News from Annals of Family Medicine: January/February 2014
Self-rated Health an Efficient and Effective Predictor of Long-Term Depression Risk
Self-rated health appears to be a strong and consistent predictor of the risk of future depression in patients with recent experience of depressive symptoms. Analyzing data from a primary care cohort of more than 500 patients with depressive symptoms, researchers found those who rated their health as poor to fair had a twofold greater risk of major depression up to five years later compared with those who rated their health as good to excellent. The association between self-rated health and future depressive status remained strong even after adjusting for age, sex, multimorbidity, and baseline depression status or severity. For family physicians, who are often the first contact for health care and required to differentiate a wide range of symptoms from a complex narrative in a short period of time, simply assessing self-rated health using the single question, "In general, would you say your health is excellent, very good, good, fair, or poor?" and assessing depression status using the PHQ-9 (widely used in primary care), could fit well within routine care, the authors assert. This limited information, they conclude, provides reliable information about the risk of future depression.
Self-Rated Health and Long-Term Prognosis of Depression
By Jane M. Gunn PhD, et al The University of Melbourne, Australia
Physicians Use Indirect Means to Explore Patients' Expectations of Antibiotics
When in a challenging consultation where antibiotics might be expected by patients or parents for an upper respiratory infection but may not be indicated by clinical findings, family physicians prefer not to explore patient expectations in a direct manner or early on in the visit, contrary to the advice of many communications experts. Interviews with 20 practicing family physicians in South Wales, United Kingdom, revealed that clinicians prefer more indirect methods to explore treatment expectations in an effort to avoid conflict and potential threats to the ongoing physician-patient relationship and trust. They report using open questions and building a foundation for non-antibiotic management by using strategies to indicate their reasoning and influence expectations, including running commentary on physical examination findings. The authors conclude interventions to promote appropriate antibiotic prescribing should include a focus on training in communication skills that integrate indirect methods as a part of building collaborative physician-patient relationships and use the running commentary of examination findings to facilitate participation in clinical decisions.
Managing Expectations of Antibiotics for Upper Respiratory Tract Infections: A Qualitative Study
Mohammed Mustafa, MBChB, MRCGP, MSc, et al Cardiff University School of Medicine, United Kingdom
Family Medicine's Intergenerational Issues and Opportunities
In the January/February issue, Annals publishes an archival manuscript from the youngest generation of participants in the Keystone III conference, held in October 2000, which stimulated the Future of Family Medicine Project and, in turn, influenced the genesis of the patient-centered medical home movement that has been at the forefront of family medicine's reform efforts over the past decade. The manuscript gives voice to the issues that resonated with newer family physicians who either were in training or newly in practice or teaching at the turn of the 21st century. While they remained committed to perpetuating the core values of family medicine, including a commitment to whole-person care, and a wide scope of practice and community health, they articulate a need to change, expand, and revitalize the discipline.
Three accompanying editorials initiate a conversation about what can be learned across generational differences. The first editorial offers reflections of the Generation III authors who are now in midcareer almost 14 years later. In a second piece, Annals' editorial fellow Kate Rowland reminds her colleagues, who are increasingly diverse in their backgrounds, career paths, interests, and approaches, that they are part of a greater family medicine whole and must actively involve themselves in solving health care's greater systemic problems. A third article by two Annals editors synthesizes all the papers and calls for an intergenerational conversation in order to find the best way forward.
A View from Cheyenne Mountain: Generation III's Perspective of Keystone III Elizabeth Steiner, MD, et al Oregon Health & Science University
The Changing World of Family Medicine: The New View from Cheyenne Mountain Elizabeth Steiner, MD, et al Oregon Health & Science University
The Voice of the New Generation of Family Physicians By Kate Rowland, MD, MS Annals of Family Medicine
Unresolved Intergenerational Issues By Kurt C. Stange, MD, PhD, and John J. Frey III, MD Annals of Family Medicine
Family Medicine Maintenance of Certification Improvement Projects Improve Quality of Diabetes Care
A study of nearly 8,000 diabetes quality improvement projects by family physicians across the United States completing a Performance in Practice module to meet recertification requirements of the American Board of Family Medicine finds nearly all projects were associated with significant and meaningful improvements in diabetes care. Successful completion of the module required quality measure abstraction from 10 patient charts before and after an improvement effort. Almost one-half of participating physicians selected diabetic foot examination or eye examination as their quality improvement measure. Other quality measures included testing for microabluminauria, checking blood glucose or lipid levels, assessing blood pressure control, and counseling for smoking cessation. Analysis showed all quality measures improved after the intervention. In particular, foot examination documentation increased from 68 percent to 86 percent, and retina examination documentation increased from 56 percent to 71 percent. The most common interventions were standing orders (52 percent) and patient education (37 percent). These findings, the authors assert, add to the evidence base for integration of quality improvement into practice. Leveraging maintenance of certification to improve the quality of care family physicians deliver helps meet the triple aim of reducing costs, raising the quality of care, and improving health, they conclude.
