Family Medicine Research in the United States From the late 1960s Into the Future.

BACKGROUND: When the new field of family medicine research began a half century ago, multiple individuals and organizations emphasized that research was a key mission. Since the field's inception, there have been notable research successes for which family medicine organizations, researchers, and leaders-assisted by federal and state governments and private foundations-can take credit. Research is a requirement for family medicine residency programs but not individual residents, and multiple family medicine departments offer research training in various forms for learners at all levels, including research fellowships. Family physicians have developed practice-based research networks (PBRNs) to conduct investigations and generate new knowledge. The field of family medicine has seen the creation of new journals to support the publication of research relevant to practicing family physicians. Nonetheless, in spite of much growth and many successes, family physicians and their research have been underrepresented in research funding. Clinical presentations in family medicine are often complex, poorly-differentiated, and exist as one of several patient complaints and diagnoses, and are not well-covered by the narrow basic-science and specialty research that defines most of the biomedical research enterprise. Overall health in the United States would benefit from a more robust research participation and greater support for family medicine research.

The adoption and use of health information technology in rural areas: results of a national survey.

CONTEXT: Health information technology (HIT) is a national policy priority. Knowledge about the special needs, if any, of rural health care providers should be taken into account as policy is put into action. Little is known, however, about rural-urban differences in HIT adoption at the national level. PURPOSE: To conduct the first national assessment of HIT in rural primary care offices, with particular attention to electronic medical record (EMR) adoption, range of capabilities in use, and plans for adoption. METHODS: A national mail survey of 5,200 primary care offices, stratified by rurality using Rural-Urban Commuting Area categories, was conducted in 2007-2008. Regression analyses were used to assess the relationship between office characteristics and EMR adoption, capabilities used, and future adoption plans. RESULTS: A commercial EMR system was present in 31% of offices, with no significant differences by rurality. Of offices with EMRs, 12% reported using a full range of EMR capabilities, with 51% using a basic range and 37% using less than the basic range. Large Rural (adjusted OR = 3.71, P= .022) and Small Rural (aOR = 3.75, P= .049) offices were more likely than Urban offices to use a broader range of EMR capabilities. Among offices without EMRs, those in Isolated areas were less likely to have more immediate plans to adopt (aOR = 0.19, P= .02). CONCLUSIONS: HIT adoption and use in rural primary care offices does not appear to be lower than in urban offices. The situation, however, is dynamic and warrants further monitoring.

Curricula for teaching the content of clinical practice guidelines to family medicine and internal medicine residents in the US: a survey study.

BACKGROUND: Teaching the content of clinical practice guidelines (CPGs) is important to both clinical care and graduate medical education. The objective of this study was to determine the characteristics of curricula for teaching the content of CPGs in family medicine and internal medicine residency programs in the United States. METHODS: We surveyed the directors of family medicine and internal medicine residency programs in the United States. The questionnaire included questions about the characteristics of the teaching of CPGs: goals and objectives, educational activities, evaluation, aspects of CPGs that the program teaches, the methods of making texts of CPGs available to residents, and the major barriers to teaching CPGs. RESULTS: Of 434 programs responding (out of 839, 52%), 14% percent reported having written goals and objectives related to teaching CPGs. The most frequently taught aspect was the content of specific CPGs (76%). The top two educational strategies used were didactic sessions (76%) and journal clubs (64%). Auditing for adherence by residents was the primary evaluation strategy (44%), although 36% of program directors conducted no evaluation. Programs made texts of CPGs available to residents most commonly in the form of paper copies (54%) while the most important barrier was time constraints on faculty (56%). CONCLUSION: Residency programs teach different aspects of CPGs to varying degrees, and the majority uses educational strategies not supported by research evidence.

Fatigue: an overview.

Fatigue, a common presenting symptom in primary care, negatively impacts work performance, family life, and social relationships. The differential diagnosis of fatigue includes lifestyle issues, physical conditions, mental disorders, and treatment side effects. Fatigue can be classified as secondary to other medical conditions, physiologic, or chronic. The history and physical examination should focus on identifying common secondary causes (e.g., medications, anemia, pregnancy) and life-threatening problems, such as cancer. Results of laboratory studies affect management in only 5 percent of patients, and if initial results are normal, repeat testing is generally not indicated. Treatment of all types of fatigue should include a structured plan for regular physical activity that consists of stretching and aerobic exercise, such as walking. Caffeine and modafinil may be useful for episodic situations requiring alertness. Short naps are proven performance enhancers. Selective serotonin reuptake inhibitors, such as fluoxetine, paroxetine, or sertraline, may improve energy in patients with depression. Patients with chronic fatigue may respond to cognitive behavior therapy. Scheduling regular follow-up visits, rather than sporadic urgent appointments, is recommended for effective long-term management.

