November/December 2004 Annals of Family Medicine tip sheet

December 02, 2004

Report Finds New Model of Health Care Can Improve Quality and Efficiency and Enhance the Financial Viability of Family Practices
A report published today as an online supplement to the November/December 2004 issue projects that implementation of the New Model of care recommended in the recently released "Future of Family Medicine" report would enhance the financial viability of family medicine practices, many of whose survival is endangered by their place on the front lines of a failing health care system. The report also projects that the patient-centered New Model of care, with its emphasis on electronic health records and primary care, would lead to improved quality of care for patients and significant savings for the U.S. health care system. The findings are based on practice- and societal-level financial models developed by the national consulting firm, The Lewin Group.

The report calls for the development of a 'proof of concept' National Demonstration Project to pilot test the New Model in 10-20 family medicine practices across the country. This November, the American Academy of Family Physicians approved funding for the development of the Project. Following on the recommendations of the report, the AAFP also approved the creation of a New Model Practice Resource Center to provide on-going consultation and support to the demonstration practices and to family medicine practices across the country looking to transition to the New Model.
Task Force 6. Report on Financing the New Model of Family Medicine
By Stephen J. Spann, M.D., M.B.A., et al

Depression Has Greater Effect on Elderly Patients' Quality of Life than Other Illnesses
Treatment of depression may lead to more dramatic improvements in the health status of elderly patients than interventions for other chronic illnesses. Analyzing baseline survey data from more than 1,800 elderly patients with major depression or dysthymia enrolled in a treatment study, researchers found that depression severity had a greater impact on functioning and quality of life than other chronic medical conditions like diabetes, lung disease, hypertension, cancer, chronic pain and heart disease. The authors note that while study participants reported an average of 3.8 chronic medical illnesses, depression severity made larger independent contributions to mental functional status, disability and quality of life than the medical comorbidities. The authors conclude that improved recognition and treatment of late-life depression, one of the most treatable chronic illnesses, has the potential to significantly improve patients' lives in spite of other medical illnesses.
Depression and Comorbid Illness in Elderly Primary Care Patients: Impact on Multiple Domains of Health Status and Well-being
By Polly Hitchcock Noël, Ph.D., et al

Rural Blacks at Increased Risk for Poor Diabetes and Hypertension Control
Blacks living in rural areas not only have higher rates of diabetes and hypertension than urban blacks and both rural and urban whites, according to a new study, they also have significantly worse control of the diseases. Analyzing nationally-representative data from the Third National Health and Nutrition Survey, the authors found that rural blacks have significantly worse glycemic and diastolic blood pressure control than the aforementioned groups. From the data, the authors conclude that being rural and black is associated with substantially worse health status, and they assert that this data supports the need for a vigorous effort to address the health problems of patients living in rural areas, especially those who are of lower income and are black.
Race, Rural Residence and Control of Diabetes and Hypertension
By Arch G. Mainous, III, Ph.D., et al

Why 42 Percent of Clinic Appointments are No-Shows: An Issue of Respect
Interviews with patients revealed three reasons why 42 percent of appointments are no-shows: 1) patients feel anxiety or fear about the cause of the symptoms and anticipated diagnostic tests, 2) they feel disrespected by the health care system, and 3) they do not understand the scheduling system. In semistructured interviews with 34 adult patients, 22 participants (65 percent) mentioned emotional barriers to keeping appointments, including fear and anxiety about both procedures and bad news. Fifteen participants (44 percent) commented on issues of respect by the health care system, commenting that the health care staff did not respect patients, discounting their time, opinions and feelings. Forty-one percent of patients indicated they did not understand how a failed appointment affects the clinic and clinic staff. Patients seemed unaware of the financial impact of a failed appointment and believed a no-show may actually be a positive event for a busy clinic. The authors assert that the single issue of respect could underlie the association between waiting, satisfaction and non-attendance. They posit that the norm of reciprocity suggests that a patient who feels disrespected would feel no obligation to respect the system, and they suggest that health care providers could begin to address this issue of no-show rates by reviewing waiting times and patients' perspectives of personal respect.
Why We Don't Come: Patient Perceptions of No-Shows
By Naomi L. Lacy, Ph.D., et al


Are Frequent Callers to Family Physicians High Utilizers?
By David E. Hildebrandt, Ph.D., et al
Studying the charts of patients in a family medicine residency practice, researchers found that patients who make frequent after hours telephone calls to physicians' offices are generally high utilizers of health resources. Compared with other patients, they are predominantly female, have three times as many office visits, diagnoses and medications, and have eight times as many hospital admissions. The authors suggest that better targeted patient education and referral to other support services may decrease the number of calls and utilization of health services among this group.

