bodenheimer, M.D., and Brian Yoshio Laing, B.S.

A Practical Way to Improve Care for Patients with Chronic Disease

In the second of two essays in this issue to explore innovative staffing models, Zweifler argues for the integration of dedicated chronic disease management workers into the primary care practice. He asserts that office-based chronic disease management workers can improve the quality of care for patients with chronic diseases and increase the satisfaction of both physicians and patients by offering self-management support, maintaining disease registries, and monitoring compliance from the point of care. They also can provide the missing link by connecting patients, families and physicians with disease management services available through health plans or in the community. He suggests that Californias well-established Comprehensive Perinatal Services Program offers a good payment model for reimbursing primary care offices for defined chronic disease management services.

The Missing Link: Improving Quality With a Chronic Disease Management Intervention for the Primary Care Office
By John Zweifler, M.D., M.P.H.


Racial Differences in Effectiveness of Antihypertensive Therapy

Because racial or ethnic differences in response to antihypertensive drug therapies may contribute to disparities in cardiovascular disease, this systematic review of 28 studies attempts to (1) identify racial differences in the efficacy of antihypertensive drug therapies and (2) quantify the number and proportion of racial and ethnic minorities participating in these clinical trials. Of the 28 trials that met the studys inclusion criteria, only five made interethnic group comparisons. Researchers found that four of the five trials had similar primary outcomes for ethnic minorities and whites. The authors assert that increased minority participation in future studies is needed to determine optimal prevention therapies, especially in outcome-driven trials that compare multi-drug antihypertensive treatment regimens.

Race and Ethnicity in Trials of Antihypertensive Therapy to Prevent Cardiovascular Outcomes: A Systematic Review
By Ina U. Park, M.D., and Anne L. Taylor, M.D.

Psychosocial Factors Affect the Overall Health Status of Seniors With Multiple Chronic Diseases A survey of seniors with multiple chronic diseases identifies a number of barriers to self-care that are associated with lower perceived health status and physical functioning, but which may be amenable to intervention. Specifically, the survey of 352 seniors with an average of 8.7 chronic diseases identified the following potentially mutable barriers to self-care: identifying and treating depressive symptoms; providing individualized patient education regarding medical conditions; enhancing physical functioning through physical therapy, manual aids and other support; resolving situations in which symptoms and treatments for separate conditions interfere with each other; and striving for collaborative care choices that take into account patients financial resources. The authors conclude that clinicians must be alert to the individual needs of these patients and have systematic approaches in place to match their needs with available resources.

Barriers to Self-Management and Quality-of-Life Outcomes in Seniors With Multimorbidities
By Elizabeth A. Bayliss, M.D., M.S.P.H., et al

Existing Measure Doesnt Predict Development of Diabetes in Young Adults

An established risk score for the development of diabetes among middle-aged adults appears to have limited utility in a younger population, according to a secondary analysis of study data for 2,543 young adults. The authors conclude that because neither body mass index nor the risk score demonstrates optimal predictive ability, future research needs to focus on identifying novel factors that may improve the risk stratification for diabetes development among young adults.

Assessing Risk for Development of Diabetes in Young Adults
By Arch G. Mainous III, Ph.D., et al

Treatment Guidelines for Sore Throat Inconsistent

The authors assess discrepancies between 10 different national guidelines (four North American and six European) for managing acute sore throat. They conclude that the differences seem to be related to the selection and/or interpretation of the available scientific evidence, and they call for transparent and standardized guideline development methods because of the implications for clinical practice and public health.

Difference Among International Pharyngitis Guidelines: Not Just Academic
By Jan Matthys, M.D., et al

Identifying the Optimal Protocol for Domestic Violence Screening in Primary Care

Three different approaches for domestic violence screening in primary care a self-administered questionnaire, medical staff interview, and physician interview all have similar results in terms of disclosure rates, comfort and time spent screening. The authors assert that brief screening tools like those tested in this study can be useful to busy primary care clinicians.

Randomized Comparison of 3 Methods to Screen for Domestic Violence in Family Practice
By Ping-Hsin Chen, Ph.D., et al

More Intensive CME Produces Limited Improvement in Communication Between Doctors and Breast Cancer Patients

A randomized controlled trial of two continuing medical education (CME) approaches aimed at improving communication between doctors and breast cancer patients finds varied effects. No significant differences were found on the communication scores of 51 physicians (family physicians, surgeons and oncologists) exposed to a traditional 2-hour CME compared with a new 6-hour intensive version. Among the family physician subgroup, however, those exposed to the intensive version had significantly higher communication scores than those exposed to the traditional CME. Additionally, patients of surgeons and oncologists who participated in the 6-hour CME were significantly more satisfied and felt better than the patients of surgeons and oncologists in the control group.

Improving Communications Between Doctors and Breast Cancer Patients
By Moira Steward, Ph.D., et al


Contact: Angela Sharma
American Academy of Family Physicians

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