January/February Annals of Family Medicine tip sheet

January 25, 2005

OCCASIONAL DRINKING ASSOCIATED WITH MORE INJURIES THAN ALCOHOLISM
Contrary to common perception, injuries attributable to alcohol consumption are more likely to be associated with an occasion of alcohol consumption than with alcohol dependence. In this population-based study of 2,517 patients admitted to three emergency departments between 1998 and 2000, most alcohol-associated injuries occurred in persons who had consumed alcohol during the six hours before injury. The proportion of injuries that would not have occurred in the absence of drinking during the six hours before injury was between 8.5 and 10.6 percent, compared to 4 percent due to alcohol dependence.

The authors assert that what is generally considered nonhazardous alcohol consumption is frequently associated with injury. Consuming two or three alcoholic drinks for women or two to four for men caused about 4 percent of all emergency department injury visits in this study, about the same proportion as is caused by alcohol dependence. An even greater proportion of major injuries (between 7.6 and 9.9 percent) was attributed to these levels of drinking.

The authors note that in 2001, 29.2 million injuries were treated in U.S. emergency departments. Of those injuries as many as 1.3 million are possibly attributable to drinking what is considered a nonhazardous amount of alcohol. The authors assert that preventing these injuries could result in a considerable benefit to individuals and society.
Alcohol-Related Injuries: Evidence for the Prevention Paradox
By Maria C. Spurling, M.D., et al

ETHICIST ASSERTS THAT PHYSICIANS SHOULD REFUSE TO SEE PHARMACEUTICAL SALES REPRESENTATIVES
Practicing family physician and ethicist Howard Brody, M.D., Ph.D., contends that because visits with pharmaceutical representatives are time-consuming and because the representatives serve interests that often are at odds with those of patients, physicians should refrain from meeting with them. In his analysis, Brody argues that spending time with representatives in a manner that preserves professional integrity would require both refusing to accept their gifts and spending a great deal of valuable time double-checking their information to correct for the inherent bias of representatives' presentations. He contends that given how busy most physicians are, the vast majority of physicians could better serve their patients by spending their time in other ways.
The Company We Keep: Why Physicians Should Refuse to See Pharmaceutical Representatives
By Howard Brody, M.D., Ph.D.

STUDY EXAMINES WHY MANY YOUNG ADULTS REFUSE TREATMENT FOR DEPRESSION
Twenty-five percent of adolescents and young adults will experience a depressive episode by age 24, yet fewer than 20 percent receive high-quality care. In a cross-sectional study of 10,962 young adults aged 16 to 29 years with significant depressive symptoms, more than one quarter (26 percent) of the participants said they did not intend to accept their physician's diagnosis of depression. The authors uncovered a number of reasons why these patients refused the diagnosis of depression. Among the most important reasons were the belief that the treatment does not work, concern about the stigma from family and friends, and lack of past helpful treatment experiences. These findings suggest that negative attitudes and concerns about stigma may be important barriers to youth accepting and complying with treatment. The authors assert that improved reimbursement to primary care physicians for visits in which they negotiate diagnosis and treatment plans with depressed patients could improve treatment rates.
Beliefs and Attitudes Associated with the Intention Not to Accept the Diagnosis of Depression Among Young Adults
By Benjamin W. Van Voorhees, M.D., M.P.H., et al

LONG-TERM DEPRESSION MANAGEMENT IS COST-EFFECTIVE, STUDY SHOWS
One of a cluster of five papers on depression in this issue of Annals, this study provides the first evidence that depression disease management produces increasingly better outcomes over time, while at the same time becoming less costly. For the study, practices providing enhanced care management supplemented acute care with systematic monitoring for two years, encouraging depressed patients to engage in active treatment and using practice nurses to provide regular care management. Analyzing the outcomes for 221 adults beginning treatment for major depression, the authors found that enhanced care significantly increased the number of days free of depression impairment for two years when compared to usual care (623 days vs. 527 days). The incremental cost-effectiveness ratio for enhanced care ranged from $5,054 to $8,073 per quality-adjusted life year. In their analysis, the authors point out that incremental quality-adjusted life years significantly increased with time while incremental costs declined. They conclude that enhanced management of depression in primary care is cost-effective and appears to be an efficient use of health care resources, and they assert that their findings should encourage health plans to provide for long- rather than short-term depression management. They note that primary care depression management results in comparable or greater cost-effectiveness than smoking cessation counseling, hypertension treatment, cholesterol treatment or chronic obstructive pulmonary disease rehabilitation.
Cost-Effectiveness of Enhancing Primary Care Depression Management on an Ongoing Basis
By Kathryn Rost, Ph.D., et al

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OTHER STUDIES IN THIS ISSUE:

STUDY POINTS TO EARLIER ONSET OF TYPE 2 DIABETES
Analyzing data from the National Health and Nutrition Examination Survey, researchers found that over the course of a decade (1988 to 2000), the age at diagnosis of type 2 diabetes decreased from 52 to 46 years. They offer three plausible explanations for the dramatic decrease, including: 1) earlier onset of type 2 diabetes, 2) improved recognition and earlier detection of the disease by clinicians, and 3) increased public awareness and education about the disease.
Changes in Age at Diagnosis of Type 2 Diabetes Mellitus in the United States, 1998 to 2000
By Richelle J. Koopman, M.D., M.S.

