May/June 2003 Tip Sheet

Media Contact:
Angela Lower
Annals of Family Medicine
(800) 274-2237, ext. 5224, or (913) 906-6253
alower@aafp.org

A Native American Community with a 7 % Cesarean Delivery Rate: Case Mix Analysis, Risk Factors and Operative Indications
Lawrence Leeman, M.D., M.P.H., et al
Family physicians may be able to reduce the cesarean delivery rates in their obstetrical units by adopting practices characteristic of communities with c-sections rates much below the national average. In an attempt to identify factors associated with low cesarean delivery rates, Dr. Lawrence Leeman and his colleague conducted an epidemiological study of a predominantly Native American community of northwestern New Mexico known to have a low cesarean delivery rate despite a high incidence of obstetrical risk factors. The authors suggest that by avoiding unneeded inductions, not routinely intervening with cesarean delivery for labor dystocia until at least four hours of adequate contractions, ensuring adequate provision of continuous labor support and facilitating consultation prior to nonemergent cesarean delivery, doctors may be able to significantly reduce the cesarean delivery rate.

Co-morbidity: Implications for the importance of Primary Care in "Case" Management
Barbara Starfield, M.D., M.P.H., F.R.C.G.P, et al
In a large-scale study of 170,447 patients, Starfield and colleagues found that people with co-morbidity turn to primary care physicians for care more frequently than they do specialists. The study also found that most health care visits by patients with co-morbidity are not for the selected conditions but for other illnesses. The findings suggest the need for an approach to health care that is oriented more toward patients' overall healthcare needs rather than diseases. The authors call for a new paradigm of care characterized by expanded communication and more effective coordination between primary care physicians and specialists.

Patient Education for Informed Decision Making about Prostate Cancer Screening: A Randomized Controlled Trial with One-year Follow-up
Robert J. Volk, Ph.D., et al
Men who are exposed to educational decision aids have improved knowledge about prostate cancer screening and are less likely to proceed with prostate-specific antigen (PSA) testing, according to the findings of this randomized clinical trial conducted by Volk and colleagues. The findings suggest that the integration of decision aids into routine clinical practice may be beneficial in promoting informed decision-making. In order to be effective, however, these decision aids need to be tailored to ethnic-group specific concerns and may need to be presented at routine intervals to ensure knowledge retention.

Descriptions of Barriers to Self-care by Persons with Co-morbid Chronic Diseases
Elizabeth A. Bayliss, M.D., M.S.P.H., et al
The growing patient population with multiple chronic diseases (co-morbidities) may experience a wide range of barriers to self-care that are specifically related to managing the simultaneous demands of more than one disease, according to this qualitative study by Bayliss and colleagues. While numerous studies have investigated the barriers to self-care experienced by patients with one disease, until now, no studies had attempted to identify barriers to self-care specific to patients with more than one chronic disease. If the study's findings are confirmed by larger studies, it would suggest a need for clinicians to create a reorganized model for self-care that emphasizes collaborative management of physical and emotional well being. Recognizing barriers to self-care could help physicians better equip patients with multiple medical conditions with the tools necessary to address specific management issues.

Glycemic Control in Medical Inpatients with Type 2 Diabetes Mellitus Receiving Sliding Scale Insulin Regimens versus Routine Diabetes Medications
Lori M. Dickerson, Pharm.D., B.C.P.S., et al
Debunking the common belief that sliding scale insulin (SSI) regimens are better able to maintain tight glycemic control and prevent glycemic events, this study by Dickerson and colleagues shows that the practice provides no benefit in glucose control or in the length of hospitalization for patients with type 2 diabetes mellitus who are hospitalized for other conditions. The findings demonstrate that the addition of the SSI regimen or the use of routine diabetes medications alone are equally acceptable treatment strategies for managing diabetes in patients hospitalized for other illnesses. The authors suggest that physicians should consider patient preferences in their treatment selection and consider the cost implications and additional nursing time demands before routinely ordering SSI coverage for their patients.

Applying a Risk-Adjustment Framework to Primary Care: Can We Improve on Existing Measures?
Amy K. Rosen, Ph.D., et al
Current risk-adjustment measures may not adequately capture all the dimensions of patient risk relevant to primary care. Rosen and colleagues propose a risk-adjustment framework for primary care that incorporates clinical features related to patients' health status and nonclinical factors related to patients' health behaviors, psychosocial factors and social environment. The authors suggest the implementation of a broad framework for risk adjustment in primary care is central to achieving high-quality care.

The Face of Cancer
John G. Scott, M.D., Ph.D. and Patrick Crommet
The essay, Face of Cancer relates the compelling story of how one patient's battle with squamous cell lung cancer metastatic to the brain transformed both the patient and his family physician. Both doctor and patient describe the course of the illness, treatment and remarkable recovery, each from his own perspective. The striking effect of the illness in redirecting the patient's creativity from dancing to painting is powerfully illustrated in his original artwork, Face of Cancer. A reproduction of the painting is included in the journal and at www.annfammed.org.