March/April 2009 Annals of Family Medicine Tip Sheet

Bulk of Specialist Care in United States is for Routine and Preventive Services

Analyzing data on more than one billion office visits to specialists in 2002 to 2004, researchers found that one-half of all visits were for routine and preventive care – services that could likely be managed in the primary care setting, lessening demand for specialists and improving coordination of care. Moreover, they found that most of these visits (73.6 percent) resulted in a return appointment with the same physician. Referrals accounted for only 30.4 percent of visits. Noting that the U.S. health system has become increasingly specialty oriented with consequent high costs and no additional health benefit, the authors argue that we must reassess the appropriate relative roles of primary care and specialist physicians and consider transferring some of the routine follow-up activities currently being performed by specialists back to primary care. This shift, they contend, would address the shortage of specialists, allow specialists to focus on those aspects of care that demand their unique skills and improve the coordination of patient care.

Ambulatory Care Provided by Office-Based Specialists in the United States
By Jose M. Valderas, M.D., Ph.D., M.P.H., et al
The University of Manchester, United Kingdom

Barley Shown to Improve Cholesterol Levels

A meta-analysis of eight clinical trials finds that consumption of barley significantly improves total cholesterol, low-density lipoprotein (LDL) cholesterol and triglycerides, but not high-density lipoprotein (HDL) cholesterol. Specifically, researchers found that the trial participants who consumed barley anywhere from four to 12 weeks reduced their total cholesterol by 13 mg/dL, low-density lipoprotein cholesterol by 10 mg/dL, and triglycerides by 12 mg/dL compared with control participants. The authors point out that the reduction in total and LDL cholesterol is in line with that seen for oats, and supports the use of barley, along with other soluble fibers, in the diets of adults with and without high cholesterol.

The Effects of Barley-Derived Soluble Fiber on Serum Lipids
By Ripple Talati, Pharm.D., et al
University of Connecticut School of Pharmacy

Pay-for-Performance Programs Lead to Dysfunctional Behaviors that Have Negative Implications for Patient Care

In-depth interviews with primary care physicians in the United Kingdom and California, where pay-for-performance programs are being implemented in an effort to improve the efficiency and quality of care, uncovered unintended consequences directly related to how the programs were designed and implemented. In the United Kingdom, the 20 interviewed physicians worried about adverse effects on the office visit, with computer systems and data collection crowding out communication by patients. In the United States, the 20 interviewed physicians expressed resentment about the structure of the audit and payment systems, which sometimes distorted the process of care. Notably, the most negative comments in the interviews were from physicians in the California program with the highest financial rewards, suggesting that the problems cannot be addressed by getting the correct level of financial reward. The authors conclude that these potential adverse effects are likely to be diminished where physicians identify with the goals and values of incentive programs and feel they have a degree of autonomy in their delivery.

Pay for Performance in Primary Care in England and California: Comparison of Unintended Consequences
By Ruth McDonald, Ph.D. and Martin Roland, D.M.
The University of Manchester, United Kingdom

Other Studies in This Issue:

Rapid Decline in the Provision of Prenatal Care by Family Physicians

The proportion of prenatal visits to family physicians in the United States declined nearly 50 percent during the decade between 1995 and 2004. Using data representing more than 244 million prenatal visits, researchers document a decrease in percentage of prenatal visits to family physicians from 11.6 percent to 6.1 percent. Historically, family physicians have been important providers of maternity care in the United States, especially for underserved patients, including those who live in rural areas or have Medicaid insurance. Notably, the percentage of visits to family physicians fell at an even greater rate in rural areas – from 38.6 percent to 12.9 percent over these years. The authors conclude that if the provision of prenatal services by family physicians continues to decline at the documented rate, it may become difficult to develop sustainable models for inclusion of maternity care in future practice, which ultimately may affect women’s access to prenatal care in communities throughout the United States, particularly in rural and underserved areas.

Declining Trends in the Provision of Prenatal Care Visits by Family Physicians
By Donna Cohen, M.D., M.Sc. and Andrew Coco, M.D., M.S.
Lancaster General Hospital, Pennsylvania

Family Physicians Serve Dual Role of Primary Care Physician and Prenatal Care Provider During Most Prenatal Visits

The care provided by family physicians during prenatal visits is more comprehensive than that provided by obstetricians-gynecologists. Analyzing 10 years of data representing more than 223 million visits to obstetricians and 21 million visits to family physicians, researchers found that fully 18 percent of prenatal visits to family physicians dealt with more than obstetrical issues, whereas only 8 percent of visits to obstetrician-gynecologists did so. The authors assert that these findings demonstrate that comprehensive primary care occurs even during prenatal visits and support the medical home model for which family physicians are trained. They conclude that the rapid decline in prenatal care by family physicians could potentially affect access to nonobstetric services for pregnant women.

