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September/October 2011 Annals of Family Medicine Tip Sheet

Why Patients Don't Disclose Depression to Their Physicians

Many adults subscribe to beliefs that inhibit them from disclosing symptoms of depression to their primary care physician. In a survey of 1,054 adults, 43 percent of patients reported one or more reasons for not talking to a primary care physician about their depression, with the most frequently cited reason being concern the physician would recommend antidepressants (23 percent). Other barriers reported by patients include the belief it is not the primary care physician's job to deal with emotional issues (16 percent) and concerns about medical record confidentiality (15 percent). Other concerns reported by at least 10 percent of respondents included fear of referral to a counselor or psychiatrist, and being labeled a psychiatric patient. The authors note that ironically, those who most subscribed to potential reasons for not talking to a primary care physician about their depression tended to be those who had the greatest potential to benefit from such conversations individuals with moderate to severe depressive symptoms. The authors call for the development of office-based interventions that address these patient concerns and encourage patients with depression symptoms to begin a conversation with their doctors.

Suffering in Silence: Reasons for Not Disclosing Depression in Primary Care
By Robert A. Bell, Ph. D., et al
University of California, Davis

Though Contraindicated, NSAIDs Commonly Used by Patients with Chronic Kidney Disease

Although avoidance of nonsteroidal anti-inflammatory drugs is recommended for most patients with chronic kidney disease, large numbers of individuals with CKD, many of whom are unaware of their condition, are using them and may be at risk for further kidney injury. Analyzing nationally representative data on 12,065 adults, researchers found current use of any NSAID (nearly every day for 30 days or longer) was reported by 2.5 percent, 2.5 percent and 5 percent of patients with no, mild, and moderate to severe CKD, respectively. Nearly all of the NSAIDs used were over-the-counter. Importantly, among those with moderate to severe CKD who were currently using NSAIDs, 10 percent had a current NSAID prescription, and 66 percent had used NSAIDs for more than one year. The authors note that NSAIDs have been associated both with acute kidney injury in the general population and with disease progression in those with CKD. As such, they recommend that primary care physicians, who are likely to manage both early-stage CKD and indications for NSAID use, be aware of the rates of NSAID use (both prescribed and over-the-counter), assess the risk of NSAID use in each patient, and most importantly, engage each patient in informed decision making about the risks and benefits of NSAID use.

Nonsteroidal Anti-Inflammatory Drug Use Among Persons With Chronic Kidney Disease in the United States
By Laura Plantinga, Sc. M., et al
University of California, San Francisco

Widely Used Coronary Disease Risk Prediction Models Fail to Accurately Predict Risk

Evaluating the performance of two long-established coronary disease risk scoring mechanisms, the original and REGICOR Framingham functions, researchers found one overestimates risk, whereas the other underestimates it. The 10-year observational study of 447 adult nondiabetic patients in Spain found the Framingham risk function overestimated coronary risk by 73 percent (by 48 percent in men and by 136 percent in women), whereas the REGICOR Framingham function underpredicted the population's coronary risk by 64 percent. Moreover, the original Framingham function selected a greater percentage of candidates for antihypertensive and lipid-lowering therapies than the REGICOR function (13 percent vs. 8 percent) and (14 percent vs. 7 percent), respectively. The proportion of patients included in the high coronary risk category also was doubled with the original Framingham equation (15 percent vs. 7 percent). That both models failed to accurately predict the population's actual coronary risk in the 10-year follow-up period was not surprising to the authors. They point out the original Framingham study was conducted before the widespread use of effective treatment for cardiovascular risk factors, so its equation currently overpredicts cardiovascular risk when applied to populations who have their risk factors actively managed. They conclude the Framingham risk functions could be improved by revising them to include additional cardiovascular risk factors and such variables as family history of cardiovascular disease in a first-degree relative, social deprivation, body mass index, and current prescription of antihypertensive therapy.

Original and REGICOR Framingham Functions in a Nondiabetic Population of a Spanish Health Care Center: A Validation Study
By Francisco Buitrago, M.D., Ph.D
Centro de Salud Universitario "La Paz", Badajoz, Spain

Patients and Clinicians Open to Integrating Alternative Therapies into Primary Care

Physicians and patients are open to integrating complementary and alternative medicine therapies into primary care, especially for patients whose conditions are not responding well to standard medical treatments. Focus groups with 44 patients and 32 clinicians revealed that while patients were open to including a wider variety of healing options, they desired some evidence of effectiveness. Moreover, patients said they wanted physicians to introduce recommendations as options, not orders, and were interested in hearing about the clinicians' personal and practice experience with different treatments. For their part, clinicians were most concerned about the safety of specific treatments, specifically herbs and dietary supplements. They expressed the need for better information regarding the nature, effectiveness and safety of alternative healing options, as well as current and reliable information on practitioners and resources in their communities to whom they could confidently refer their patients. The authors call for further research to clarify the safety, clinical effectiveness and cost-effectiveness of specific healing options and of the integration of various packages of such options into primary care.

Patient and Clinician Openness to Including a Broader Range of Healing Options in Primary Care
By Clarissa Hsu, Ph.D., et al
Group Health Research Institute, Seattle, Wash.

