News Release

January/February 2013 Annals of Family Medicine tip sheet

Peer-Reviewed Publication

American Academy of Family Physicians

Electronic Health Record Adoption by Family Physicians Doubles, Projected to Reach 80 Percent by 2013

Adoption of electronic health records by family physicians has doubled since 2005, reaching 68 percent nationally in 2011. According to analysis of two independent data sets, researchers found family physicians are adopting electronic health records at a higher rate than other office-based physicians and are likely to exceed 80 percent penetration by 2013 if the current trend continues. State-level analysis, however, indicates significant variation in EHR adoption—from a low of 44 percent in North Carolina to a high of 88 percent in Hawaii, according to one of the two data sets, and a low of 47 percent in North Dakota and a high of 95 percent in Utah, according to the other—pointing to important geographical gaps that may result from significant variation in states' commitment to health information technology adoption. They note that states with higher EHR adoption among family physicians generally had higher EHR adoption for other office-based physicians, consistent with a state-level effect. The researchers call for further research and policy making focused on targeted interventions and funding adjustments to address the significant interstate variability.

The Rise of Electronic Health Record Adoption Among Family Physicians
By Imam M. Xierali, PhD, et al
Care Association of American Medical Colleges
Washington, D.C.

Large Mismatch Between Patients' Expectations and the Actual Duration of a Cough

There is a large mismatch between patients' expectations regarding the duration of an acute cough and the actual duration based on the best available evidence, and this disparity has important implications for unnecessary antibiotic prescribing. A systematic review of the medical literature showed the mean duration of a cough is 17.8 days. When surveyed, nearly 500 adults in Georgia reported a median duration of only five to seven days and a mean duration of seven to nine days, depending on the specific scenario. The researchers found patients expecting a longer duration of illness were more likely to be white, female and have self-reported asthma or lung disease. Those who were of nonwhite race (OR = 1.82), reported some college education or less (OR = 2.08), and had previously taken antibiotics for acute cough (OR =2.20) were more likely to believe antibiotics are always helpful for cough. Addressing the important implications these findings have for antibiotic prescribing, the authors assert that if a patient expects an episode of cough should last about six to seven days, it makes sense they might seek care for antibiotics after five to six days. Furthermore, they posit, if they begin taking an antibiotic seven days after the onset of symptoms, they may begin to feel better three or four days later with the episode fully resolving 10 days later. Although this outcome may reinforce the mistaken idea the antibiotic worked, it is merely a reflection of the natural history of acute cough. The authors conclude it is therefore important that physicians emphasize the natural history of acute cough with patients when they seek care for symptoms. Moreover, if physicians themselves also underestimate the duration of acute cough, they may require continuing professional education to correct these beliefs.

How Long Does a Cough Last? Comparing Patients' Expectations With Data From a Systematic Review of the Literature
By Mark H. Ebell, MD, MS, et al
University of Georgia, Athens

Clinicians' Implicit Racial Bias Associated with Black Patients' Perceptions of Care, May Contribute to Health Disparities

Clinicians with higher levels of implicit ethnic or racial bias—bias that may not be consciously acknowledged but operates in more subtle ways—are rated less favorably by their black patients than are clinicians with lower levels of implicit bias. Surveys of nearly 3,000 patients, randomly selected from patient panels of 134 clinicians who had previously completed tests of implicit ethnic or racial bias, found black patients rated clinicians who had greater implicit bias against blacks lower in patient-centered care than they did clinicians with little or no such implicit bias. Interestingly, the researchers found Latino patients' ratings were not associated with clinicians' implicit bias, though they tended to give clinicians lower ratings overall than did other groups. The findings suggest that clinicians' implicit bias may jeopardize their clinical relationships with black patients, which could have negative effects on other care processes. The authors conclude these findings support the Institute of Medicine's suggestion that clinician bias may contribute to health disparities. They note that implicit bias is malleable, and they encourage interventions that may help render bias less implicit and unconscious, thereby fostering real reflection, analysis and change.

