May/June 2008 Annals of Family Medicine tip sheet

The Unintended Consequences of Pay-for-Performance Programs

At a time when pay-for-performance programs are proliferating, this study finds that while such programs may succeed in improving clinical outcomes and increasing physician income, they also change the nature of patient consultations and the way doctors and nurses work together. In-depth interviews with 41 family physicians and nurses working in the United Kingdom three years after implementation of a new pay-for-performance initiative revealed that participants believed the aims of the program had been met in terms of improvements in disease-specific processes of patient care and physician income, as well as improved data capture. Participants also reported unintended consequences of the program, including reduced continuity of care and care fragmentation. While acknowledging the positive impact of the program, many physicians expressed concern that the guideline-driven process of care leaves them feeling they are becoming less skilled, are losing their sense of place in the enterprise and are less connected with patients.

The Experience of Pay for Performance in English Family Practice: A Qualitative Study By Stephen M. Campbell, Ph.D., et al

Efficacy and Side Effects of Treatment for Restless Legs Syndrome

A meta-analysis of 14 trials involving 3,197 patients with restless legs syndrome finds that although drug therapy using nonergot dopamine agonists – the mainstay of therapy for patients with the condition – reduces the severity of symptoms, significant numbers of patients discontinue their use because of adverse side effects, including nausea, dizziness, drowsiness and fatigue. Further analysis suggests these treatments are most beneficial in the first weeks of therapy, with their effects diminishing somewhat over time. The researchers call for future research to compare directly the efficacy of individual nonergot dopamine agonists with each other, as well as to include a longer follow-up period to assess the long-term effects of these agents.

Effect of Nonergot Dopamine Agonists on Symptoms of Restless Legs Syndrome By William L. Baker, Pharm.D., et al

Age-Related Pulmonary Crackles Often Benign

Kataoka and Matsuno describe the often benign nature of pulmonary crackles – discontinuous, interrupted, explosive respiratory sounds heard during inspiration – in many older patients. Examining a panel of 274 patients 45 to 95 years old, they found many had audible pulmonary crackles, even in the absence of apparent cardiac dysfunction and comorbid pulmonary disease. The older the age-group, the more frequently the patients had audible pulmonary crackles. In fact, the findings show that the risk for audible crackles increased approximately threefold every 10 years after 45 years of age in patients with cardiovascular disease and apparently normal heart function. They conclude that the recognition of age-related crackles is important, because such clinically unimportant crackles are so common among elderly patients that, without knowledge of this phenomenon, their existence might interfere with the physician’s management of patients with suspected heart failure or presumable pulmonary disease.

Age-Related Pulmonary Crackles (Rales) in Asymptomatic Cardiovascular Patients By Hajime Kataoka, M.D. and Osamu Matsuno, M.D.

OTHER STUDIES IN THIS ISSUE

A Call for Greater Attention to Physicians’ Mental Health

An estimated 250 physicians will commit suicide this year. In this essay, a family physician shares her grief and guilt over the suicide of a colleague while reflecting on both the scale of this largely unacknowledged problem and the stigma that prevents the profession from adequately addressing it.

Today I’m Grieving a Physician Suicide By Jennifer L. Middleton, M.D., M.P.H.

Patients Prefer Doctors With Whom They Share Values

In a study involving 214 patients, researchers found that the patient-physician relationship is strengthened when patients see themselves as similar to their physicians in personal beliefs, values and communication style. Further analysis revealed that patients’ perception of similarity to their physician is a multidimensional construct that includes both personal and ethnic components, some of which are more strongly related to outcomes than others. Researchers found that of the two dimensions, personal similarity appears more strongly related to patient trust, satisfaction and intent to follow the doctor’s recommendations. Regardless of issues of race and gender, a doctor who is skilled in providing information, showing respect, and supporting patient involvement can establish a connection with the patient that contributes to greater patient satisfaction, trust, and commitment to treatment. The authors assert that these findings support the need for communication skills training as a foundational part of medical education at all levels.