The medical home: growing evidence to support a new approach to primary care.

INTRODUCTION: A medical home is a patient-centered, multifaceted source of personal primary health care. It is based on a relationship between the patient and physician, formed to improve the patient's health across a continuum of referrals and services. Primary care organizations, including the American Board of Family Medicine, have promoted the concept as an answer to government agencies seeking political solutions that make quality health care affordable and accessible to all Americans. METHODS: Standard literature databases, including PubMed, and Internet sites of numerous professional associations, government agencies, business groups, and private health organizations identified over 200 references, reports, and books evaluating the medical home and patient-centered primary care. FINDINGS: Evaluations of several patient-centered medical home models corroborate earlier findings of improved outcomes and satisfaction. The peer-reviewed literature documents improved quality, reduced errors, and increased satisfaction when patients identify with a primary care medical home. Patient autonomy and choice also contributes to satisfaction. Although industry has funded case management models demonstrating value superior to traditional fee-for-service reimbursement adoption of the medical home as a basis for medical care in the United States, delivery will require effort on the part of providers and incentives to support activities outside of the traditional face-to-face office visit. CONCLUSIONS: Evidence from multiple settings and several countries supports the ability of medical homes to advance societal health. A combination of fee-for-service, case management fees, and quality outcome incentives effectively drive higher standards in patient experience and outcomes. Community/provider boards may be required to safeguard the public interest.

Computer visualisation of patient safety in primary care: a systems approach adapted from management science and engineering.

Patient safety and medical errors in ambulatory primary care are receiving increasing attention from policy makers, accreditation bodies and researchers, as well as by practising family physicians and their patients. While a great deal of progress has been made in understanding errors in hospital settings, it is important to recognise that ambulatory settings pose a very large and different set of challenges and that the types of hazards that exist and the strategies required to reduce them are very different. What is needed is a logical theoretical model for understanding the causes of errors in primary care, the role of healthcare systems in contributing to errors, the propagation of errors through complex systems and, importantly, for understanding ambulatory primary care in the context of the larger healthcare system. The authors have developed such a model using a formal 'systems engineering' approach borrowed from the management sciences and engineering. This approach has not previously been formally described in the medical literature.This paper outlines the formal systems approach, presents our visual model of the system, and describes some experiences with and potential applications of the model for monitoring and improving safety. Applications include providing a framework to help focus research efforts, creation of new (visual) error reporting and taxonomy systems, furnishing a common and unambiguous vision for the healthcare team, and facilitating retrospective and prospective analyses of errors and adverse events. It is aimed at system redesign for safety improvement through a computer-based patient-centred safety enhancement and monitoring instrument (SEMI-P). This model can be integrated with electronic medical records (EMRs).

Managing Alzheimer dementia tomorrow.

BACKGROUND: Acetylcholinesterase inhibitors are the first drugs to alter the devastating effects of Alzheimer disease. The next generation of drugs will prevent the beta-amyloid plaques and neurofibrillary tangles or block enzymes that lead to neuron destruction. Effective use of these medications will require early identification of patients at risk. METHODS: Using the PubMed service of the National Library of Medicine, all English language articles published in 2000, 2001 and the first half of 2002 with a key word of 'dementia' were reviewed for articles that described the emerging pathophysiologic model for Alzheimer disease. FINDINGS: Standardized clinical screening tools, such as the mini-mental status examination and the clock test, administered longitudinally and correlated with family observations, can identify many at-risk patients. Genetic testing can identify a known mutation in 70% of patients who have a high family incidence of Alzheimer disease but awaits effective prevention before being useful. The molecular mechanisms of Alzheimer disease will eventually lead to prevention. CONCLUSION: Today, these patients benefit from nutritional support and lifestyle enhancement encouraged through a continuous primary care relationship.

Prealbumin: a marker for nutritional evaluation.

Determining the level of prealbumin, a hepatic protein, is a sensitive and cost-effective method of assessing the severity of illness resulting from malnutrition in patients who are critically ill or have a chronic disease. Prealbumin levels have been shown to correlate with patient outcomes and are an accurate predictor of patient recovery. In high-risk patients, prealbumin levels determined twice weekly during hospitalization can alert the physician to declining nutritional status, improve patient outcome, and shorten hospitalization in an increasingly cost-conscious economy.