Family Physicians' Quality Interventions and Performance Improvement Through the ABFM Diabetes Performance in Practice Module
By Lars E. Peterson, MD, PhD, et al American Board of Family Medicine, Lexington, KY
Researchers Compare Three Approaches to Practice Facilitation to Improve Diabetes Care
Comparing the effectiveness of three different approaches for implementing and sustaining Chronic Care Model-based interventions to improve diabetes care in primary care, researchers found all methods resulted in significant improvement in diabetes care measures, but there were differences in the extent and duration of improvement and trade-offs in work culture change. The cluster-randomized trial including 40 small to midsize primary care practices investigated three strategies: 1) Continuous Quality Improvement, in which practices followed a prescribed strategy of implementing registries to have diabetes quality measures motivate practice action, identify needed changes, and monitor progress; 2) Reflective Adaptive Process, in which practices followed a more practice-determined approach particularly aimed at improving practice culture; and 3) Self-Directed, in which practices were provided with information and resources about the Chronic Care Model and quality improvement but without facilitation. Although measures of the quality of diabetes care improved in all three groups, improvement was greater in CQI practices compared with both SD and RAP practices, and improvement was greater in SD practices compared with RAP practices. In RAP practices, change culture scores showed a trend toward improvement at nine months, but decreased below baseline at 18 months, and work culture scores decreased from nine to 18 months. By contrast, both scores were stable over time in SD and CQI practices. The authors conclude that traditional CQI interventions are effective at improving measures of the quality of diabetes care, but may not improve practice culture. Additionally, short-term practice facilitation based on RAP principles appears to be less effective at improving quality measures and does not produce sustained improvements in practice culture. Recognizing that not all primary care practices need the same type, intensity, or duration of assistance, they call for practices to tailor the approach to their practice, and they call for the development and testing of new models that can produce the long-term improvements in both quality measures and practice cultures necessary for sustained care enhancement.
Practice Facilitation to Improve Diabetes Care in Primary Care: A Report From the EPIC Randomized Clinical Trial
By W. Perry Dickinson, MD, et al University of Colorado School of Medicine, Aurora
Researchers Identify Strategies for Achieving Whole-Practice Buy-in to the Patient-Centered Medical Home
Researchers identify 13 distinct strategies for obtaining organizational buy-in and whole-staff engagement in patient-centered medical home transformation and practice improvement efforts. The findings are based on in-depth interviews with 136 individuals and seven focus groups with 46 individuals from 20 small- to medium-sized medical practices in Pennsylvania participating in a statewide medical home initiative. The list of 13 strategies cluster into three overarching lessons that facilitate practice buy-in: effective internal communication, effective resource utilization, and creation of a team environment. The authors conclude these strategies can be particularly useful for facilitating PCMH transformation in primary care.
Strategies for Achieving Whole-Practice Engagement and Buy-in to the Patient-Centered Medical Home
By William K. Bleser, MSPH, et al Pennsylvania State University
Melanoma Prevention Intervention Efficient Means of Promoting Patient Behaviors That May Reduce Risk
A targeted intervention to reduce the risk and increase the early detection of melanoma using the validated Self-Assessment of Melanoma Risk Score screening tool appears to be efficient and effective. In a pilot cluster-randomized controlled trial involving 173 patients in western France, researchers randomized patients to either an intervention group, who were assessed using the SAMScore tool and underwent a total skin examination and counseling using information leaflets, or a control group, whose physicians displayed a poster and the leaflets in their waiting room and examined patients' skin at their own discretion. Compared with control patients, intervention patients were more likely to remember the campaign (81 percent vs. 50 percent) and to correctly identify their elevated risk of melanoma (71 percent vs. 42 percent). Furthermore, intervention patients had higher levels of prevention behaviors: they were less likely to sunbathe in summer (25 percent vs. 41 percent) and more likely to have performed skin self-examinations in the past year (53 percent vs. 37 percent). The authors conclude the combination use of the SAMScore and physician examination and counseling during consultations appears to be an efficient way to promote patient behaviors that may reduce melanoma risk. They call for future research that extends the duration of follow-up and examines the intervention's impact on morbidity and mortality.
Targeted Melanoma Prevention Intervention: A Cluster-Randomized Controlled Trial
By Cédric Rat, MD, et al Faculté de Médicine of Nantes, France
Closing the Gap Between Intention and Achievement for Healthy Diet and Physical Activity: The Importance of Understanding Practical Opportunities
Recognizing that the choices people make for diet and physical activity are contingent on the choices they have, researchers identify how the resources available in an economically disadvantaged community interact with personal circumstances to create feasible opportunities. In a mixed methods study, researchers in Texas analyze focus group and survey data from more than 400 socioeconomically disadvantaged individuals and make a compelling case for practical opportunities as a primary target for clinical and public health assessment and intervention. They assert that systematic assessment of practical opportunities holds promise for understanding the different supports needed by different people to achieve healthy patterns of diet and physical activity. Developing interventions responsive to the intersection of personal and environmental determinants, they conclude, may help close the gap between intention and achievement.
Measuring Capability for Healthy Diet and Physical Activity
By Robert L. Ferrer, MD, MPH, et al University of Texas Health Science Center
Using Complex Systems Theories to Better Understand the Phenomena Observed in Primary Care
In this historical review, researchers describe the development of family medicine in relation to complex adaptive systems theories and show how systems sciences reflect the specialty's philosophy and identity. The authors point out that although complex systems theories and family medicine both emerged at the same time during the second half of the 19th century, it took family medicine 30 to 40 years to start engaging with systems theories as a means to better understand the nature of health and illness in general and its implications for primary care in particular. They call for a continued expansion of systems and complexity thinking in primary care and for future research focused on applying nonlinear dynamics and empirical modeling to patient care, practice organization and community development and influencing health care reform.
Systems and Complexity Thinking in the General Practice Literature: An Integrative, Historical Narrative Review
By Joachim P. Sturmberg, MBBS, Dip RACOG, FRACGP, MFM, PhD, et al Wamberal, New South Wales, Australia