A comparison of morbidity patterns in public and private primary care clinics in malaysia

OBJECTIVES

To compare the morbidity patterns in public and private primary care clinics; determine patients' reasons for encounter (RFE) and diagnoses using the ICPC-2, and compare ten commonest diagnoses and RFEs.

METHODS

A cross-sectional study on randomly selected clinics was conducted nationwide. Doctors completed the Patient Encounter Record (PER) for systematically selected encounters for a week.

RESULTS

Response rate was 82.0% (public clinic) and 33% (private clinic) with 4262 encounters and 7280 RFE. Overall, the three commonest disease categories encountered were respiratory (37.2%), general and unspecified (29.5%), and cardiovascular diseases (22.2%). Public and private clinics handled 27% versus 50% acute cases and 20.0% versus 3.1% chronic cases i.e. 33.7 and 5.6 chronic diseases per 100 RFE respectively.

CONCLUSION

Doctors in public clinics saw more chronic and complex diseases as well as pregnancy related complaints and follow-up cases while in private clinics more acute and minor illnesses were seen. Health services should be integrated and support given to co-manage chronic diseases in both sectors.

Over-, under- and misuse of pain treatment in Germany

BACKGROUND

The HTA-report (Health Technology Assessment) deals with over- and undertreatment of pain therapy. Especially in Germany chronic pain is a common reason for the loss of working hours and early retirement. In addition to a reduction in quality of life for the affected persons, chronic pain is therefore also an enormous economic burden for society.

OBJECTIVES

Which diseases are in particular relevant regarding pain therapy?What is the social-medical care situation regarding pain facilities in Germany?What is the social-medical care situation in pain therapy when comparing on international level?Which effects, costs or cost-effects can be seen on the micro-, meso- and macro level with regard to pain therapy?Among which social-medical services in pain therapy is there is an over- or undertreatment with regard to the micro-, meso- and macro level?Which medical and organisational aspects that have an effect on the costs and/or cost-effectiveness have to be particularly taken into account with regard to pain treatment/chronic pain?What is the influence of the individual patient's needs (micro level) in different situations of pain (e. g. palliative situation) on the meso- and macro level?Which social-medical and ethical aspects for an adequate treatment of chronic pain on each level have to be specially taken into account?Is the consideration of these aspects appropriate to avoid over- or undertreatment?Are juridical questions included in every day care of chronic pain patients, mainly in palliative care?On which level can appropriate interventions prevent over- or undertreatment?

METHODS

A systematic literature research is done in 35 databases. In the HTA, reviews, epidemiological and clinical studies and economic evaluations are included which report about pain therapy and in particular palliative care in the years 2005 till 2010.

RESULTS

47 studies meet the inclusion criteria. An undertreatment of acupuncture, over- and misuse with regard to opiate prescription and an overuse regarding unspecific chest pain and chronic low back pain (LBP) can be observed. The results show the benefit and the cost-effectiveness of interdisciplinary as well as multi-professional approaches, multimodal pain therapy and cross-sectoral integrated medical care. Only rough values can be determined about the care situation regarding the supply of pain therapeutic and palliative medical facilities as the data are completely insufficient.

DISCUSSION

Due to the broad research question the HTA-report contains inevitably different outcomes and study designs which partially differ qualitatively very strong from each other. In the field of palliative care hospices for in-patients and palliative wards as well as hospices for out-patients are becoming more and more important. Palliative care is a basic right of all terminally ill persons.

CONCLUSION

Despite the relatively high number of studies in Germany the HTA-report shows a massive lack in health care research. Based on the studies a further expansion of out-patient pain and palliative care is recommended. Further training for all involved professional groups must be improved. An independent empirical analysis is necessary to determine over or undertreatment in pain care.

Bipolar disorder: new perspectives in health care and prevention

OBJECTIVE

High rates of misdiagnosis, delayed diagnosis, and lack of recognition and treatment of comorbid conditions often lead patients with bipolar illness to have a chronic course with high disability, unemployment rates, and mortality. Despite the recognition that long-term outcome of bipolar disorder depends on systematic assessment of both interepisodic dysfunctional domains and comorbid psychiatric and medical conditions, treatment of bipolar disorder still focuses primarily on alleviation of acute symptoms and prevention of future recurrences. We propose here to review the evidence offering a modern view of bipolar disorder defined as a chronic and progressive multisystem disorder, taking into account characteristics of each patient as well as biosignatures in order to help design personalized treatments.

DATA SOURCES

We conducted a systematic PubMed search of all English-language articles, published between 2000 and 2010, focusing on the English and French literature with bipolar disorder cross-referenced with the following search terms: emotional dysregulation, sleep and circadian rhythm disturbances, cognitive impairment, age at onset, comorbid medical and psychiatric conditions, psychosocial and medical interventions, outcome, remission, and personalized medicine. The search was conducted between July 2009 and July 2010. The literature on bipolar disorder was reviewed to provide supporting evidence that the assessment of various symptom domains that are dysfunctional between episodes should all be considered as core dimensions of the disorder.

STUDY SELECTION

Forty-one articles were identified through the PubMed search described above and selected on the basis of addressing any combination of the search terms in conjunction with bipolar disorder.

DATA SYNTHESIS

Current guidelines advocate the use of more or less similar treatment algorithms for all patients, ignoring the clinical, pathophysiological, and lifetime heterogeneity of bipolar disorder. Systematic assessment of interepisodic dimensions, along with comorbid medical and psychiatric risk factors, should be performed along the life cycle in order to plan specific and personalized pharmacologic, medical, and psychosocial interventions tailored to the needs of each patient and ready-to-test biosignatures to serve as risk factors or diagnostic or prognostic tools.

CONCLUSIONS

Medical and research findings, along with health economic data, support a more modern view of bipolar disorder as a chronic, progressive, multisystem disorder. This new comprehensive framework should guide the search to identify biomarkers and etiologic factors and should help design a new policy for health care, including prevention, diagnosis, treatment, and training.

Changes in patient experiences of primary care during health service reforms in England between 2003 and 2007

PURPOSE

Major primary care reforms have been introduced in recent years in the United Kingdom, including financial incentives to improve clinical quality and provide more rapid access to care. Little is known about the impact of these changes on patient experience. We examine patient reports of quality of care between 2003 and 2007, including random samples of patients on practice lists and patients with long-term conditions.

METHODS

We conducted a cross-sectional design study of family practices in which questionnaires were sent to serial samples of patients in 42 representative general practices in England. Questionnaires sent to samples of patients with chronic disease (asthma, angina, and diabetes) and random samples of adult patients (excluding patients who reported any long-term condition) in 2003, 2005, and 2007 addressed issues of access, communication, continuity of care, coordination, nursing care, and overall satisfaction.

RESULTS

There were no significant changes in quality of care reported by either group of patients between 2003 and 2007 for communication, nursing care, coordination, and overall satisfaction. Some aspects of access improved significantly for patients with chronic disease, but not for the random samples of patients. Patients in both samples reported seeing their usual physician less often and gave lower satisfaction ratings for continuity of care. Most scores were significantly higher for the chronic illness samples than for the random samples of patients in 2003, even after adjusting for age.

