Sept/Oct 2005 Annals of Family Medicine tip sheet

September 27, 2005

Expanded testing for primary HIV infection among patients with fever or other viral symptoms may be a good expenditure of healthcare resources according to a cost-effectiveness analysis of three tests for primary HIV infection. The researcher found expanded testing among a hypothetical cohort of 3 million patients with fever and other viral symptoms, regardless of HIV risk factors, using the p24 antigen EIA test would identify 17,054 cases and avoid infection in 435 sexual partners. Of the three tests examined, the author found the p24 antigen EIA to be the most cost-effective for expanded testing, and also found this test to have the lowest rate of false-positive diagnoses. The author asserts that expanded testing for primary HIV infection could have a large impact on curtailing the HIV epidemic in the United States. They point out that the cost-effectiveness of this testing compares favorably with widely-accepted screening programs such as colon cancer, annual pap smears in HIV-infected women and breast cancer.

In a related study also in this issue, the same researcher developed prevalence estimates of primary HIV infection for patients seeking care for fever, rash, sore throat - all symptoms consistent with primary HIV infection. Analysis of data from the 2000 National Ambulatory Medical Care and National Hospital Ambulatory Medical Surveys found patients complaining of fever and other visit reasons consistent with primary HIV infection, regardless of risk factors, had a disease prevalence of 0.66 percent, those with rash had a prevalence of 0.5 percent, and those with pharyngitis had a prevalence of 0.16 percent. The author asserts that these estimates can aid with development of clinical testing guidelines and clinical decisions around testing for acute HIV infection.

An accompanying editorial to these articles argues that cost-effectiveness analyses should not be used to guide the care of individual patients, but rather to assist health policy decision makers. The editorialist asserts that although it may be premature to implement such screening into practice, researchers now have new areas of investigation to provide better data for this cost-effectiveness model. Additionally, policy makers have information to inform their decisions related to screening patients with viral symptoms for acute HIV disease. The Annals editor notes that he already has made subtle changes in his clinical approach as a result of these papers.

The Cost-Effectiveness of Expanded Testing for Primary HIV Infection
The Prevalence of Primary HIV Infection in Symptomatic Ambulatory Patients
By Andrew Coco, M.D., M.S.
Should We Screen Patients With Viral Symptoms for HIV Disease?
By Theodore G. Ganiats, M.D.
In This Issue: Subtle Clinical Policy
Kurt C. Stange, M.D., PhD, Editor

The vast majority of patients with clinical depression are seen in a primary care setting. Yet most studies examining the effectiveness of antidepressant medications are done with patients who see a psychiatric specialist and who may have a different etiology, pathophysiology and natural history for their depression. The first systematic review of antidepressants versus placebo in primary care, this study finds that both tricyclic antidepressants (TCA) and selective serotonin reuptake inhibitors (SSRI) are significantly more effective than placebo in primary care settings. Additionally, the study finds that the relatively low doses of TCAs sometimes used in primary care may be effective.

Efficacy and Tolerability of Tricyclic Antidepressants and SSRIs Compared with Placebo in Primary Care Treated Depression. A Meta-analysis.
By Bruce Arroll, MBChB, PhD, et al

Patient-centered Communication is Associated with Lower Health Care Costs
When physicians use a patient-centered communication style, they tend to generate lower health care costs, according to an analysis of patient visits to 100 primary care physicians. For their analysis, the authors defined patient-centered communication as interactions that helped patients feel understood through inquiry into their needs, perspectives and expectations, and attending to the psychosocial context and expanding patients' involvement in understanding their illness and in decisions that affect their health. Prior studies show that patients generally prefer a patient-centered style and that patient-centered care can improve health outcomes. The study suggests that patient-centered communication may actually decrease the overall cost of care through reductions in spending on diagnostic testing. The authors assert that this should reassure those who fear that patient-centered physicians would try to fulfill all patient requests. However, the authors also noted that patient-centered physicians take more time for their patients, which may go unreimbursed.