HOW DO OSTEOPOROTIC FRACTURES CHANGE WOMEN'S PERCEPTIONS OF FUTURE RISK?
In a qualitative study of 22 women over the age of 40 who had experienced an osteoporotic fracture in the previous year, researchers found that only a minority recognized their previous fracture as an indicator of increased susceptibility for future fractures and committed themselves to long-term prevention. The majority of the women's perceptions fell into one of two groups: 1) They took a laissez faire approach, preferring to wait and see what the future held, or 2) They recognized some of the things they should be doing to reduce their risk but were inconsistent in maintaining changes or seeking information.
Women's Perceptions of Future Risk After Low-Energy Fractures at Midlife
By Lynn M. Meadows, Ph.D., et al

YOUNGER PHYSICIANS IN HMOS DON'T FEEL STRONG SENSE OF RESPONSIBILITY TO INDIVIDUAL PATIENTS
Physician values may be shifting, according to a cross-sectional survey of 372 physicians from 11 managed care organizations. The researchers found that a strong sense of physician responsibility to individual patients is less common among younger physicians and physicians who practice in staff-model managed care organizations (compared to network-model managed care organizations). They also found that physicians with a strong sense of responsibility to individual patients were significantly more likely to report being satisfied with the quality of care they provide and with their ability to serve the needs of their patients.
Physician Conceptions of Responsibility to Individual Patients and Distributive Justice in Health Care
By Mary Catherine Beach, M.D., M.P.H., et al

DEPRESSED PATIENTS WHO COMPLAIN OF PHYSICAL RATHER THAN PSYCHOLOGICAL SYMPTOMS REQUIRE DIFFERENT TREATMENT APPROACH, STUDY FINDS
A primary care depression intervention is more effective for patients with predominantly psychological versus physical symptoms, according to this group-randomized trial involving 200 patients. A two-year ongoing intervention for patients who complained of psychological symptoms improved clinical outcomes while reducing outpatient costs by $980 per patient. In contrast, a two-year ongoing intervention for patients who complained exclusively of physical symptoms failed to improve clinical outcomes beyond usual care, while increasing outpatient costs by $1,378 per patient over two years. The findings suggest a need for developing new intervention approaches for depressed patients who complain of physical symptoms.
RTC of a Care Manager Intervention for Major Depression in Primary Care: 2-Year Costs for Patients with Physical vs Psychological Symptoms
By L. Miriam Dickson, Ph.D., et al

STUDY EXAMINES WHY SOME PATIENTS DON'T TAKE THEIR ANTIDEPRESSANT MEDICATIONS
Patients' adherence to maintenance antidepressant therapy varies widely and can be explained by their beliefs about the medications prescribed. In a survey of 81 patients, researchers found that adherence was highest among patients whose perceived need for the medication exceeded their concerns about taking it, and it was lowest for those whose concerns about taking the medication exceeded their perceived need.
Adherence to Maintenance-Phase Antidepressant Medication as a Function of Patient Beliefs About Medication
By James E. Aikens, Ph.D., et al

HOW DO PHYSICIANS DIAGNOSE DEPRESSION?
This qualitative study identifies three processes used by clinicians to sort through the often unclear symptoms of depression and arrive at a diagnosis - ruling out, opening the door and recognizing the person. The authors explain that how these processes are used and the speed with which clinicians sort through the symptoms are influenced by three factors - their familiarity with the patient, their clinical experience and their time availability.
The Recognition of Depression: The Primary Care Clinician's Perspective
By Seong-Yi Baik, Ph.D., R.N., et al

STUDY OFFERS SUGGESTIONS FOR INVOLVING COMMUNITIES IN MENTAL HEALTH RESEARCH
The study of a community advisory board identifies key issues for engaging the community voice in participatory research in mental health and primary care.
Mental Health Research in Primary Care: Mandates from a Community Advisory Board
By Roberto Chené, M.A., et al
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Annals of Family Medicine is a peer-reviewed research journal that provides a cross-disciplinary forum for new, evidence-based information affecting the primary care discipline. Launched in May 2003, the journal is sponsored by six family medical organizations, including the American Academy of Family Physicians, the American Board of Family Practice, the Society of Teachers of Family Medicine, the Association of Departments of Family Medicine, the Association of Family Practice Residency Directors and the North American Primary Care Research Group. The journal is published six times each year and contains original research from the clinical, biomedical, social and health services areas, as well as contributions on methodology and theory, selected reviews, essays and editorials. A board of directors with representatives from each of the sponsoring organizations oversees Annals. Complete editorial content and interactive discussion groups can be accessed free of charge on the journal's Web site, www.annfammed.org.

American Academy of Family Physicians

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