CONCLUSIONS

There was a modest improvement in access to care for patients with chronic illness, but all patients now find it somewhat harder to obtain continuity of care. This outcome may be related to the incentives to provide rapid appointments or to the increased number of specialized clinics in primary care. The possibility of unintended effects needs to be considered when introducing pay for performance schemes.

Guidelines for the primary care of lesbian, gay, and bisexual people: a systematic review

PURPOSE

We assessed whether existing guidelines for the primary care of lesbian, gay, and bisexual (LGB) people meet appropriate standards of developmental rigor, and whether they provide consistent recommendations useful for primary care clinicians.

METHODS

We performed a systematic review of such guidelines using the Cochrane Collaboration method. The countries searched were Australia, Canada, Ireland, New Zealand, the United Kingdom, and the United States. For sources, we used electronic databases, guidelines databases, primary care professional organizations, government departments of public health, LGB health care textbooks, and national LGB organizations. We assessed the quality of existing guidelines using the validated Appraisal of Guidelines for Research and Evaluation (AGREE) instrument and compared the recommendations from all fully appraised guidelines.

RESULTS

Our search did not identify any previous systematic reviews on primary care of LGB people. Of 2,421 documents identified, we initially reviewed 30 and fully appraised 11, none of which completely satisfied the AGREE criteria for quality and only 2 of which were specifically designed for primary care. Developmental rigor was poor. Particular gaps were a lack of explicit inclusion criteria, independent reviewers, and updating procedures. Nonetheless, we did identify several consistent recommendations pertinent to primary care settings: guidance on inclusive clinical environments, standards for clinician-patient communication, sensitive documentation of sexual orientation, knowledge for cultural awareness, staff training, and addressing population health issues.

CONCLUSIONS

Currently available guidelines for LGB care are philosophically and practically consistent, and provide a degree of evidence-based clinical and systems support to primary care clinicians. There is a need, however, for evidence-based LGB guidelines that are more rigorously developed, disseminated, and evaluated specifically for the primary care setting.

Adolescent primary care visit patterns

PURPOSE

Many clinical preventive care services are recommended for adolescents. Little is known about whether most adolescents have a sufficient number of preventive care services visits over time to receive those services. We wanted to measure how frequently adolescents who are insured either through private insurance or government programs have preventive vs nonpreventive care visits.

METHODS

We conducted a retrospective descriptive analysis based on claims data from a large health plan in Minnesota with about 700,000 members. All study patients were aged 11 to 18 years between January 1, 1998, and December 31, 2007. Our outcome measure was rates of preventive and nonpreventive care visits.

RESULTS

One-third of adolescents with 4 or more years of continuous enrollment had no preventive care visits from age 13 through 17 years, and another 40% had only a single such visit. Nonpreventive care visits were more frequent in all age-groups, averaging about 1 per year at age 11 years, climbing to about 1.5 per year at age 17 years. Differences in rates between government insurance and commercial insurance were small. In older adolescence, girls had more preventive care visits and more nonpreventive care visits than did boys.

CONCLUSIONS

Most adolescents come in infrequently for preventive care visits but more often for nonpreventive care visits. We recommend using the same approach in adolescence for preventive care that is being used in adults: the no-missed-opportunities paradigm. All visits by adolescents should be viewed as an opportunity to provide preventive care services, and systems should be set up to make that possible, even in busy practices with short encounters with a clinician.

More than measurement: practice team experiences of screening for type 2 diabetes

BACKGROUND

The feasibility, cost-effectiveness and best means to implement population screening for type 2 diabetes remain to be established.

OBJECTIVE

To learn from the experiences of practice staff undertaking a diabetes screening programme in order to inform future screening initiatives.

METHODS

Qualitative analysis of interviews with staff in six general practices in the 'ADDITION-Cambridge' trial; three randomly allocated to intensively manage screen-detected patients and three providing usual care. We conducted semi-structured interviews with seven nurses, four doctors, three health care assistants and four managers. Four researchers analysed the transcripts practice by practice, preparing vignettes and comparing interpretations. Participants commented on a summary report.

RESULTS

Each practice team implemented the screening and intervention programme differently, depending on numbers at risk and decisions about staff contributions. Several emphasized the importance of administrative support. As they screened, they extended the reach of the programme, testing patients outside the target group if requested, checking other risk factors, providing health information and following up people with impaired glucose tolerance. Staff felt that patients accepted the screening and subsequent management as any other clinical activity.

CONCLUSIONS

Although those developing screening programmes attempt to standardize them, primary care teams need to adapt the work to fit local circumstances. Staff need a sense of ownership, training, well-designed information technology systems and protected time. Furthermore, screening is more than measurement; at the individual level, it is a complete health care interaction, requiring individual explanations, advice on health-related behaviour and appropriate follow-up. The UK 'NHS Health Checks' programme should embrace these findings.

Assessment of certified athletic trainers' levels of cultural competence in the delivery of health care

CONTEXT

The concept of culture and its relationship to athletic training beliefs and practices is virtually unexplored. The changing demographics of the United States and the injuries and illnesses of people from diverse backgrounds have challenged health care professionals to provide culturally competent care.

OBJECTIVE

To assess the cultural competence levels of certified athletic trainers (ATs) in their delivery of health care services and to examine the relationship between cultural competence and sex, race/ethnicity, years of athletic training experience, and National Athletic Trainers' Association (NATA) district.

DESIGN

Cross-sectional survey.

SETTING

Certified member database of the NATA.

PATIENTS OR OTHER PARTICIPANTS

Of the 13 568 ATs contacted, 3102 (age = 35.3 +/- 9.41 years, experience = 11.2 +/- 9.87 years) responded.

DATA COLLECTION AND ANALYSIS

Participants completed the Cultural Competence Assessment (CCA) and its 2 subscales, Cultural Awareness and Sensitivity (CAS) and Cultural Competence Behavior (CCB), which have Cronbach alphas ranging from 0.89 to 0.92. A separate univariate analysis of variance was conducted on each of the independent variables (sex, race/ethnicity, years of experience, district) to determine cultural competence.

RESULTS

The ATs' self-reported scores were higher than their CCA scores. Results revealed that sex (F(1,2929) = 18.63, P = .001) and race/ethnicity (F(1,2925) = 6.76, P = .01) were indicators of cultural competence levels. However, we found no differences for years of experience (F(1,2932) = 2.34, P = .11) or NATA district (F(1,2895) = 1.09, P = .36) and cultural competence levels.

CONCLUSIONS

Our findings provide a baseline for level of cultural competence among ATs. Educators and employers can use these results to help develop diversity training education for ATs and athletic training students. The ATs can use their knowledge to provide culturally competent care to athletes and patients and promote a more holistic approach to sports medicine.

A medical home versus temporary housing: the importance of a stable usual source of care

OBJECTIVES

Little is known about how the stability of a usual source of care (USC) affects access to care. We examined the prevalence of USC changes among low-income children and how these changes were associated with unmet health care need.