Improving Test Ordering in Primary Care: The Added Value of a Small-Group Quality Improvement Strategy Compared with Classic Feedback Only
By Wim Verstappen, M.D., Ph.D.
With the number of tests ordered by primary care physicians on the rise, Verstappen and colleagues find that small-group quality improvement meetings, which give physicians an opportunity to discuss their test ordering performance with colleagues on the basis of actual performance data, are effective at changing physician test-ordering behavior. They conclude that the current practice of merely sending written feedback reports to physicians does not have a significant impact on test-ordering behavior. They suggest that to be effective, feedback reports must be incorporated into a more ambitious continuous quality improvement program.

The Unexpected in Primary Care: A Multicenter Study on the Emergency of Unvoiced Patient Agenda
By Michael Peltenberg, M.D., F.A.A.F.P., et al
Collecting data from 2,243 patients in several European countries, researchers uncovered an "emerging agenda" in nearly one of every seven outpatient visits. The researchers describe an "emerging agenda" as unexpectedly revealed concerns or issues that were neither on the patient's list of items for discussion nor anticipated by the physician.

Lay Understanding of Familial Risk of Common Chronic Diseases: A Systematic Review and Synthesis of Qualitative Research
By Fiona M. Walter, M.A., M.Sc., F.R.C.G.P., et al
In a systematic review of 11 research articles about familial risk of common chronic diseases, researchers found that elements of family history may be perceived differently by patients and clinicians and thereby affect perceptions of disease risk. Whereas clinicians include in their assessment of family history the number of affected relatives and their age at illness and death, patients' perception of risk also includes other factors, including their personal experience of a relative's disease and sudden or premature death. The authors point out that conflicts between patients' and clinicians' understanding of heredity could result in persistent misconceptions and fears concerning familial risk.

Health Care Seeking Among Urban Minority Adolescent Girls: The Crisis at Sexual Debut
By M. Diane McKee, M.D., M.S., et al
In-depth interviews revealed that urban adolescent black and Latina girls dramatically shift how and where they seek help for health needs after becoming sexually active. Before the onset of sexual activity, most girls meet health needs within the context of family, relying heavily on mothers for health care and advice. Once sexually-active, girls attempt to meet reproductive needs by extending their search for advice and care to "mother alternatives," such as older female family members, but they still seek personalized care modeled on that they received from their mothers. The authors note that many sexually active adolescent girls fail to establish trusting relationships with clinicians or "mother alternatives," and, as a result, have unmet sexual health needs.

The Biopsychosocial Model 25 Years Later: Principles, Practice, and Scientific Inquiry
By Francesc Borrell-Carrió, M.D., et al
Researchers suggest three clarifications to the biopsychosocial model posited by George Engle 25 years ago. They add to the model the need to balance a circular model of causality with the need to make linear approximations (especially in planning treatments) and the need to change the clinician's stance from objective detachment to reflective participation, thus infusing care with greater warmth and caring. They also suggest that the relationship between mental and physical aspects of health is complex and not reducible to the laws of physiology.

Effect on Health-Related Outcomes of Interventions to Alter the Interaction Between Patients and Practitioners: A Systematic Review of Trials
By Simon J. Griffin, M.Sc., D.M., et al
Studies show that a wide range of interventions can improve the participation of patients during an office visit and can improve interactions between patients and physicians; however, a systematic review of 35 medical trials found that there is little research that measures the effectiveness of specific interventions and approaches on health outcomes.

Bag of Worms
By James L. Glazer, M.D.
A family physician describes his experience as a resident physician working to resuscitate the victim of a drunk driving accident while at the same time caring for another patient undergoing his tenth admission for detoxification. He relates what it was like, as he attempted to resuscitate the victim, to hold a beating heart for the first time.

American Academy of Family Physicians

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Maternal depression increases odds of depression in offspring, study shows
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Depression in adults who are overweight or obese
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