Understanding Concordance in Patient-Physician Relationships: Personal and Ethnic Dimensions of Shared Identity By Richard L. Street, Jr., Ph.D., et al

Education Campaign Reduces Antibiotic Prescribing

A multi-pronged campaign promoting judicious antibiotic use through physician education and public information was successful in reducing the prescribing of antibiotics, but the campaign did not affect physicians’ self-reported attitudes or practices. Physicians exposed to the campaign reported that frequent repetition of messages to both themselves and patients, brief written handouts on specific topics for themselves and patients, and promotion in the mass media were the most effective strategies for reducing prescribing. The authors conclude that educational campaigns that repeat brief, consistent reminders to multiple stakeholder groups may make them more likely to stand out in an environment of similar competing messages.

Physician Responses to a Community-Level Trial Promoting Judicious Antibiotic Use By Christopher J. Stille, M.D., M.P.H., et al

Family Physician Urges Peers to Lead Health Care Reform Effort

Using patient stories, a family physician elucidates the magnitude of the U.S. health care crisis, describing problems at all levels of the system – from financing structures to the current delivery system. Invoking the need for individual responsibility, she encourages fellow clinicians to be proactive and lead meaningful change.

The Unsustainable US. Health Care System: A Blueprint for Change By Jennifer DeVoe, M.D., D.Phil.

Pictures Are More Powerful Than Words

When conveying important information about the benefits of a medication to patients, pictures appear to be more powerful than words. A study of 100 patients with cardiovascular disease finds that 57 percent prefer information about the risks and benefits of treatment be presented graphically. Other ways of expressing risk and benefit were less popular among study participants. Only 19 percent preferred information expressed as relative risk, 13 percent preferred absolute risk, 9 percent preferred natural frequencies, and only one patient preferred the information be presented in terms of an odds ratio. Notably, no patients preferred number needed to treat, a method for communicating risk and benefit that is very useful to clinicians. The authors assert that these findings support the need for the development of visual aids to support shared clinical decision making.

An accompanying editorial by Spiegelhalter highlights one of the essential elements of primary care – living with uncertainty – and explains why there is uncertainty both for doctors and patients. He explains that physicians’ attempts to clarify things inevitably bump up against the fundamental truth of clinical care: there is no answer, only a series of choices that change with time, information and human unpredictability.

Patients Prefer Pictures to Numbers to Express Cardiovascular Benefit From Treatment By Felicity Goodyear-Smith, M.B.Ch.B., M.G.P., F.R.N.Z.C.G.P., et al

Understanding Uncertainty By David J. Spiegelhalter, Ph.D., F.R.S.

Diabetes Flow Sheets May Improve Patient Care

Analyzing the medical records of more than 1,000 diabetic patients, researchers found that the use of medical record flow sheets may improve adherence to guidelines for diabetes assessment and treatment, but not intermediate outcome targets.

Diabetes Flow Sheet Use Associated With Guideline Adherence By Karissa A. Hahn, M.P.H., et al

Using Decision Aids During the Office Visit to Improve Patient Satisfaction

Involving patients in decisions about their own health care by using decision aids – tools designed to help people better understand the risks and benefits of different options – during the patient-physician consultation appears to improve patient satisfaction and involvement. In a study of 1,132 patients, those who were exposed to a simple decision aid to facilitate shared decision making about cardiovascular disease prevention were more involved and expressed higher satisfaction with the decision-making process than those who were not. Additionally, those who used the decision aid showed less decisional regret after six months. Notably, cardiovascular disease risk decreased among all study participants, regardless of whether they were exposed to the decision aid.

Absolute Cardiovascular Disease Risk and Shared Decision Making in Primary Care: A Randomized Controlled Trial By Tanja Krones, M.D., et al

New Diabetes Distress Screening Instrument

Recognizing the high prevalence of depressive symptoms among patients with diabetes, Fisher and colleagues report on the development of an easily scored, two-item diabetes distress screening instrument that asks patients to rate the degree to which the following items cause distress: 1) feeling overwhelmed by the demands of living with diabetes, and 2) feeling that I am often failing with my diabetes regimen. They call for future research to determine whether similar distress constructs apply to chronic diseases other than diabetes.

Development of a Brief Diabetes Distress Screening Instrument By Lawrence Fisher, Ph.D., et al

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