METHODS

We conducted a cross-sectional survey of Oregon's food stamp program in 2005. We analyzed primary data from 2681 surveys and then weighted results to 84087 families, adjusting for oversampling and nonresponse. We then ascertained the percentage of children in the Oregon population who had ever changed a USC for insurance reasons, which characteristics were associated with USC change, and how USC change was associated with unmet need. We also conducted a posthoc analysis of data from the Medical Expenditure Panel Survey to confirm similarities between the Oregon sample and a comparable national sample.

RESULTS

Children without a USC in the Oregon population had greater odds of reporting an unmet health care need than those with a USC. This pattern was similar in national estimates. Among the Oregon sample, 23% had changed their USC because of insurance reasons, and 10% had no current USC. Compared with children with a stable USC, children who had changed their USC had greater odds of reporting unmet medical need, unmet prescription need, delayed care, unmet dental need, and unmet counseling need.

CONCLUSIONS

This study highlights the importance of ensuring stability with a USC. Moving low-income children into new medical homes could disturb existing USC relationships, thereby merely creating "temporary housing."

Management of test results in family medicine offices

PURPOSE

We wanted to explore test results management systems in family medicine offices and to delineate the components of quality in results management.

METHODS

Using a multimethod protocol, we intensively studied 4 purposefully chosen family medicine offices using observations, interviews, and surveys. Data analysis consisted of iterative qualitative analysis, descriptive frequencies, and individual case studies, followed by a comparative case analysis. We assessed the quality of results management at each practice by both the presence of and adherence to systemwide practices for each results management step, as well as outcomes from chart reviews, patient surveys, and interview and observation notes.

RESULTS

We found variability between offices in how they performed the tasks for each of the specific steps of results management. No office consistently had or adhered to office-wide results management practices, and only 2 offices had written protocols or procedures for any results management steps. Whereas most patients surveyed acknowledged receiving their test results (87% to 100%), a far smaller proportion of patient charts documented patient notification (58% to 85%), clinician response to the result (47% to 84%), and follow-up for abnormal results (28% to 55%). We found 2 themes that emerged as factors of importance in assessing test results management quality: safety awareness-a leadership focus and communication that occurs around quality and safety, teamwork in the office, and the presence of appropriate policies and procedures; and technological adoption-the presence of an electronic health record, digital connections between the office and testing facilities, use of technology to facilitate patient communication, and the presence of forcing functions (built-in safeguards and requirements).

CONCLUSION

Understanding the components of safety awareness and technological adoption can assist family medicine offices in evaluating their own results management processes and help them design systems that can lead to higher quality care.

Elements of the patient-centered medical home in family practices in Virginia

PURPOSE

The patient-centered medical home (PCMH) is a widely accepted theory of a practice model to improve quality of care, patient satisfaction, and access to primary care services. This study explores existing elements of the PCMH and characteristics of family practices in Virginia.

METHOD

We developed and administered a survey questionnaire to capture information on practice characteristics and PCMH elements. We randomly sampled 700 family medicine offices in Virginia from a population of practices derived from the Virginia Board of Medicine Practitioner Information Database. We used a mixed-mode survey, allowing practices in the sample to respond by mail or Internet or at a regional family medicine conference.

RESULTS

The survey resulted in a response rate of 56%, with 342 office locations participating in the study. Most practices reported continuity-of-care processes (87%) and clinical guidelines (77%). Fewer reported use of patient surveys (48%), electronic medical record for internal coordination (38%), community linkages for care (31%), and clinical performance measurement (28%). A small number reported patient registries for multiple diseases (19%). Very few practices exhibited all elements outlined in the PCMH model (1%). Practice size (number of physicians) is significantly related to PCMH model alignment.

CONCLUSIONS

Most family practices in Virginia exhibit some elements of the PCMH model. Full implementation of the PCMH model is low. Baseline information on practice characteristics, prevalence of PCMH, and challenges of small practices should be considered in guiding efforts, evaluating progress, and developing policies for care model reform.

Offering annual fecal occult blood tests at annual flu shot clinics increases colorectal cancer screening rates

PURPOSE

We wanted to determine whether providing home fecal occult blood test (FOBT) kits to eligible patients during influenza inoculation (flu shot) clinics can contribute to higher colorectal cancer screening (CRCS) rates.

METHODS

The study was time randomized. On 8 dates of an annual flu shot clinic at the San Francisco General Hospital, patients were offered flu shots as usual (control group) and on 9 other dates, patients were offered both flu shots and FOBT kits (intervention group).

RESULTS

The study included 514 patients aged 50 to 79 years, with 246 in the control group and 268 in the intervention group. At the conclusion of flu season, FOBT screening rates increased by 4.4 percentage points from 52.9% at baseline to 57.3% (P = .07) in the control group, and increased by 29.8 percentage points from 54.5% to 84.3% (P <.001) in the intervention group, with the change among intervention participants 25.4 percentage points greater than among control participants (P value for change difference <.001). Among patients initially due for CRCS, 20.7% in the control group and 68.0% in the intervention group were up-to-date at the conclusion of the study (P <.001). In multivariate analyses, the odds ratio for becoming up-to-date with screening in the intervention group (vs the control group) was 11.3 (95% CI, 5.8-22.0).

CONCLUSIONS

Offering FOBT kits during flu shot clinics dramatically increased the CRCS rate for flu shot clinic attendees. Pairing home FOBT kits with annual flu shots may be a useful strategy to improve CRCS rates in other primary care or public health settings.

Human resource staffing and service functions of community health services organizations in China

PURPOSE

We report a study on the developmental status of human resource staffing and service functions of community health services (CHS) in China and offer recommendations for improving the CHS in the future.

METHODS

A study questionnaire was completed by 712 CHS organizations distributed in 52 cities and districts in all areas of China using a multilevel stratified randomized sampling method. Data were collected on the backgrounds, human resources, and service functions of CHS organizations.

RESULTS

We found that 68.2% of doctors and 86.5% of nurses employed in CHS centers have low-level medical training. The doctor-nurse ratio in CHS centers is 1.2 to 1 and in CHS stations is 1.3 to 1. More than 50% of CHS organizations have developed on-the-job training programs, causing cost trends for staff training to increase. Although the delivery of basic clinical services and public health services is steadily increasing, 58.6% of stations are open less than 12 hours per day. Health records are established in a high proportion of CHS organizations. Two kinds of health education--general public health education, and personal education for specific problems--have been adopted by more than 92% of CHS centers and 90% of CHS stations.

CONCLUSIONS

Desired functions for CHS organizations have been partially achieved. Training for doctors and nurses engaged in CHS should be promoted and improved as quickly as possible. Training in basic clinical services and management of noncommunicable chronic diseases should be strongly promoted. Changes in government policies should be pursued to promote effective support for the development of CHS.

Should the chiropractic profession embrace the doctrine of informed consent?

