November/December 2009 Annals of Family Medicine tip sheet

Pay for Performance Reporting Costly for Primary Care Practices

Responding to payer requests for quality and performance data can be costly for primary care practices, with estimated costs of implementation ranging from less than $1,000 to $11,100 per practitioner, and maintenance from less than $100 to $4,300 per year. Analyzing data from eight diverse practices in North Carolina, researchers found substantial variation among the four reporting programs studied (Medicare's Physician Quality Reporting Initiative, Community Care of North Carolina, Bridges to Excellence and Improving Performance in Practice) in the way measurement data elements are defined, gathered and transmitted. Major expenses included personnel time for planning, training, registry maintenance, visit coding, data-gathering and entry. Importantly, the authors note that electronic health record systems do not automatically lend themselves to performance-reporting requirements and often require expensive changes to generate data for payers. In light of the high cost of performance measurement and reporting, the authors caution programs to choose their performance measures judiciously. Furthermore, they recommend that programs offer financial incentives that allow practices to at least recoup their costs, as well as other motivators such as computer skills training, assistance with electronic system challenges, and quality improvement training for staff.

Cost to Primary Care Practices of Responding to Payer Requests for Quality and Performance Data
By Jacqueline R. Halladay, M.D., M.P.H., et al
University of North Carolina at Chapel Hill

Substantial and Important Undisclosed Changes Made to Outcomes of Published Randomized Controlled Trials

Authors frequently change the outcomes of clinical trials between trial registration and publication without explanation or disclosure. Analyzing 110 randomized controlled trials published in consecutive issues of five major medical journals in a six month period and their associated trial registry entries, researchers found that a primary outcome had been changed in 34 (31 percent) of the articles and a secondary outcome was changed in 77 (70 percent) without disclosure. The authors assert that allowing researchers to change their outcomes without reason or disclosure threatens the underpinnings of the scientific enterprise and the ability of practicing physicians to apply published research to patient care. Undisclosed Changes in Outcomes in Randomized Controlled Trials: An Observational Study
By Robert Ewart, M.D.
Southern Illinois University, Springfield

Early Abortion in Family Medicine Practices Safe and Effective

In a study validating the safety and efficacy of early abortion care by family physicians, researchers find the rates of complications of first trimester abortion care in family medicine clinical sites are very low and within the range of outcomes published for obstetric-gynecology and specialty abortion sites. Assessing the outcomes of 1,309 medication and 1,149 aspiration abortion procedures among family physicians in four residency training programs and one private practice, researchers found 96.5 percent of the medication and 99.1 percent of the aspiration abortions were successful. Less than 4 percent of either the medication or aspiration abortions had any related complications, and most complications were minor and managed within the family medicine practices without reliance on emergency services or those of specialists. The most serious adverse event observed was missed ectopic pregnancy in four patients, however the authors note that the rates of undiagnosed ectopic pregnancy treated with medication and aspiration in this study are within the range of rates previously reported. Noting that family physicians who provide early abortion care can promote continuity of care within the context of the medical home and may help to ameliorate abortion provider shortages across the United States, researchers call for initiatives to bring first-trimester abortion training into family medicine settings.

Early Abortion in Family Medicine: Clinical Outcomes
By Ian M. Bennett, M.D., Ph.D., et al
University of Pennsylvania School of Medicine, Philadelphia

Education Campaign Not Successful in Decreasing the Use of Antibiotics Without Prescription Among Latinos

With recent evidence from Latino communities indicating that self-medication with antibiotics without prescription is common, researchers were disappointed to find that a year-long multimedia campaign was not effective in decreasing the high incidence of acquiring antibiotics without a prescription among Latinos in a South Carolina community. Although most of the 250 adults surveyed in the intervention community had read or heard something on the radio regarding the appropriate use of antibiotics (69 percent), the exposure did not lead to differences in attitudes toward nonprescription antibiotics or having bought them in the last 12 months. Immigrants who had previously purchased antibiotics without prescription in their home county (where there are no or lax laws restricting antibiotic sales) indicated they were like to continue this practice in the United States. The authors conclude that these results suggest that usual forms of health education may not be sufficient to overcome the strong influence of past behavior. Successful interventions, they offer, may need to incorporate education about the rationale for why antibiotics are regulated in the United States.

A Community Intervention to Decrease Antibiotics Used for Self-Medication Among Latino Adults
By Arch G. Mainous III, Ph.D., et al
Medical University of South Carolina, Charleston

Medical Assistant-Based Intervention Ineffective at Reducing Unhealthy Behaviors

With most primary care patients having at least one of four major health risk behaviors -- smoking, risky drinking, low physical activity or unhealthy diet -- researchers sought to determine the effectiveness of a medical assistant-driven program to screen for the unhealthy behaviors, arrange appropriate interventions and ultimately reduce the behaviors. The randomized control trial of 864 adult patients from six primary care practices found that the program was much more effective than usual care at linking patients with interventions, more than doubling the proportion of patients referred (67.4 percent vs. 21.8 percent). Despite the process improvement, however, success in changing any of the four behaviors did not follow. The dissociation between process and outcomes, the authors conclude, underscores the difficulty of changing health behaviors. In addition to the need for more extensive training for medical assistants, the authors identify the need for changes in practice culture, and more concerted, sustained behavior interventions in order to improve risk behavior outcomes.