Clinicians' Implicit Ethnic/Racial Bias and Perceptions of Care Among Black and Latino Patients
By Irene V. Blair, PhD, et al
University of Colorado Boulder

High Out-of-Pocket Health Expenses Cause Patients Considerable Anxiety and Life Disruptions

With American families contributing a growing proportion of their personal income to health care, researchers find patients are consequently experiencing a range of social, medical, financial and sometimes legal disruptions resulting from high out-of-pocket expenses. In interviews with 33 insured patients seeking philanthropic financial assistance, all of whom faced major chronic illnesses and most of whom were covered by Medicare, researchers found patients experienced considerable anxiety and major debt problems, as well as disruptions of medical care because of high levels of cost sharing. Participants described various borrowing strategies (e.g., credit cards), legal problems (e.g., debt collections), and threats to their nonmedical household budgets (e.g., food, housing). Although participants understood their health benefits with exceptional detail, they described considerable anxiety about changes to those benefits that could easily disrupt carefully managed household budgets. Specifically, benefit designs that resulted in large variation in financial liability from month to month (e.g., large deductibles or coverage gaps) imposed considerable financial challenges. As health care cost sharing grows, the researchers urge policy makers to consider the consequences of high cost sharing for families facing strained household budgets. Continuity of benefits and month-to-month stability of financial liability are important considerations that may be undervalued in policy discussions.

Life Disruptions for Midlife and Older Adults With High Out-of-Pocket Health Expenditures
By David Grande, MD, MPA, et al
University of Pennsylvania, Philadelphia

Clinicians Miss Most Patients with Alcohol Problems When They Rely on Clinical Suspicion, Routine Use of Screening Tools Necessary

In the absence of systematic screening for alcohol consumption in primary care, detection of alcohol problems relies on clinicians' suspicion. In this study, researchers found primary care clinicians miss most (more than 70 percent) of patients with an alcohol problem when they rely on clinical suspicion instead of using a screening instrument. Specifically, the cross-sectional study of office visits with a large sample of 1,699 patients, found 171 patients (10 percent) screened positive for hazardous drinking and 64 patients (4 percent) screened positive for harmful drinking using validated screening instruments. Clinicians suspected either hazardous or harmful drinking in only 81 of those patients (5 percent). Of those 81 patients, 50 (62 percent) screened positive. Clinicians didn't suspect an alcohol problem in almost three-fourths of those who screened positive. These findings, the authors, conclude, support the routine use of a screening tool to supplement clinicians' suspicions.

Clinician Suspicion of an Alcohol Problem: An Observational Study From the AAFP National Research Network
By Daniel C. Vinson, MD, MSPH, et al
University of Missouri, Columbia

Wide Variability in Family Physicians' Approaches to Counseling Patients on Prostate Cancer Screening

In light of recent guideline changes recommending against routine prostate cancer screening for asymptomatic men, researchers examined and found considerable variability in primary care physicians' approaches to engaging patients in prescreening discussions regarding the potential benefits and harms of prostate cancer screening. Moreover, they find much of the variability in these practice styles can be attributed to physicians' personal beliefs about prostate cancer screening, some of which may be amenable to change. Analysis of survey responses from 243 family physicians found that compared with physicians who ordered screening without discussion (24 percent), physicians who discussed harms and benefits with patients and then let them decide (48 percent) were more likely to believe that scientific evidence does not support screening, that patients should be told about the lack of evidence and that patients have a right to know the limitations of screening. They were also less likely to endorse the belief that there was no need to educate patients because they wanted to be screened. Notably, researchers also found that physicians who discuss the harms and benefits and recommend the test more often expressed concerns about the legal risk associated with not screening compared with physicians who discuss and let the patient decide. The authors call for the use of patient decision aids and efforts to educate physicians about the shared decision-making process, including countering the false beliefs that perpetuate routine screening.

Primary Care Physicians' Use of an Informed Decision-Making Process for Prostate Cancer Screening
By Robert J. Volk, PhD, et al
The University of Texas MD Anderson Cancer Center, Houston

Regardless How Type 2 Diabetes is Diagnosed, Vascular Outcomes in Seven Year Follow-Up Similar

Regardless of how a patient's diagnosis of type 2 diabetes is arrived at—through clinical diagnosis based on signs and symptoms (e.g., excessive thirst and/or urination, fatigue, infections, blurred vision) or using opportunistic targeted screening of high-risk patients (e.g., family history of diabetes, history of cardiovascular disease, obesity, hypertension, high cholesterol)—the rate of morbidity and mortality from cardiovascular disease in seven years follow-up did not significantly differ between the two. Analyzing data on 565 patients with newly diagnosed type 2 diabetes, researchers found that composite primary event rates during follow-up did not differ between the opportunistic targeted screening and clinical diagnosis groups (9.5 percent vs. 10.2 percent). There were also no significant differences in the separate events rates of deaths from CVD, nonfatal heart attacks and nonfatal strokes, perhaps suggesting that efforts in primary prevention among those at high risk for developing diabetes may be more important than early detection and treatment of undiagnosed diabetes. Because these findings show that within the first decade after diagnosis, opportunistic targeted screening for type 2 diabetes results in similarly low macrovascular event rates compared with diabetes diagnosed on the basis of signs and symptoms, the researchers call for future research to investigate the findings in a larger setting and with longer follow-up.