This commentary provides a narrative review of the literature focusing on the use of a health care informed consent process in the United States. This article reviews the current positions of the World Medical Association, American Medical Association, American Chiropractic Association, Wisconsin and New Jersey State Courts, US Federal Government Office of Health Policy and Clinical Outcomes, and 1 college of chiropractic regarding the doctrine of informed consent. The authors recommend that the chiropractic profession embrace the doctrine of informed consent and promulgate it as a standard of care. The implementation of this doctrine by chiropractic physicians promotes and improves the safety of chiropractic interventions.

Impact of spiritual symptoms and their interactions on health services and life satisfaction

PURPOSE

Recent work suggests that the biopsychosocial model should be expanded to include the spiritual dimension as well. The purpose of this study was to assess the independent effects of spiritual symptoms and their interactions with biopsychosocial symptoms on health care utilization, extreme use of services, and life satisfaction among primary care patients.

METHODS

Three hundred fifty-three adult waiting room patients at 2 primary care clinics completed the Biopsychosociospiritual Inventory (BioPSSI) as well as measures of life satisfaction and health care use. Hierarchical logistic regression analysis was performed with each outcome to determine whether adding spiritual symptoms and their interaction terms better accounted for outcomes than demographics, functional status, and chronic medical problems alone.

RESULTS

Spiritual symptoms (alone or in interaction) were associated with 7 of the 10 outcomes and were particularly important to extreme use of health care services and life satisfaction. Among best-fit models, spiritual symptoms alone were significantly associated with any mental health use (beta =0.694, P < or = .05), fair-poor health status (beta =0.837, P < or = .05), and life lacking meaning (beta =1.214, P < or = .001).

CONCLUSIONS

This study has shown the relevance of spiritual symptoms and their interactions to understanding health outcomes. Extreme utilization outcomes were related to the number of chronic problems, as well as to the social-spiritual interaction. Satisfaction outcomes were associated with physical and spiritual symptoms. These findings may have important implications for providing comprehensive, outcome-based care, as well as for modeling of research findings.

Healing in primary care: a vision shared by patients, physicians, nurses, and clinical staff

PURPOSE

We wanted to understand the views of patients and clinicians on the central concept of healing and to identify major facilitators of and barriers to promoting healing in primary care.

METHODS

We undertook a qualitative analysis of focus group discussions. Participants were drawn from primary care clinics of a large, integrated, health care system in Washington State in 2005. Nine focus groups included 84 participants: 28 patients, 23 primary care physicians (19 family physicians), 20 registered nurses, 11 licensed practical nurses, and 2 medical assistants. Randomly sampled established patients were aged from 21 to 65 years; 71% were female.

RESULTS

We found remarkable concordance across focus groups and among types of participants in the definition of healing: Healing is a dynamic process of recovering from a trauma or illness by working toward realistic goals, restoring function, and regaining a personal sense of balance and peace. Healing is a multidimensional process with physical, emotional, and spiritual dimensions. The key themes are as follows: (1) healing is multidimensional and holistic; (2) healing is a process, a journey; (3) the goal of healing is recovery or restoration; (4) healing requires the person to reach a place of personal balance and acceptance; and (5) relationships are essential to healing. Factors that facilitate healing help build relationships, improve communication, and share responsibility between the patient and clinician. Major barriers are logistical factors that limit high-quality time with healing professionals.

CONCLUSIONS

Patients and health care team members share a vision of healing and agree on ways to enhance the process in primary care.

The unsustainable US health care system: a blueprint for change

As a family physician, I have become increasingly uncomfortable being associated with the US health care system. While shiny, new buildings go up each day, there is still little movement toward a model that will shore up the crumbling foundation. The current delivery system and financing structures are unsustainable. Inequitable distribution of resources continues, and an increasing number of American families do not have access to adequate care. In this essay, patient stories are woven into a narrative that highlights the magnitude of the problem at multiple levels of the system. My intent is not to compare stories, because we all have patients, friends, and family members who have been affected. The purpose of this essay is to encourage each reader to reflect on his or her own experiences and to present an imperative to lead change.

Healing with the needles

A child's spontaneous desire to help her mother during an office visit prompts me to reflect upon the multidimensional nature of healing and how, as family physicians, we often encounter these unique moments in our day-to-day practice.

Primary care after psychiatric crisis: a qualitative analysis

PURPOSE

Patients with serious psychiatric problems experience difficulty accessing primary care. The goals of this study were to assess whether care managers improved access and to understand patients' experiences with health care after a psychiatric crisis.

METHODS

A total of 175 consecutive patients seeking care in a psychiatric emergency department were randomly assigned to an intervention group with care managers or a control group. Brief, semistructured interviews about health care encounters were conducted at baseline and 1 year later. Five raters, using the content-driven, immersion-crystallization approach, analyzed 112 baseline and year-end interviews from 28 participants in each group. The main outcomes were patients' responses about their care experiences, connections with primary care, and integration of medical and mental health care. Scores for physical function and mental function were compared by analysis of variance (ANOVA).

RESULTS

At baseline, most participants described negative experiences in receiving care and emphasized the importance of listening, sensitivity, and respect. Fully 71% of patients in the intervention group said that having a care manager to assist them with primary care connections was beneficial. Patients in the intervention group had significantly better physical and mental function than their counterparts in the control group at 6 months (P = .03 for each) but not at 12 months. There was also a trend toward functional improvement over the course of the study in the intervention group.

CONCLUSIONS

This analysis suggests that care management is effective in helping patients access primary care after a psychiatric crisis. It provides evidence on and insight into how care may be delivered more effectively for this population. Future work should assess the sustainability of care connections and longer-term patient health outcomes.

Language access services for Latinos with limited English proficiency: lessons learned from Hablamos Juntos

BACKGROUND

The Robert Wood Johnson Foundation funded Hablamos Juntos (HJ), a $10-million multiyear demonstration to improve access to health care for Latinos with limited English proficiency and to explore cost-effective ways for health care organizations to provide language access services.

HABLAMOS JUNTOS

In this manuscript, the authors draw on their experiences in evaluating HJ, provide brief descriptions of innovative interventions, estimate operating costs, and synthesize lessons learned about implementation. A number of barriers and facilitators are documented.

CONCLUSION

The experience of HJ grantees provides guidance for organizations contemplating similar efforts. In particular, it highlights the need for health care organizations to involve physicians in the design and adoption of language services.

Pursuing equity: contact with primary care and specialist clinicians by demographics, insurance, and health status

PURPOSE

Long-term shifts in specialty choice and health workforce policy have raised concern about the future of primary care in the United States. The objective of this study was to examine current use of primary and specialty care across the US population for policy-relevant subgroups, such as disadvantaged populations and persons with chronic illness.

METHODS

Data from the Medical Expenditure Panel Survey from 2004 were analyzed using a probability sample patients or other participants from the noninstitutionalized US population in 2004 (N = 34,403). The main and secondary outcome measures were the estimates of the proportion of Americans who accessed different types of primary care and specialty physicians and midlevel practitioners, as well as the fraction of ambulatory visits accounted for by the different clinician types. Data were disaggregated by income, health insurance status, race/ethnicity, rural or urban residence, and presence of 5 common chronic diseases.

