July/August 2006 Annals of Family Medicine Tip Sheet

Media Contact: Kristin Robinson
Annals of Family Medicine
(800) 274-2237 ext. 5221
kristinr@aafp.org

Primary Care Offices Key to Rapid Identification of Emerging Infectious Outbreaks
Syndromic surveillance, the monitoring of health data to identify possible outbreaks associated with bioterrorism or pandemic illness, has been used for early detection of disease outbreaks and allows for detection before public health authorities would otherwise note them. This one-year study of a primary care practice found billing data could be readily converted into daily summaries of diagnosis codes, which can be used for rapid surveillance of disease patterns in a community. It also finds that these systems can be easily implemented at a low cost and with minimal effort. Primary care practices may be able to provide more timely surveillance than emergency departments because patients with developing illness often see their primary care physician when they first become sick. Therefore, it appears that billing data from primary care practices can be used to identify emerging infections in the community. The authors assert that this type of surveillance could be useful in detecting bioterrorism attacks and emerging infections, especially those that are not lethal and resemble common infections. They point out that the trend for primary care practices to convert to electronic medical records opens up the possibility of new, potentially low-cost, early detection systems for emerging infectious diseases.
Syndromic Surveillance for Emerging Infections in Office Practice Using Billing Data
By Philip D. Sloane, M.D., M.P.H., et al

Most People Who Don't Have A Regular Physician Choose Not To
Studies have shown that patients who have a usual source of care (a regular physician or a regular place where they get their health care) receive more preventive services and have better control of chronic medical conditions. This study finds that most adults who lack a usual source of care do so for reasons of preference. Of the 9,011 adults analyzed in this nationally representative sample, approximately 47 percent of people without insurance did not have a usual source of care. More than 66 percent of the respondents reported their reason for not having a usual source of care was that they were seldom or never sick. The second most common reason (10.2 percent) was cost. Not having a usual source of care is associated with being male, Hispanic ethnicity, younger age, lack of health insurance and being in excellent reported health. The authors suggest that educational messages about the importance of a usual source of care targeted to these groups might be a tactic to educate them in the importance of a personal medical home.
Adults' Lack of a Usual Source of Care: A Matter of Preference?
By Anthony Viera, M.D., et al

Effectiveness of the Chronic Care Model and Implementation Challenges
The Chronic Care Model, a conceptual framework for transforming health care for patients with chronic conditions, is being widely used to guide practice and health care system reform. Two companion articles evaluate the implementation experience and health care outcomes of this model as experienced by the 17 primary care clinics of a 600 physician multispecialty group. In the first article, Solberg and colleagues found that during the two-year time period of model implementation, care improved for three chronic illnesses over a (diabetes, heart disease and depression) and three of the six Model components. However, their analysis only found a relationship between two components of the Chronic Care Model and quality improvements for people with diabetes.

In the companion article, Hroscikoski and colleagues conclude that implementation of the Chronic Care Model without a blueprint is a challenge for physician practices. An in-depth qualitative comparative case study of five of the 17 clinics 18-23 months after implementation of the model highlighted specific organizational challenges with health care transformation in the absence of a guide for implementing the Chronic Care Model. The authors suggest that effective models of organizational change and detailed examples of proven, feasible changes are needed in order to successfully transform care to this model.
Care Quality and Implementation of the Chronic Care Model: A Qualitative Study
By Leif I. Solberg, M.D., et al
The Challenge of Change: A Qualitative Study of Chronic Care Model Implementation
By Mary C. Hroscikoski, M.D., M.S., et al

Nasal Irrigation Effective for Chronic Sinus Sufferers
This study gives voice to the patient perspective on how hypertonic saline nasal irrigation can serve as a safe, effective, long-term therapy for patients with chronic sinonasal symptoms. Subjects in this qualitative study had been part of two previous studies evaluating nasal irrigation. These studies reported significant objective improvements in quality of life and sinus symptoms, and reduction in the use of nasal sprays and antibiotic medication. In this study, qualitative interviews of 28 patients who used the therapy identified four themes important to the use of nasal irrigation therapy: 1) nasal irrigation improves self-management of sinus symptoms, creating a sense of empowerment, 2) it produces rapid and long-term improvement in quality of life, 3) there are barriers to use including discomfort, time and mild side effects and 4) training and at-home use helps overcome these barriers. The authors assert that physicians can confidently and safely prescribe this method to patients with chronic sinonasal symptoms. They also suggest providing patient education in a group setting is effective in helping patients understand how to perform nasal irrigation as well as its benefits.
Qualitative Aspects of Nasal Irrigation Use by Patients with Chronic Sinus Disease in a Multimethod Study
By David Rabago, M.D., et al