Vascular Outcomes in Patients With Screen-Detected or Clinically Diagnosed Type 2 Diabetes: Diabscreen Study Follow-up
By Erwin P. Klein Woolthuis, MD, et al
Radboud University Nijmegen Medical Centre, The Netherlands

Which Physician Assistants Choose Careers in Primary Care? Demographics Mirror Those of Physicians, Policy Measures Should as Well

In light of the recent decline in the percentage of physician assistants choosing careers in primary care, researchers examine the demographics associated with an increased likelihood of primary care practice among PAs in hopes that such knowledge may aid efforts to increase that number. Analyzing data on more than 18,000 PAs from the 2009 American Academy of Physician Assistants Census Survey, researchers found the demographic characteristics associated with an increased likelihood of primary care practice are similar to those of medical students who choose primary care specialties. Specifically, they found female, Hispanic and older PAs were more likely to work in primary care practice. Consequently, they conclude that workforce policy measures aimed at increasing the number of primary care physicians, such as loan repayment, improved levels of reimbursement for primary care physicians and expansion of Title VII Section 747 of the Public Health Service Act, are also likely to successfully increase the percentage of primary care PAs.

Physician Assistants in Primary Care: Trends and Characteristics
By Bettie Coplan, MPAS, PA-C, et al
Northern Arizona University, Phoenix

The Complementary Roles of Practice Facilitators and Care Managers in Enhancing Primary Care

In a joint article, Mathematica Policy Research and the Agency for Healthcare Research and Quality examine the distinct and complementary roles practice facilitators and care managers play in redesigning and improving primary care delivery. Practice facilitators, they assert, play a vital systems-level role in coordinating practice quality improvement and redesign efforts, helping build capacity for activities that improve quality and safety and the implementation of evidence-based practices. Care managers, on the other hand, do the critical work of coordinating patient care and helping patients navigate the system, improving access and communicating across the care team. The authors assert these two members of the primary care team work in a complementary fashion to help primary care practices deliver coordinated, accessible, comprehensive and patient-centered care.

Enhancing the Primary Care Team to Provide Redesigned Care: The Roles of Practice Facilitators and Care Managers
By Erin Fries Taylor, PhD, et al
Mathematica Policy Research, Washington, D.C.

Intervention Improves Patient-Physician Communication About New Prescriptions

An intervention seeking to improve patient education and counseling about new medications by targeting physician communication appears to be effective. Using a combination of patient surveys and audio recordings of office visits with 27 physicians during which 113 new medications were prescribed to 82 patients, researchers found the mean Medication Communication Index (a 5-point index giving points for discussion of medication name, purpose, directions for use, duration of use and side effects) score for medications prescribed by physicians who participated in a one-hour interactive educational session, was 3.95, significantly higher than that for medications prescribed by physicians in the control group (2.86). Patients' ratings of new medication information transfer were also higher for medications prescribed by physicians in the intervention group. The authors call for future research testing the clinical impact of the intervention.

Intervention to Enhance Communication About Newly Prescribed Medications
By Derjung M. Tarn, MD, PhD, et al
University of California, Los Angeles

Clinical Intuition—A Complex Concept Characterized by Numerous Cognitive Processes

To gain a better understanding of "clinical intuition" as experienced by physicians, researchers conducted in-depth interviews with 18 family physicians, analyzing 24 different patient cases in which the physicians believed they had experienced an intuition. While the medical literature discusses clinical intuition as "first impressions" or the first thing that comes to a physician's mind, researchers found this is only a part of what most family physicians understand by the term intuition. Specifically, they identified three types of decision processes: gut feelings, recognitions and insights. In all cases examined, participants experienced conflict between their intuition and a decision they perceived to be more rational, or between their intuition and their expectations about what other physicians would do. The authors conclude the outcomes of clinical intuition can be negative or positive, and until research further specifies the circumstances under which intuitive process produce accurate judgments, clinicians should not be admonished not to trust their intuition.

Clinical Intuition in Family Medicine: More Than First Impressions
By Amanda Woolley, BA, and Olga Kostopoulou, MSc, PhD
King's College London, United Kingdom


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.

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