RESULTS

Family physicians were the most common clinician type accessed by adults, seniors, and reproductive-age women, and they were second to pediatricians for children. Disadvantaged adults with 3 markers of disadvantage (poverty, disadvantaged minority, uninsured) received 45.6% (95% CI, 40.4%-50.7%) of their ambulatory visits from family physicians vs 30.5% (95% CI, 30.0%-32.1%) for adults with no markers. For children with 3 vs 0 markers of disadvantage, the proportion of visits from family physicians roughly doubled from 16.5% (95% CI, 14.4%-18.6%) to 30.1% (95% CI, 18.8%-41.2%). Family physicians constitute the only clinician group that does not show income disparities in access. Multivariate analyses show that patterns of access to family physicians and nurse-practitioners are more equitable than for other clinician types.

CONCLUSIONS

Primary care clinicians, especially family physicians, deliver a disproportionate share of ambulatory care to disadvantaged populations. A diminished primary care workforce will leave considerable gaps in US health care equity. Health care workforce policy should reflect this important population-level function of primary care.

The teamlet model of primary care

The 15-minute visit does not allow the physician sufficient time to provide the variety of services expected of primary care. A teamlet (little team) model of care is proposed to extend the 15-minute physician visit. The teamlet consists of 1 clinician and 2 health coaches. A clinical encounter includes 4 parts: 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. Medical assistants or other practice personnel would require retraining to assume the health coach role. Some organizations have instituted aspects of the teamlet model. Primary care practices interested in trying out the teamlet concept need to train 2 health coaches for each full-time equivalent clinician to ensure smooth patient flow.

Specialty referral completion among primary care patients: results from the ASPN Referral Study

PURPOSE

This study describes referral completion from the perspectives of patients and primary care physicians and identifies predictors of adherence to the referral recommendation.

METHODS

We observed a cohort of 776 referred patients from the offices of 133 physicians in 81 practices and 30 states. Referring physicians and patients completed self-administered questionnaires at the time of the referral decision and 3 months later.

RESULTS

Physicians reported that 79.2% of patients referred had a specialist visit, and 83.0% of patients indicated they completed the referral. The most common reasons for not completing the referral were "lack of time" and patient belief that the "health problem had resolved." The kappa statistic for patient-physician agreement on referral completion was 0.34, indicating only fair concordance. Patients in Medicaid plans were less likely than others to complete the referral, and more likely to experience a health plan denial. A longer duration of the patient relationship with the primary care physician and physician/staff scheduling of the specialty appointment were both positive predictors of referral completion.

CONCLUSIONS

About 8 in 10 patients referred from primary care complete a specialty referral within 3 months. Findings from this study suggest that referral completion rates may be increased by assisting patients with scheduling their specialty appointments and promoting continuity of care.

Operational definitions of attributes of primary health care: consensus among Canadian experts

PURPOSE

In 2004, we undertook a consultation with Canadian primary health care experts to define the attributes that should be evaluated in predominant and proposed models of primary health care in the Canadian context.

METHOD

Twenty persons considered to be experts in primary health care or recommended by at least 2 peers responded to an electronic Delphi process. The expert group was balanced between clinicians (principally family physicians and nurses), academics, and decision makers from all regions in Canada. In 4 iterative rounds, participants were asked to propose and modify operational definitions. Each round incorporated the feedback from the previous round until consensus was achieved on most attributes, with a final consensus process in a face-to-face meeting with some of the experts.

RESULTS

Operational definitions were developed and are proposed for 25 attributes; only 5 rate as specific to primary care. Consensus on some was achieved early (relational continuity, coordination-continuity, family-centeredness, advocacy, cultural sensitivity, clinical information management, and quality improvement process). The definitions of other attributes were refined over time to increase their precision and reduce overlap between concepts (accessibility, quality of care, interpersonal communication, community orientation, comprehensiveness, multidisciplinary team, responsiveness, integration).

CONCLUSION

This description of primary care attributes in measurable terms provides an evaluation lexicon to assess initiatives to renew primary health care and serves as a guide for instrument selection.

Disease management: panacea, another false hope, or something in between?

Disease management is being promulgated by many policy makers, legislators, and a burgeoning new disease management industry as the next major hope, together with information technology and consumer-directed health care, to bring cost containment to runaway costs of health care. Many expect quality improvement as well. The concept is being aggressively marketed to employers, health plans, and government in the wake of managed care's failure to contain costs. There is widespread confusion, however, about what disease management is and what impact it will have on patients, physicians, and the health care system itself. In this article I give a current snapshot of disease management by briefly addressing (1) its rationale and growth, (2) its track record concerning costs and quality of care, and (3) its impacts on primary care.

Improving medical practice: a conceptual framework

PURPOSE

The purpose of this article is to produce a relatively simple conceptual framework for guiding and studying practice improvement.

METHODS

I summarize the lessons from my experience with a variety of quality improvement research studies during the last 30 years, supplemented with relevant literature from both medicine and other industries about the issues associated with successful quality improvement.

RESULTS

My experience suggests that organizational leadership with an urgent vision for change, ability to manage the change process, and selection of systematic changes capable of fulfilling the vision are each critical for successful quality improvement. Published literature from other industries emphasizes the importance of a goal-directed change process managed by leaders who recognize the need to engage their employees and other leaders in a disciplined but flexible way that accommodates external and internal factors and uses teams and group learning. It also suggests the importance of organizational context and the level of external and internal barriers and facilitators for change. The resulting model proposes that priority, change process, and care process content are necessary for measurable improvements in quality of care and patient outcomes, although internal and external barriers must also be attended to and addressed.

CONCLUSION

This framework may provide a guide to those in the front lines of care who would like to make the care transformations that are needed to greatly improve care. It may also be helpful to those who are developing or testing interventions and recruiting medical practices for such change efforts.

BiDil: assessing a race-based pharmaceutical

Isosorbide and hydralazine in a fixed-dose combination (BiDil) has provoked controversy as the first drug approved by the Food and Drug Administration marketed for a single racial-ethnic group, African Americans, in the treatment of congestive heart failure. Family physicians will be better prepared to counsel their patients about this new drug if they understand a number of background issues. The scientific research leading to BiDil's approval tested the drug only in African American populations, apparently for commercial reasons, so the drug's efficacy in other populations is unknown. Race as a biological-medical construct is increasingly controversial; BiDil offers a good example of how sociocultural factors in disease causation may be overlooked as a result of an overly simplistic assumption of a racial and hence presumed genetic difference. Past discrimination and present disparities in health care involving African American patients are serious concerns, and we must welcome a treatment that promises to benefit a previously underserved group; yet the negative aspects of BiDil and the process that led to its discovery and marketing set an unfortunate precedent. Primary care physicians should be aware of possible generic equivalents that will affect the availability of this drug for low-income or uninsured patients.