How Often Do Physicians Address Other Medical Problems While Providing Prenatal Care?
By Andrew Coco, M.D., M.S.
Lancaster General Hospital, Pennsylvania

Ordering Tests Not Necessarily the Best Way to Reassure Patients with Unexplained Symptoms

Contrary to what many physicians believe, ordering blood tests for patients with unexplained symptoms does not increase patients’ satisfaction with the consultation or lessen their anxiety. A randomized clinical trial including 489 patients in the Netherlands found that a watchful waiting approach resulted in patient satisfaction and anxiety equal to immediate blood testing. Specific aspects of patient communication were more important predictors of patient satisfaction and reduced anxiety, including patients feeling generally satisfied with their physician, feeling they were taken seriously, understanding the seriousness of their complaints, and physicians discussing testing with them. The authors point out this finding is especially remarkable considering patient satisfaction and anxiety are important factors in physicians’ decisions about ordering tests. They conclude that primary care physicians underestimate how much they can contribute to the well-being of their patients simply by discussing their worries.

Influence of Watchful Waiting on Satisfaction and Anxiety Among Patients Seeking Care for Unexplained Complaints
By Marloes A. van Bokoven, M.D., et al
Maastricht University, The Netherlands

National Research Organization Calls for a New Approach to Primary Care Research and Quality Improvement

In response to the Institute of Medicine’s 2001 report Crossing the Quality Chasm, which revealed concerns about the quality and costs of American health care, a working group of the North American Primary Care Research Group challenges policymakers, researchers, funders and journal editors to take a new approach to confronting the quality chasm in primary care. Among their recommendations, they call for changing the research paradigm from “translating research into practice” to “optimizing health and health care through research and quality improvement” in order to better identify the real customers for research – patients and care. They call on key stakeholders to bridge the current gap between clinical research and quality improvement by encouraging partnerships among those who conduct, fund, disseminate and implement primary care research. They conclude that a renewed focus on the problems of patients and patient care – with concomitant changes in concepts, attitudes, expectations, and methods for all those involved – will serve to shorten the path from problems in practice to solutions in systems, and they call for an increase in federal funding for this important research.

How Can Primary Care Cross the Quality Chasm?
By Leif I. Solberg, M.D., et al
North American Primary Care Research Group, Committee on Advancing the Science of Family Medicine

Barriers to Patient-Clinician Communication About Complementary and Alternative Medicine

Researchers in New Mexico identify key practices and attitudes that determine whether and how communication about the use of traditional and alternative health practices (TM/CAM) takes place between patients and their primary care doctors. The qualitative study of 114 patients and 60 clinicians at eight clinics in a low-income, Native American and Hispanic community identified three themes that predicted communication about TM/CAM: 1) acceptance and nonjudgment, 2) initiation of communication, and 3) concerns about safety and efficacy. Notably, patients did not expect their clinicians to be experts in the TM/CAM therapies; they simply wanted clinicians to show interest, acceptance and candor regarding their limited knowledge. These findings point to simple strategies clinicians can employ to communicate more effectively with their patients about complementary and alternative medicine therapies they might be using.

‘They Don’t Ask Me So I Don’t Tell Them’: Patient-Clinician Communication About Traditional, Complementary, and Alternative Medicine
By Brian M. Shelley, M.D., et al
University of New Mexico School of Medicine, Albuquerque

Opening Pandora’s Box to Gain a Deeper Understanding of Patients’ Worries

In this essay, a family physician reflects on the value of opening the proverbial Pandora’s box of feelings and fears during the patient encounter. She asserts it is a physician’s job to question, probe, order tests and raise issues patients would just as soon leave alone. She concludes that a clinician’s curiosity and courage to ask simple, personal questions can lead to important insights that open the doors for healing.

One Last Question: Opening Pandora’s Box?
By Janet M. Townsend, M.D.
Albert Einstein College of Medicine, New York

Personality is a Key Predictor of Missing Study Data

Exploring how personality factors may create important biases in response to surveys of primary care patients, researchers find that personality is a powerful predictor of missing study data. In a randomized controlled trial of 415 individuals, they find that missing data was significantly less likely for participants with higher levels of openness, conscientiousness and agreeableness, three personality factors in the widely accepted Five Factor Model. These biases, they point out, may compromise the validity and applicability of research findings if researchers fail to measure and adjust for them.

Is Personality a Key Predictor of Missing Study Data? An Analysis From a Randomized Controlled Trial
By Anthony Jerant, M.D., et al
University of California Davis School of Medicine

The Advances of Modern Medicine Require Doctors to be Physician-Healers

In this essay, Egnew reflects on the meaning of suffering and healing in the world of modern medicine where medical advances have wrought a growing population of chronically ill patients. He contends that today’s physicians are called on to be holistic healers – to care for patients’ souls as well as their bodies. He explains that physicians who can help patients transcend suffering by helping them discover or create new illness narratives with fresh meanings that connect them to the world and to others are essential to preserving medicine as a healing profession in the contemporary world. In the process, Egnew adds, physician-healers may discover meaningful connections with patients that bring new and refreshing perspectives to their work.

Suffering, Meaning, and Healing: Challenges of Contemporary Medicine
By Thomas R. Egnew, Ed.D., L.I.C.S.W.
University of Washington School of Medicine, Seattle

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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. Launched in May 2003, Annals is sponsored by seven 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, the North American Primary Care Research Group, and the College of Family Physicians of Canada. 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.