OTHER STUDIES IN THIS ISSUE

Preventive Counseling for Obesity is Influenced by a Complex Set of Factors
A complex set of factors influence a clinician's decision to provide preventive counseling for obesity. The factors fall into two categories: 1) those that "set the stage" prior to the encounter, such as the physician's life values and definitions of success, and 2) those that are more contextual, coming into play "as the door opens" for the encounter, such as the physician's perception of the patient's receptivity to the counseling message. The authors suggest that efforts to increase the delivery of preventive counseling in primary care should focus on research and interventions aimed at changing clinicians' preventive counseling practices and should take into consideration the complex and dynamic nature of the clinician decision-making process in the encounter.
The Art and Complexity of Primary Care Clinicians' Preventive Counseling Decisions: Obesity as a Case Study
By Andrew Sussman, Ph.D., M.C.R.P., et al

Communication Is Key in Effective Patient-Clinician Communication in Prenatal Care
In interviews with 202 low-income African-American women, researchers find that communication with clinicians, not literacy level, is the most important factor in determining whether women receive adequate prenatal care. Of the women interviewed, 33 (16 percent) had low literacy levels, 120
(61 percent) initiated care after the first trimester and 101 (50 percent) had inadequate prenatal care utilization. From the patient's perspective, the ability to communicate clearly by breaking down topics, providing continuous prenatal care, being trusted by the patient, and having a close patient-clinician relationship are critical to effective patient-provider communication.
"Breaking It Down:" Patient-Clinician Communication and Prenatal Care Among African American Women of Low and Higher Literacy
By Ian Bennett, M.D., Ph.D., et al

Telephone-Based Assistance Is Effective in Reducing Pain for Patients With Psychosocial Problems
This study of 1,337 patients finds that for patients with pain and psychosocial problems, a telephone-based intervention that includes cognitive-behavioral pain management strategies and problem-solving therapy can significantly reduce pain and improve both psychosocial and physical function to a clinically meaningful degree.
A Controlled Trial of Methods for Managing Pain in Primary Care Patients With or Without Co-Occurring Psychosocial Problems
By Tim A. Ahles, Ph.D., et al

Patient Experiences and Expectations About Depression Influence Ways They Communicate About Depression
When patients come to the physician's office, they bring with them experiences and expectations about depression that may have an impact on what they are willing to tell their physicians. When asked to reflect on how they discuss emotional issues with their doctor, 48 older adults identified four themes: 1) "My doctor just picked it up," 2) "I'm a good patient," 3) "They just check out your heart and things," 4) "They'll just send you to a psychiatrist." The authors conclude that physicians may signal to patients, wittingly or unwittingly, how emotional problems will be addressed, and this influences how patients perceive their interactions with physicians regarding emotional problems.
Unwritten Rules of Talking to Doctors About Depression: Integrating Qualitative and Quantitative Methods
By Marsha N. Wittink, M.D., M.B.E., et al

House Calls Are Not A Thing of the Past
In this essay, a family physician reflects on his experience in making house calls and how it is satisfying for both patients and clinicians. He concludes that house calls to patients are potentially key to the future of family medicine, rather than a thing of the past.
Home Care: A Key to the Future of Family Medicine?
By Steven H. Landers, M.D., M.P.H.

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Annals of Family Medicine is a peer-reviewed, indexed research journal that provides a cross-disciplinary forum for new, evidence-based information affecting the primary care disciplines. Annals 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. Complete editorial content and interactive discussion groups for each published article can be accessed free of charge on the journal's Web site, www.annfammed.org.

Editor's Note:
To arrange an interview with one of the authors or for full-text copies of any of the embargoed articles included in the July/August 2006 issue of Annals of Family Medicine, contact Kristin Robinson at (800) 274-2237 ext. 5221 or via e-mail at kristinr@aafp.org. The full text of all articles is available free at www.annfammed.org. Annals of Family Medicine welcomes diverse people with relevant experience or expertise to participate in online discussions of these studies at www.annfammed.org