Short-term impacts of coverage loss in a Medicaid population: early results from a prospective cohort study of the Oregon Health Plan

PURPOSE

Medicaid programs in all 50 states recently implemented cost-saving strategies, including benefit reductions, cost sharing, and tightened administrative rules. These changes resulted in loss of insurance coverage for thousands of low-income adults nationwide. In this study we assessed the immediate impacts of disrupted and lost Medicaid coverage on adults enrolled in the Oregon Health Plan (OHP) when program changes were implemented.

METHODS

Data come from baseline survey results of a prospective cohort study designed to assess the impacts of OHP changes on adult beneficiaries. We used bivariate and multivariate analyses to examine the effects of disrupted and lost insurance coverage on unmet health care needs, utilization, and medical debt occurring in the first 10 months after OHP changes were implemented.

RESULTS

After OHP changes were implemented, 31% of enrolled adults reported losing coverage, and another 15% reported disrupted coverage. Controlling for demographic characteristics, income, and health status, those with disrupted coverage were less likely to have a primary care visit (odds ratio [OR] = .66; P <.05) and more likely to report unmet health care needs (OR = 1.85; P <.01) and medical debt (OR = 1.99; P <.01) when compared with those continuously insured. Those who lost coverage were less likely to have a primary care visit (OR = 0.18; P <.01) and more likely to report unmet health care needs (OR = 5.55; P <.01), unmet medication needs (OR = 2.05; P <01), and medical debt (OR = 3.06; P <.01) than those continuously insured.

CONCLUSIONS

Medicaid program changes that increase cost sharing and limit enrollment have significant negative impacts on health care access and utilization among Medicaid beneficiaries; these impacts occur rapidly, within the first 10 months after changes.

Values-based practice in primary care: easing the tensions between individual values, ethical principles and best evidence

BACKGROUND

The provision of health care is inseparable from universal values such as caring, helping and compassion. Consideration for individual values, particularly those of the patient, has also been increasing. However, such consideration is difficult within the context of modern health care, where complex and conflicting values are often in play. This is particularly so when a patient's values seem to be at odds with evidence-based practice or widely shared ethical principles, or when a health professional's personal values may compromise the care provided.

SUGGESTED NEW FRAMEWORK

Values-based practice, a framework developed originally in the domain of mental health, maintains that values are pervasive and powerful parameters influencing decisions about health, clinical practice and research, and that their impact is often underestimated. Although it shares starting points with other approaches to values, it suggests that our current approaches lead us to ignore some important manifestations of values at both the general level, as relevant in legal, policy and research contexts, as well as at the individual level, as relevant in clinical practice. Drawing on ideas from philosophy, values-based practice significantly extends the range of phenomena that may be regarded as value-laden. It suggests that one of the reasons for overlooking values is that they are presumed to be shared when not apparently conflicting. Values-based practice is an approach to supporting clinical decision-making, which provides practical skills and tools for eliciting individual values and negotiating these with respect to best available evidence.

Adults' lack of a usual source of care: a matter of preference?

PURPOSE

We wanted to identify characteristics of adults who do not have a usual source of care and then stratify the analysis by those who prefer vs those who do not prefer to have a usual source of care.

METHODS

We analyzed data from a nationally representative sample of 9,011 adults to identify characteristics of those more likely to not have a usual source of care. Based on stated reasons for lacking a usual source of care, we created 2 subpopulations of adults without a usual source of care: those who had no preference and those who did. We identified and compared characteristics of each subpopulation.

RESULTS

In the year 2000, 20% of adults did not have a usual source of care. Among all adults, lack of insurance (odds ratio [OR] = 3.2; 95% confidence interval [CI], 2.6-3.9) was independently associated with lacking a usual source of care, as were male sex (OR = 2.1; 95% CI, 1.7-2.4), excellent reported health (OR = 2.0; 95% CI, 1.2-3.2), younger age (for ages 18-29 years, OR = 4.1; 95% CI, 3.1-5.4) and Hispanic ethnicity (OR = 1.5; 95% CI,1.2-1.9). Of those without a usual source of care, 72% cited reasons indicating no preference to have one. Associations among such respondents were similar to those found among adults as a whole. Among respondents who preferred to have a usual source of care, however, the sex of the respondent became less significant, lack of insurance became more significant, and reported health status became nonsignificant.

CONCLUSIONS

Most adults who lack a usual source of care do so for reasons of preference, evidently placing little value on having a usual source of care. Helping these persons have a usual source of care will likely require different interventions than needed to help those who want a usual source of care but cannot get one.

Care quality and implementation of the chronic care model: a quantitative study

PURPOSE

We wanted to test whether improvements in care quality were correlated with changes in the Chronic Care Model (CCM) in a large medical group that attempted to implement the CCM.

METHODS

The leaders of 17 primary care clinics in this medical group completed the Assessing Chronic Illness Care (ACIC) survey measure of CCM implementation before and after care system changes were made. We used administrative data to measure care quality changes for yearly samples of patients with diabetes, coronary heart disease, or depression.

RESULTS

The total ACIC score for the CCM increased by an overall average of 1.4 points (from 5.8 to 7.2 on a scale of 1 to 11, P = .02) and significant increases occurred for 3 of the 6 components of the CCM. During this time, patients experienced a significant increase in the proportion meeting a composite outcome measure for low-density lipoprotein (LDL) and glycated hemoglobin levels (from 15.7% to 25.5%, P = .001). Heart disease patients meeting a composite measure for LDL values increased from 46.8% to 57.8%, and the percentage of patients with 1 or more cardiac events dropped from 17.2% to 11.4% (P = .001 for each). Persistent use of new antidepressants did not change, but more of these patients had follow-up visits (P = .02). Only the diabetes measure was significantly correlated with 2 CCM elements-clinical information systems and decision support.

CONCLUSION

Despite implementation of the CCM and improvements in quality measures for 3 chronic diseases, there were few significant correlations between these changes. Showing such a relationship may require larger changes, a larger number of clinics, changes in other CCM elements, or a more-sensitive measurement tool.

Transforming medical care: case study of an exemplary, small medical group

PURPOSE

Most published descriptions of organizations providing or improving quality of care concern large medical groups or systems; however, 90% of the medical care in the United States is provided by groups of no more than 20 physicians. We studied one such group to determine the organizational and cultural attributes that seem related to its achievements in care quality.

METHODS

A 15-family physician medical group was identified from comparative public performance scores of 27 medical groups providing most of the primary care in our metropolitan area. Semistructured interviews were conducted with diverse personnel in this group, operations were observed, and written documents were reviewed. Four primary care physician researchers and a consultant then reviewed transcriptions, field notes, and materials during semistructured sessions to identify the main attributes of this group and their probable origins.

RESULTS

This medical group ranked first in a composite measure of preventive services and fourth and sixth, respectively, in composite scores for coronary artery disease and diabetes care. Our analysis identified 12 attributes of this group that seemed to be associated with its good care quality, with patient-centeredness being the foundational attribute for most of the others. Historical factors important to most of these attributes included small size, physician ownership, and a high value on practice consistency among the clinicians in the group.

