Practices with Nurse-Practitioners Outperform Practices with Physician Assistants in Diabetes Care Measures
Family medicine practices with nurse-practitioners (NPs) perform better at providing some types of diabetes care (primarily monitoring tests) than physician-only practices and especially better than practices using physician assistants (PAs). This cross-sectional study of 45 family medicine practices measured adherence to American Diabetes Association guidelines via chart audits of 846 diabetic patients and found that compared with practices employing PAs, practices employing NPs were more likely to measure hemoglobin A1c levels (66 percent vs. 33 percent), lipid levels (80 percent vs. 58 percent), and urinary microalbumin levels (32 percent vs. 6 percent); to have treated for high lipid levels (77 percent vs. 56 percent); and to have patients attain lipid targets (54 percent vs. 37 percent). Practices with NPs were more likely than physician-only practices to assess hemoglobin A1c levels (66 percent vs. 49 percent) and lipid levels (80 percent vs. 68 percent).
The authors note it is not possible to conclude that the nurse-practitioner is the cause of the observed differences, but in light of the burgeoning use of PAs and NPs in attempts to cut costs and implement new models of clinical care, they assert these results point to a need to further explore these associations and their causes.
Quality of Diabetes Care in Family Medicine Practices: Influence of Nurse-Practitioners and Physician's Assistants
By Pamela A. Ohman-Strickland, Ph.D., et al
Pedometer-based Walking Programs Result in Moderate Weight Loss
Walking programs that use a pedometer as a motivational tool result in a moderate amount of weight loss in overweight or obese sedentary adults. According to a meta-analysis of nine studies that examined the effectiveness of weight loss programs that included walking but not dietary interventions, researchers found that the average participant in a pedometer-based walking program without dietary change can expect to lose about one pound every 10 weeks, which translates to about five pounds over the course of a year. The analysis also found that programs of longer duration are associated with greater weight loss. The authors point out the increase in physical activity can be expected to result in health benefits independent of weight loss.
A Meta-Analysis of Pedometer-Based Walking Interventions and Weight Loss
By Caroline R. Richardson, M.D., et al
Patients' Socioeconomic Status Affects How Physicians Care for Them
Patients' socioeconomic status affects physicians' day-to-day clinical management decisions. In in-depth interviews, 18 primary care physicians revealed they commonly made changes to their management plans to make care more affordable, feasible or comprehensible for patients with low socioeconomic status. The authors assert that these changes, while made in an effort to enhance patient outcomes given the constraints associated with low socioeconomic status, may contribute to observed socioeconomic disparities in health care. Interviews also exposed the personal and financial strains physicians experience when caring for patients with low socioeconomic status. They call for more explicit recognition of the role of socioeconomic factors in clinical decision making during the development of quality standards to ensure high-quality care and a physician workforce willing to care for vulnerable populations.
Influence of Patients' Socioeconomic Status on Clinical Management Decisions: A Qualitative Study
By Susannah M. Bernheim, M.D., M.H.S., et al
OTHER STUDIES IN THIS ISSUE
Editorialist: Scientific Journals Must Provide a Forum for New Discoveries Based on Clinical Observation
Recalling some of the great discoveries from research in general practice, Ian McWhinney, M.D., suggests journals need to develop standards that provide space for novel findings that are based on clinical observation and do not fit any of the traditional research categories. This kind of clinical research is often carried out by single practitioners working with their own patients - the essence of general practice. He suggests that if research journals are to provide a forum for, rather than squelch, new discoveries, traditional methodological standards may be less important than plausibility, support from the basic sciences and appropriate literature, clarity of concepts and reproducibility of the procedures.
Assessing Clinical Discoveries
By Ian R. McWhinney, O.C., M.D., F.R.C.G.P., F.C.F.P., F.R.C.P.
Adding Smoking Status as a Vital Sign May Increase Quit Rates
Inquiring about smoking status as a routine vital sign in primary care practice results in a modest increase in simple advice to quit but not in more intensive counseling. This cluster-randomized, controlled trial of 6,729 patients at 18 primary care practices found an 8.6 percent proportional increase in counseling that consisted mainly of simple advice to quite with little additional discussion of how to do so. The authors estimate that by adopting the vital sign intervention, a practice of four clinicians could expect to gain an additional ex-smoker every six weeks. The estimate is based on a previous meta-analysis that concluded that one of 40 patients who receive simple advice will quit.
Effect on Cessation Counseling of Documenting Smoking Status as a Routine Vital Sign: An ACORN Study
By Stephen F. Rothemich, M.D., M.S., et al
Patients' Trust and Commitment to their Physician Favorably Influence Behavior
Patients' trust and commitment to their family physician strengthen the patient-physician relationship and are associated with adherence to their physician's medical recommendations and healthy eating behavior according to an analysis of 869 patient questionnaires from four primary care clinics in central Texas.