Customized Dashboard Improves Physician Efficiency and Accuracy in Accessing Data Needed to Care for Diabetic Patients

Electronic health records systems with a "diabetes dashboard" summarizing information physicians need to care for diabetes patients greatly improves the efficiency and accuracy of finding chart data. Comparing the use of a new diabetes dashboard screen with use of a conventional approach of viewing multiple electronic health record screens to find 10 data elements needed for ambulatory diabetes care, researchers found the mean time needed to find all elements using the diabetes dashboard was 1. 3 minutes vs. 5. 5 minutes using the conventional approach. The 10 physicians participating in the study correctly identified 100 percent of the data requested when using the dashboard vs. 94 percent when using the conventional method. Moreover, the average number of mouse clicks was three with the diabetes dashboard vs. 60 using conventional searching. The authors conclude that although tools like the dashboard studied in this article require a large commitment of resources and money to design and develop, they could translate to a substantial cost benefit when one considers the physician time saved, unnecessary tests avoided, and medical errors prevented.

A Diabetes Dashboard and Physician Efficiency and Accuracy in Accessing Data Needed for High Quality Diabetes Care
By Richelle J. Koopman, M. D., M. S., et al
University of Missouri, Columbia

*One of the study's co-authors received financial support from Cerner Corporation, developer of the diabetes dashboard reported on in the article

E-Prescribing: Takeaways from Five Exemplar Primary Care Practices

Close examination of five primary care practices identified as exemplars of effective e-prescribing revealed that successful use of e-prescribing requires substantial investments of planning time and the ongoing transformation of work processes. Researchers found the practices studied had substantial resources to support e-prescribing use, including local physician champions, ongoing training for practice members, and continuous on-site technical support. They note that even these practices faced considerable challenges during the use of e-prescribing that derived from problems coordinating new work processes with pharmacies and ineffective health information exchange that required workarounds to ensure the completeness of patient records. The authors conclude that although e-prescribing features prominently among the technologies that are expected to transform health care in the near future, widespread successful implementation will require a longer-term commitment to supporting practice transformation, resources to aid in making these changes and improvements to the infrastructure for health information exchange.

Meaningful Use of Electronic Prescribing in 5 Exemplar Primary Care Practices
By Jesse C. Crosson, Ph. D., et al
UMDNJ-Robert Wood Johnson Medical School, Somerset, New Jersey

Editorials Examine the Complexities of Health Information Technology Implementation

Two editorials provide context for the Koopman and Crossen articles on implementing health information technology in primary care practice. The editorial by Jan reminds readers of the kind of major adaptation and transformation necessary in practices in order for practices and patients to fully reap the benefits of technology. He notes EHRs are designed for documentation and billing purposes, not clinical operations and ongoing illness care. He calls for stakeholders to bring together technical expertise and clinical relevance, while opening to the major changes HIT will engender. An editorial by Sittig and Ash analyzes the two studies through the lens of an 8-point model for the use of health information technology. Offering a systems-level view, the model posits that all of the eight interconnected dimensions must be adequately addressed if an organization is to achieve safe and effective electronic record use.

Successful Health Information Technology Implementation Requires Practice and Health Care System Transformation
By Carlos Roberto Jan, M. D., Ph. D., F. A. A. F. P.
University of Texas Health Science Center at San Antonio, Texas

On the Importance of Using a Multidimensional Sociotechnical Model to Study Health Information Technology
By Dean F. Sittig, Ph. D., and Joan S. Ash, Ph. D.
University of Texas Health Sciences Center, Houston and Oregon Health & Science University, Portland

Study Finds Only Limited Physical Activity Counseling in Primary Care

Researchers report on a newly developed 5As strategy for physical activity counseling that encourages clinicians to ask about current behavior, advise a change, assess readiness to change, assist with goal setting, and arrange follow-up. Evaluating the degree to which patients and physicians accomplished the 5As in discussions about physical activity during 361 recorded office visits, researchers found the overall frequency of any 5As talk about physical activity was 38 percent (139 visits). They found physicians infrequently assessed patients' readiness to change (23 percent), though it was commonly revealed by patients in response to the physicians' assessment of their current level of activity (53 percent). Researchers also found patients often expressed ambivalence about changing their behavior (48 percent), and physicians' response to patient ambivalence was split between limited attempts to offer assistance (51 percent) or no attempt (49 percent) to offer assistance. They conclude clinicians must improve their skills in exploring patient ambivalence and readiness to change and increase explicit mention of recommended guidelines for physical activity.

Evaluation of Physical Activity Counseling in Primary Care Using Direct Observation of the 5As
By Jennifer K. Carroll, M. D., M. P. H., et al
University of Rochester Medical Center, New York

Decision Making and Shared Mind During Serious Illness

Researchers introduce the concept of "shared mind," ways in which new ideas and perspectives can emerge through the sharing of thoughts, feelings, perceptions, meanings and intentions among patients, their families and members of the health care team. They explore how shared mind might be cultivated and its implications for decision making and patient autonomy, especially in the context of serious illness when individuals rely on others to help them think and feel their way through difficult decisions.

Shared Mind: Communication, Decision Making, and Autonomy in Serious Illness
By Ronald M. Epstein, M. D., and Richard L. Street, Ph. D.
University of Rochester Medical Center, New York and Texas A&M University, Houston

Using Care Coordination to Improve Health Behavior Counseling in Primary Care

Examining the barriers and facilitators to coordinating health behavior counseling in primary care, researchers found the combination of in-practice health risk assessment and brief counseling, coupled with referral with outreach to a valued and known counseling resource, was the best way to consistently coordinate care and encourage follow-through. Researchers evaluated data collected by nine practice-based research networks participating in national Prescription for Health: Promoting Healthy Behaviors in Primary Care Research Networks Program and found this approach led to improvement in patients' health behaviors. They call for the implementation of easy-to-use point-of-delivery reminders and decision support tools to help facilitate the coordination of health behavior counseling.

Coordination of Health Behavior Counseling in Primary Care
By Deborah J. Cohen, Ph. D., et al
Oregon Health Sciences University, Portland


Contact: Angela Sharma
American Academy of Family Physicians

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