CONCLUSIONS

The identified 12 attributes of this medical group seem to be associated with its superior care quality, and most of them might be replicable by other small groups if they choose to work toward that end.

Effect of primary health care orientation on chronic care management

PURPOSE

It has been suggested that the best way to improve chronic illness care is through a redesign of primary care emphasizing comprehensive, coordinated care as espoused by the Chronic Care Model (CCM). This study examined the relationship between primary care orientation and the implementation of the CCM in physician organizations.

METHODS

The relationship between measures of primary care orientation and the CCM was examined in a sample of 957 physician organizations from the National Study of Physician Organizations, a cross-sectional telephone survey of all US medical groups and independent practice associations with 20 or more physicians (response rate, 70%).

RESULTS

After adjusting for potential confounders, 6 of 8 measures of primary care orientation were associated with physician organizations' adoption of 11 elements of CCM chronic care management. These 6 measures were severity of chronic illness treated in primary care, health promotion activity, health education activity, any accepted financial risk for hospitalization, required reporting, and presence of an electronic standardized problem list. Presence of an electronic medical record and the 5-year primary care physician turnover rate were not associated.

CONCLUSIONS

Organizations that have adopted 6 core attributes of primary care, representing comprehensive health service delivery and a commitment to overall patient health, appear to use more chronic care management practices. Policy makers and other stakeholders may wish to focus on creating an improved primary care home in their quest to close the "quality chasm" in chronic illness care.

Facilitating collaboration among academic generalist disciplines: a call to action

To meet its population's health needs, the United States must have a coherent system to train and support primary care physicians. This goal can be achieved only though genuine collaboration between academic generalist disciplines. Academic general pediatrics, general internal medicine, and family medicine may be hampering this effort and their own futures by lack of collaboration. This essay addresses the necessity of collaboration among generalist physicians in research, medical education, clinical care, and advocacy. Academic generalists should collaborate by (1) making a clear decision to collaborate, (2) proactively discussing the flow of money, (3) rewarding collaboration, (4) initiating regular generalist meetings, (5) refusing to tolerate denigration of other generalist disciplines, (6) facilitating strategic planning for collaboration among generalist disciplines, and (7) learning from previous collaborative successes and failures. Collaboration among academic generalists will enhance opportunities for trainees, primary care research, and advocacy; conserve resources; and improve patient care.

A practice-sponsored Web site to help patients pursue healthy behaviors: an ACORN study

PURPOSE

We tested whether patients are more likely to pursue healthy behaviors (eg, physical activity, smoking cessation) if referred to a tailored Web site that provides valuable information for behavior change.

METHODS

In a 9-month pre-post comparison with nonrandomized control practices, 6 family practices (4 intervention, 2 control) encouraged adults with unhealthy behaviors to visit the Web site. For patients from intervention practices, the Web site offered tailored health advice, a library of national and local resources, and printouts for clinicians. For patients from control practices, the Web site offered static information pages. Patient surveys assessed stage of change and health behaviors at baseline and follow-up (at 1 and 4 months), Web site use, and satisfaction.

RESULTS

During the 9 months, 932 patients (4% of adults attending the practice) visited the Web site, and 273 completed the questionnaires. More than 50% wanted physician assistance with health behaviors. Stage of change advanced and health behaviors improved in both intervention and control groups. Intervention patients reported greater net improvements at 1 month, although the differences approached significance only for physical activity and readiness to change dietary fat intake. Patients expressed satisfaction with the Web site but wished it provided more detailed information and greater interactivity with clinicians.

CONCLUSIONS

Clinicians face growing pressure to offer patients good information on health promotion and other health care topics. Referring patients to a well-designed Web site that offers access to the world's best information is an appealing alternative to offering handouts or impromptu advice. Interactive Web sites can facilitate behavior change and can interface with electronic health records. Determining whether referral to an informative Web site improves health outcomes is a methodological challenge, but the larger question is whether information alone is sufficient to promote behavior change. Web sites are more likely to be effective as part of a suite of tools that incorporate personal assistance.

Quality of preventive care for diabetes: effects of visit frequency and competing demands

PURPOSE

We sought to determine the association between timely receipt of diabetes-related preventive services and the longitudinal pattern of outpatient service use as characterized by a novel taxonomy that prioritized visits based on the Oregon State Prioritized Health Services List.

METHODS

We performed a cross-sectional analysis of mail survey and automated health care data for a population-based sample of patients with diabetes enrolled in a health maintenance organization in Washington State (N = 4,463). Outcomes included American Diabetes Association-recommended preventive services, including regular hemoglobin A1C (HbA1C) monitoring, retinal examination, and microalbuminuria screening. Patients with fewer than 8 visits during the 2-year study period were considered infrequent users, while patients with 8 or more visits were classified as lower-priority users if most visits were for conditions of relatively low rank on the Oregon list and as higher-priority users otherwise.

RESULTS

After adjustment for social, demographic, and clinical factors, and depression, infrequent users had significantly reduced odds of receiving at least 1 HbA1C test (odds ratio [OR] = 0.35, 95% confidence interval [CI], 0.24-0.51), retinal examination (OR = 0.74, 95% CI, 0.63-0.86), and microalbuminuria screening (OR = 0.75, 95% CI, 0.58-0.96) relative to higher-priority users during the previous year. Lower-priority users also had relatively reduced odds of receiving at least 1 HbA(1C) test (OR = 0.59, 95% CI, 0.35-1.01), retinal examination (OR = 0.68, 95% CI, 0.56-0.84), and microalbuminuria screening (OR = 0.79, 95% CI, 0.57-1.09) despite attending a similar mean number of total visits as higher-priority users.

CONCLUSIONS

Patients who attend relatively few outpatient visits or who attend more frequent visits for predominantly lower-priority conditions are more likely to receive substandard preventive care for diabetes.

Routes to better health for children in four developing countries

Despite the availability of effective, affordable interventions for the most common causes of death, more than ten million children in developing countries die each year. This article describes the circumstances of four countries whose reductions in child mortality exceeded what might be expected from their poor economic circumstances, and it asks whether they followed common routes to improved health for children. The findings suggest that contextual factors, such as the degree of economic development, good governance, and strong health care systems, matter less than do targeted health intervention, foreign aid, and technical assistance. In general, these findings contradict prevailing U.S. foreign policy regarding the circumstances in which progress toward health goals can be made.

Stories from the sharp end: case studies in safety improvement

Motivated by pressure and a wish to improve, health care organizations are implementing programs to improve patient safety. This article describes six natural experiments in health care safety that show where the safety field is heading and opportunities for and barriers to improvement. All these programs identified organizational culture change as critical to making patients safer, differing chiefly in their methods of creating a patient safety culture. Their goal is a safety culture that promotes continuing innovation and improvement, transcending whatever particular safety methodology is used. Policymakers could help stimulate a culture of safety by linking regulatory goals to safety culture expectations, sponsoring voluntary learning collaborations, rewarding safety improvements, better using publicly reported data, encouraging consumer involvement, and supporting research and education.