Patients' Commitment to Their Primary Physician and Why it Matters
By Leonard L. Berry, Ph.D., et al
Patients' Beliefs About Antidepressants: Demographics and Clinical Characteristics
A study aimed at identifying the demographic and clinical characteristics that account for patients' beliefs about the necessity and harmfulness of antidepressants finds that skepticism about antidepressants is strongest among younger patients who have never taken them, who view their symptoms as mild and transient and who are unclear about the factors contributing to their depression. The findings are based on an analysis of interviews with 165 patients with major depression. Because patients' beliefs and attitudes about medication have been shown to predict medication adherence, treatment outcome, or both, these findings suggest that this group of patients might benefit from belief-focused interventions aimed at enhancing adherence and improving clinical outcomes.
Explaining Patients' Beliefs About the Necessity and Harmfulness of Antidepressants
By James E. Aikens, Ph.D., et al
Care Managers Help Psychiatric Patients Access Primary Care
Among patients who had experienced a psychiatric crisis, this study found that those who were assigned a care manager had easier access to primary care and felt it was of benefit to them compared to those who were not. Fully 71 percent of those with a care manager said that having someone to assist them with primary care connections was beneficial. Additionally, those patients with a care manager reported significantly better physical and mental function than their counterparts at six months. At one year, however, the differences in physical function were no longer significant. These findings provide insight into how care may be delivered more effectively for patients with serious psychiatric problems.
Primary Care After Psychiatric Crisis: A Qualitative Analysis
By Kim S. Griswold, M.D., M.P.H., et al
Barriers to Implementing Care Management for Depression in Primary Care
Primary care clinicians see value in care management for their depressed patients and believe it enhances the quality of care. Through interviews with 42 primary care clinicians, researchers also found that the slow adoption of care management for depression in primary care can be attributed to lack of reimbursement and the competing time demands of primary care. The authors conclude that these findings further underscore the urgency for more enlightened reimbursement policies.
Care Management for Depression in Primary Care Practice: Findings From the RESPECT-Depression Trial
By Paul A. Nutting, M.D., M.S.P.H., et al
The Effects of Intimate Partner Violence on Pregnant Latina Women
Interviews of 210 pregnant Latinas in Los Angeles, Calif., revealed that those who were exposed to intimate partner violence had more than twice the odds of reporting high levels of symptoms of depression or posttraumatic stress disorder. Moreover, compared to those who were not, women exposed to intimate partner violence also reported being exposed to more trauma (e.g. child abuse), social undermining, and stress with less social support. These findings support screening pregnant women for mental health outcomes and violence to identify those at risk of future violence and developing culturally appropriate intervention strategies.
Intimate Partner Violence, Depression, and PTSD Among Pregnant Latina Women
By Michael A. Rodriguez, M.D., M.P.H., et al
In this personal essay, an inner-city family physician describes a chance encounter on a New York subway that prompts him to reflect on the nature of physicians' interactions with their patients and others they come across in their lives. He contends these everyday interactions offer a string of opportunities to witness the lives of others, see things differently and learn something about their patients and themselves.
By Peter A. Selwyn, M.D., M.P.H., et al
One Physician's Search for Purpose on a Montana Reservation
In this essay, a family physician reflects on his experience caring for Native American patients on a reservation in Montana. As he tells of rescuing a teenage girl in labor with a footling breach, he describes his search for meaningful purpose while struggling with his own preconceptions and expectations.
Stuck in the Mud
By Richard E. Allen, M.D., M.P.H., et al
With the January/February 2008 issue, Annals also features a Resident Research Supplement that provides a snapshot of the current state of resident research. The supplement, which is devoted to research conducted by family medicine residents, includes six original research articles and an analysis by two guest editors. The articles address a variety of clinical, health services, and primary care epidemiologic questions using qualitative and quantitative methods.
- patient attitudes and beliefs about emergency contraception;
- identifying patients with uncontrolled asthma using a mailed questionnaire;
- the impact of obstetric practice on physician workload;
- the use of complementary and alternative medicine by Spanish-speaking Hispanics in South Carolina;
- the effectiveness of a poster at promoting patient-physician conversations about weight loss; and
- improving anticoagulation therapy using point-of-care testing and a standardized protocol.
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.
An indicator of the young journal's influence, Annals of Family Medicine's inaugural impact factor (the frequency with which the average article in the journal has been cited in a particular period) of 3.8 as of July 2007 places the journal in the top tier of general and internal medicine journals (#15/103).