A Medical Assistant-Based Program to Promote Healthy Behaviors in Primary Care
By Robert L. Ferrer, M.D., M.P.H., et al
University of Texas Health Science Center at San Antonio

Understanding Low Vaccination Rates in Disadvantaged Urban Settings

Given the relatively low vaccination rates in disadvantaged urban populations, researchers sought to understand the influence of physician and practice characteristics on pneumococcal polysaccharide (PPV) and influenza vaccination rates. Analyzing data for 2,021 patients aged 65 and older receiving care in 17 different practices, they found that PPV and influenza vaccination rates varied widely across individual physicians (11-98 percent for PPV vaccine and 22-96 percent for influenza vaccine). They also found that longer reported well-visit length and enhanced vaccine documentation (use of electronic medical record or health maintenance flow sheets to record immunizations) were associated with vaccination for PPV. The use of standing orders and average physician examination room time were associated with vaccination for influenza. The authors conclude that given the difficulty in increasing physician time, particularly in health professional shortage areas that often occur in disadvantaged urban communities, enhanced vaccination documentation using flow sheets or electronic medical records, and standing orders may be the most feasible way to increase vaccination rates.

Understanding Adult Vaccination in Urban, Lower-Socioeconomic Settings: Influence of Physician and Prevention Systems
By Richard K. Zimmerman, M.D., M.P.H., et al
University of Pittsburgh, Pennsylvania

A solution to the primary care workforce shortage

Recent growth in the number of federally funded community health centers and patients served, combined with a decrease in the number of primary care trainees have exacerbated a health workforce crisis. Recognizing that training family medicine residents in community health centers may provide one solution to this workforce shortage, researchers offer a description of the factors that determine a successful affiliation between a community health center and family medicine residency. They conclude that a successful partnership relies on the development of a shared mission of education and service, as well as innovation and flexibility by the organizations that govern them.

Training Residents in Community health Centers: Facilitators and Barriers
By Carl G. Morris, M.D., M.P.H. and Frederick M. Chen, M.D., M.P.H.
University of Washington, Seattle

Understanding the Current Health Care Situation in the Context of Adaptive-Renewal Cycles

The fifth in a seven-part series of commentaries to understand health and health care Amid the ongoing health care reform debate in Washington, D.C., Annals of Family Medicine editor Kurt Stange, M.D., Ph.D. and colleagues continue the journal's seven-part series of commentaries designed to help make sense of the problems and opportunities we face for understanding and improving health care and health. The series' fifth installment explores how the current health care situation can be understood through the framework of adaptive-renewal cycles, which are grounded in the ecological, economic and social sciences. The authors assert that health care in the United States is nearing the end of a phase of exploitation and conservation in which rapid growth, specialization and institutionalization were fueled by advances in science and related economic and social cycles. The U.S. health care system, they believe, is now likely to experience the strong turbulence of creative destruction that comes with a subsequent release phase in which rapid environmental changes overwhelm old ways of operating and bring about a new reorganization phase. They challenge readers to reconsider how they think about change and to develop a broader awareness about how health care is connected to other aspects of society.

Making Sense of Health Care Transformation as Adaptive-Renewal Cycles
By Kurt C. Stange, M.D., Ph.D., et al
Case Western Reserve University, Ohio

Understanding the Experiences of Health Care Assistants Who Provide Case Management to Depressed Patients

With health care assistants (HCAs) playing an increasingly prominent role in primary care practices, researchers in Germany sought to understand how HCAs tasked with providing case management for depressed patients felt about their new and expanded roles. Interviews with 26 HCAs at small primary care practices revealed that HCAs found their case management work personally and professionally enriching. That said, they experienced limited capacity for the increased workload and the challenges that came with working with depressed patients. The researchers conclude that before shifting depression case management to HCAs, practices should appropriately train future case managers for the job, clearly define case management tasks to prevent overburdening, acknowledge the significant increased workload associated with these tasks, and provide additional financial compensation for the new responsibilities.

Health Care Assistants in Primary Care Depression Management: Role Perception, Burdening Factors, and Disease Conception
By Jochen Gensichen, M.D., M.A., M.P.H., et al
Friedrich-Schiller University, Jena, Germany

Practice-Based Research Network Membership Representative of Family Physicians at Large

A study from the American Academy of Family Physicians National Research Network (AAFP NRN) finds that its physician members are representative of family physicians at large in terms of self-reported practice patterns, knowledge and clinical beliefs. The findings are based on the results on three separate surveys of random samples of active AAFP members and physician members of the AAFP NRN. Representativeness of PBRN Physician Practice Patterns and Related Beliefs: The Case of the AAFP National Research Network
By James M. Galliher, Ph.D., et al
American Academy of Family Physicians, Leawood, Kan.

Lack of Evidence to Support the Use of Microfilament Testing to Diagnose Peripheral Neuropathy

A systematic review by Dros et al evaluates monofilament testing for diagnosis of peripheral neuropathy of the feet, a condition which causes numbness or a complete loss of sensation. Despite frequent recommendations for use of the test, researchers conclude that existing data are limited in their ability to draw conclusions about its accuracy because of a lack of diagnostic studies with adequate methods. Accordingly, the authors recommend against the sole use of microfilament testing to diagnose peripheral neuropathy.

Accuracy of Monofilament Testing to Diagnose Peripheral Neuropathy: A Systematic Review
By Jacquelien Dros, M.D., et al
University of Amsterdam, The Netherlands

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.