The dark bridal canopy

Physician narratives in family medicine have the potential to convey the vibrant spirit of our field and provide meaningful insights into disease, illness, suffering, and the nature of healing. They may also complement empirical research, education, and practice through their integrative, expressive nature. This true story depicts a challenge faced by the author while serving as a family physician in a desolate, desert region in Israel's southern Aravah Valley (south of the Dead Sea), where he was privileged to practice for a decade. The episode, a fatal car crash in which a newlywed Druse woman (a member of a secretive sect) was killed, involved much more than just the terse details listed in the emergency log. An example of a family medicine physician-and-self drama, this piece takes the reader beyond the basic medical facts into the experience and sensations of the event. It also provides a stark contrast to the usual medical description and emphasizes the importance of stories as reflective opportunities for improving health care, sustaining ourselves as practitioners, and maintaining the vitality of our field.

Targeted routine asthma care in general practice using telephone triage

BACKGROUND

There is a high non-attendance rate for traditional clinic-based routine asthma care in general practice. Alternative methods of providing routine asthma care need to be examined.

AIM

To examine the cost and effectiveness of targeted routine asthma care in general practice using telephone triage, compared to usual clinic care.

DESIGN OF STUDY

An open randomised controlled trial.

SETTING

A single semi-rural practice in the southwest of England.

METHOD

Adult patients with asthma were randomised to receive either their routine asthma care in the surgery or care by telephone triage. Asthma control parameters, health status and NHS resource utilisation were measured over the 12-month study period.

RESULTS

One hundred and ninety-four patients were randomised and 35% per cent more patients (n = 84 versus n = 62) received more than one consultation in the telephone group. Asthma control as measured by the asthma control questionnaire (ACQ) was similar in the clinic and telephone groups: mean change in ACQ = -0.11 (95% CI = -0.32 to 0.11) versus -0.18 (95% CI = -0.38 to 0.02). Mean NHS costs were 210 pounds sterling per patient per year in the telephone group compared to 334 pounds sterling in the clinic group (P-value of bootstrapped difference = 0.071).

CONCLUSION

Targeted routine asthma care by telephone triage of adult asthmatics can lead to more asthma patients being reviewed, at less cost per patient and without loss of asthma control compared to usual routine care in the surgery.

To care is to coprovide

Although primary care, including family medicine, recognizes different types of clinician-patient interaction, I argue that only interactions characterized by coprovision define care. By coprovision I mean that clinicians and patients each provide the expertise in health care that they have the capacity to contribute in any given situation. I argue that paternalism and consumerism cannot signify care in any real sense. Some implications of this analysis include a reconceptualization of family medicine and its defining attributes; support for features of caring relationships, such as mutual responsiveness and responsibility; and an acknowledgment that clinicians and patients need to be self-regarding as well as other-regarding. In a previous issue of the Annals, I called for a new dictionary for family medicine, one that would redefine attributes of family medicine in ways not exclusively clinician-centric. Specifically, it would acknowledge the role of patients and their informal caregivers as coproviding, not merely consuming, health care.

The break-even point: when medical advances are less important than improving the fidelity with which they are delivered

Society invests billions of dollars in the development of new drugs and technologies but comparatively little in the fidelity of health care, that is, improving systems to ensure the delivery of care to all patients in need. Using mathematical arguments and a nomogram, we demonstrate that technological advances must yield dramatic, often unrealistic increases in efficacy to do more good than could be accomplished by improving fidelity. In 2 examples (the development of anti-platelet agents and statins), we show that enhanced efficacy failed to achieve the health gains that would have occurred by delivering older agents to all eligible patients. Society's huge investment in technological innovations that only modestly improve efficacy, by consuming resources needed for improved delivery of care, may cost more lives than it saves. The misalignment of priorities is driven partly by the commercial interests of industry and by the public's appetite for technological breakthroughs, but health outcomes ultimately suffer. Health, economic, and moral arguments make the case for spending less on technological advances and more on improving systems for delivering care.

Antibiotic treatment and survival of nursing home patients with lower respiratory tract infection: a cross-national analysis

PURPOSE

Although lower respiratory tract infections are a leading cause of death in frail elderly patients, few studies have compared treatments and outcomes. We assessed the effects of different antibiotic treatment strategies on survival of elderly nursing home residents with lower respiratory tract infections in the United States and the Netherlands, where treatment approaches are quite different.

METHODS

We combined data from 2 prospective cohort studies of lower respiratory tract infections conducted in 36 nursing homes in the United States and 61 in the Netherlands. We included residents whose infections were treated with antibiotics: 806 in the United States and 415 in the Netherlands. Outcome measures were 1-month and 3-month mortality. We used logistic regression to adjust for differing illness severity.

RESULTS

Dutch residents had higher mortality than US residents (28.1% vs 15.1% at 1 month, respectively; P <.001). After adjusting for illness severity with logistic regression, the differences between the Dutch and US populations were not significant (odds ratio 1.34; 95% confidence interval, 0.94-1.90). Predicted mortality was overestimated for more severely ill US residents at 1 month but not at 3 months. No antibiotic regimen was consistently associated with increased or decreased mortality.

CONCLUSION

Despite differences in illness severity and treatment, adjusted mortality did not differ between the 2 countries. Although we cannot exclude a short-term survival benefit from more aggressive treatment in the United States, differences in baseline health appear prognostically more important than the type of antibiotic treatment.

The cost-effectiveness of expanded testing for primary HIV infection

PURPOSE

Primary infection with the human immunodeficiency virus (HIV) is a major factor in the HIV epidemic. Most patients become symptomatic and seek care, but seldom are they tested or is their condition diagnosed. The objectives of this study are to determine whether it is cost-effective to expand testing for primary HIV infection to a larger cohort of patients, and, if so, which diagnostic assay is most cost-effective.

METHODS

We undertook a cost-effectiveness analysis of testing a hypothetical cohort of more than 3 million outpatients with fever and other viral symptoms regardless of HIV risk factors using 3 diagnostic assays: p24 antigen enzyme immunosorbent assay (EIA), HIV-1 RNA assay, and third-generation HIV-1 EIA. Antiretroviral therapy was started when the CD4 cell count decreased to 350/microL. Outcome measures were the incremental cost-effectiveness of the diagnostic assays, number of cases identified, cases avoided in sexual partners, and threshold prevalence. For sensitivity analyses, we used 50,000 dollars as the threshold for cost-effectiveness.

RESULTS

At the baseline prevalence of 0.66%, p24 antigen EIA testing was the most cost-effective option at a cost of 30,800 dollars per quality-adjusted life-year gained when compared with no testing. There were 17,054 cases identified, and infection was avoided in 435 partners. Probabilistic sensitivity analysis, in which the estimates for all variables are varied simultaneously, determined that expanded testing with p24 antigen EIA compared with no testing had a 67% probability of being cost-effective at the baseline prevalence and a 71% probability at a prevalence of 1%.

CONCLUSIONS

Expanded testing for primary HIV infection with p24 antigen EIA may be a sound expenditure of health care resources.