Public Release:  Embargoed news From Annals of Internal Medicine

Annals of Internal Medicine tip sheet for March 3, 2009, issue

American College of Physicians

1. Patient-Physician "Connectedness" Affects Quality of Care

Philadelphia, March 3, 2009 - Health care in the United States is often fragmented and uncoordinated. It is common for patients to receive episodic care from different physicians. A new study in Annals of Internal Medicine, however, finds that patients who are connected to a specific primary care physician are more likely to receive guideline-consistent care than those who are connected to a practice but not a physician.

Researchers looked at 155,590 adults in a primary care network to determine which patients received most of their care from a specific physician, practice, or neither. They found that patients who were not connected to a particular physician were less likely to receive recommended care. In addition, these patients were less likely to complete recommended testing for preventive and chronic illness care.

"This study provides strong evidence for the value of having a regular doctor," said Steven Atlas, M.D., Director of Primary Care Quality Improvement at Massachusetts General Hospital, and lead author of the study.

Researchers used the term "connectedness" to describe the closeness of the relationship between a patient and an individual physician. The researchers found that patients who were connected to a physician were more likely to have health insurance, speak English, and be non-Hispanic white. However, connectedness was associated with larger disparities in screening rates than was race or ethnicity.

"The process of establishing a strong relationship with a specific physician may represent an important key to understanding disparities in care," said Dr. Atlas. "Greater insight into the role of patient- provider- or practice-level barriers to establishing a closely connected primary care relationship may lead to improved quality of care for vulnerable patients."

But according to researchers, continuity of care is a shared responsibility between physicians and patients. Even if physicians or practices treated all patients similarly, patients vary in their ability and willingness to adhere to recommendations.

According to Dr. Atlas, this study has health care policy implications as well.

"Pay-for-performance initiatives hinge on the ability to accurately assign performance measures to those practitioners who have some control over the outcome. Our study results suggest that physicians with a relatively low percentage of connected patients are likely to receive lower scores on performance measures when compared to physicians with a higher proportion of connected patients," said Dr. Atlas.


2. Black Patients Fare Worse than White Patients After Heart Attack: Risk Factors, Not Care, to Blame

Following a heart attack, black patients tend to do worse and are more likely to die than white patients. To find out what factors contribute to these differences in patient outcomes, researchers looked at 1,849 adults who had a heart attack and were hospitalized at one of 10 U.S. hospitals that participated in a registry of heart attack care. The registry included information about patients' health and social factors. It also included information about death, rehospitalization, chest pain, and quality of life after heart attack. The researchers found that black and white patients who had similar severity of heart and other diseases and similar social factors, such as level of education, had similar heart attack outcomes. Researchers conclude that the differences in heart attack outcomes between black and white patients seem to be due to worse risk factors for heart disease in black patients rather than to differences in the care that patients receive. Strategies to reduce black-white differences in outcomes after heart attack should focus on improving heart risk factors in black patients.


3. Vitamin K Same as Placebo for Treating Effects of Warfarin Overdose

Doctors prescribe warfarin to treat or prevent blood clots. But an overdose of warfarin can thin the blood too much, causing a bleeding event. Vitamin K can rapidly reverse the effects of a warfarin overdose. However, it is not known how vitamin K affects patient outcomes. Researchers sought to determine if patients taking vitamin K have fewer bleeding events or greater risk of clots. They conducted a study of 712 people taking warfarin whose blood tests showed their blood was too thin. Patients stopped taking warfarin and were randomly assigned either a low dose of vitamin K or placebo over a 90-day period. Researchers found that Vitamin K rapidly reduced the effects of warfarin. However, there were no differences between groups in the number of participants with bleeding events, clots, or other complications. Researchers conclude that temporarily stopping warfarin may be all that is needed to treat the effects of too much warfarin.

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