Patient Centered Communication and Diagnostic Testing
Ronald M. Epstein, M.D., et al


Calling into question the efficacy of current U.S. treatment of nursing home patients, this analysis finds that aggressive antibiotic treatment is less predictive of mortality than is a patient's illness severity when treating nursing home patients for lower respiratory tract infection. The article analyzed data from two studies of lower respiratory tract infection outcomes of nursing home patients - one in the United States and one in the Netherlands, where treatment approaches are quite different. The authors note that compared with the United States, hospitalization, use of intravenous antibiotics, multiple antibiotic regimens, intravenous fluids and feeding tubes are relatively rare in the Netherlands. The study found that despite differences in the severity of the patients' illnesses and the treatments provided mortality rates did not differ between the two countries. The authors suggest the lack of demonstrated benefit of more aggressive treatment lends support for treating nursing home residents with simpler regimens that involve less discomfort.

Antibiotic Treatment and Survival of Nursing Home Patients with Lower Respiratory Infection: A Cross-National Analysis
By Robin L. Kruse, M.D., et al

An in-depth qualitative study of 30 patients with a family history of cancer, heart disease or diabetes finds that a patient's understanding of their familial risk of common chronic diseases depends not only on the biomedical approach of counting affected relatives, but also on such factors as the emotional impact of witnessing illness in the family and the nature of personal relationships with the relative with the disease. Several important themes emerge from this study, including the influence of likeness with affected relatives and closeness within a family upon a personal sense of risk; the effects of personal experience of familial illness on risk perception; and strategies patients apply to cope with or control familial risk. The authors suggest there is a role for the physician to determine the patient's perspective when discussing risk for chronic disease that could inform a more patient-centered approach to risk assessment and communication.

'Coming Down the Line' - Patients' Understanding of Their Family History of Common Chronic Disease
By Fiona M. Walter, M.A., MSc, FRCGP, et al

Physician practices develop individualized approaches for delivering clinical preventive services, such as smoking cessation counseling, cholesterol screening and immunizations, with no one approach being successful across practices. This mixed methods study of Midwestern family medicine practices used medical records, observation of outpatient encounters, and patient exit cards to calculate practice level rates of delivery of preventive services. Often acute and chronic illness care competes with delivery of preventive services, therefore crowding out prevention services. In addition, preventive services delivery rates appeared to be influenced by economic concerns of the practice and having a physician champion within the practice who prioritizes prevention.

Delivery of Clinical Preventive Services in Family Medicine Offices
By Benjamin F. Crabtree, Ph.D., et al

This systematic review finds insufficient evidence to support the use of metformin, a drug used for the treatment of type 2 diabetes and polycystic ovary syndrome, as treatment of overweight or obese adults who do not have diabetes or polycystic ovary syndrome.

Metformin as Treatment for Overweight and Obese Adults: a Systematic Review
By Kara Levri, M.D., M.P.H., et al

Social network analysis, a way of measuring personal relationships, is a valuable tool for quantitatively analyzing relationships among people and understanding differences between practices. The study finds this tool, which has traditionally been reserved for use in public and community health settings, could also be used in a primary care setting to analyze complex systems and help design interventions to promote organizational change within the practice.

Social Network Analysis as an Analytic Tool for Interaction Patterns in Primary Care Practices
By John Scott, M.D., Ph.D., et al

This methodology study finds the Rochester Participatory Decision-Making Scale (RPAD) is a reliable, valid and easy-to-code objective measure of participatory decision-making. The RPAD assesses physician behavior that encourages patient participation in decision making.

Rochester Participatory Decision-Making Scale (RPAD): Reliability and Validity
By Cleveland G. Shields, Ph.D., et al

In this personal essay, a physician relates the story of a patient who experienced a traumatic event, which led to increased anger and continued to dramatically affect the patient's life. The physician realizes he may have missed an opportunity to help this patient earlier by asking more questions about his history.

The Decade Dance
By Jon O. Neher, M.D.
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 Medicine, the Society of Teachers of Family Medicine, the Association of Departments of Family Medicine, the Association of Family Medicine Residency Directors and the North American Primary Care Research Group. Annals 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 for each published article can be accessed free of charge on the journal's Web site,

American Academy of Family Physicians

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