Issue Of JGIM Research Articles

Medical Decision Making: What Do We Trust?

Medical Decision Making: What Do We Trust?

From the Editor’s Desk: Legislating Change

Seismic changes in medical practice typically have come from discovery (such as DNA or penicillin) or new innovation (for example, new imaging devices such as MRI scanners), but rarely as the result of legislation. However, the American Reinvestment and Renew Act (ARRA), passed by Congress in February 2009, may do just that. The ARRA, which allocates $19 billion specifically to incentivize the use of electronic health records (EHR), is poised to dramatically change medical practice in the US. This money would be paid directly to physician’s practices, with early non-hospital-based adopters of EHRs receiving up to $63,000 per physician ($42,500 for pediatricians) over 6 years through add-ons to Medicare payments.

The New Heart Failure Diet: Less Salt Restriction, More Micronutrients

The New Heart Failure Diet: Less Salt Restriction, More Micronutrients

Medicare Part D—Lessons Learned and Guidance for Health-care Reform

Medicare Part D—Lessons Learned and Guidance for Health-care Reform

Routine HIV Testing Hits the Primary Care Clinic

In September 2006, the Centers for Disease Control and Prevention (CDC) recommended screening all persons 13–64 years of age for human immunodeficiency virus (HIV) infection.1 Prior to this, screening recommendations were targeted to specific high-risk individuals and settings, and to all pregnant women. The rationale for expanded screening is that early diagnosis can reduce morbidity and mortality,2 and that persons who know their HIV status will modify their risk behaviors and reduce transmission.3 Furthermore, an estimated 25% of persons with HIV infection remained undetected with the existing screening strategy. Recently, the American College of Physicians and the HIV Medicine Association have come out in support of the CDC’s screening recommendation.4 Other organizations, such as the US Preventive Services Task Force, have not come out for or against the CDC recommendations, in part due to limited direct evidence on the benefits of screening.5 As new evidence emerges, key issues to consider for any screening program are the validity of the screening test, the feasibility of implementing the screening program, and the overall effectiveness in improving health outcomes. In this issue of JGIM, Myers and colleagues describe their experience of systematically implementing the CDC recommendations within six community care centers in the Southeastern US6. With programmatic support and some funding, the practices developed a systematic procedure to implement screening within the practice that did not directly involve the health care provider. In this study, over 16,000 persons were offered HIV testing, and of the 10,769 persons who accepted testing, 19 received a false-positive result, whereas 17 were confirmed positive, of whom 12 were successfully referred to care. Three patients did not have confirmatory testing. The findings from this study demonstrate key issues involving screening test validity and feasibility.

The SGIM Policy Analysis: Supporting the Generalist Voice for Participation in Policymaking

This issue ofJGIM contains an article entitled “High Quality Care and Ethical Pay-for-Performance: A Society of General Internal Medicine Policy Analysis” by Wharam and colleagues 1 . The importance of this topic is addressed in an accompanying thought-provoking editorial by Dr. Matt Wynia. This second editorial has a different purpose. We highlight the Wharam article as SGIM’s first full example of an officially sanctioned SGIM policy analysis. While SGIM has always developed position papers on key issues of relevance to our members, the Society has not previously used a systematic process to publish in-depth analyses of its positions in JGIM. Because the product is new for SGIM, this editorial outlines how it developed from an idea to a finished product, focusing on how the preparation and review of the document differs from the typical journal article. By doing so, we hope to inspire SGIM members, committees, interest groups, and task forces to create other policy analyses addressing the critical issues facing general internal medicine practice, education, and research. SGIM’s Council and Health Policy Committee have long wrestled with the challenge of how best to articulate the views of SGIM members on problems and issues facing general internal medicine. This is a critical role for our Society, and one that has become more pressing recently as the prospects for major health-care reform escalate. The central role of primary care appears to be poised for recognition at the same time that the declining workforce threatens the future of our field. At this critical juncture, how can SGIM make its voice heard? We believe that as an organization, SGIM is well positioned to exert influence. SGIM represents a broad-based generalist point of view. We have strong connections to academic medicine and to the trainees who represent the future of our field. Among medical societies, SGIM has gained credibility by establishing its independence from for-profit pharmaceutical and other industries involved in health-care delivery. These are among the qualities that lead other societies and political entities to request SGIM’s participation or support. Yet our member-supported financing, our support for research, education, and quality improvement activities, and our reliance primarily on volunteer labor limit the number of policy issues in which our governing bodies can effectively engage. A solution to this dilemma is to engage SGIM committees and interest groups in creating a broad set of policy analyses that our members can use to participate more effectively in local, regional, and national policy venues. In this way, SGIM can support but also extend the reach of individual members. A policy analysis will differ from the product of SGIM individual members by having a defined process of review and input from the SGIM Council and Health Policy Committee. We envision published SGIM policy analyses as a subset of those posted on the SGIM web pages. Published policies would be salient, high quality, peer-reviewed products of general interest to our members. These published analyses would represent collaborative effort among the authors working with the SGIM Council, Health Policy Committee, and the JGIM editorial team. The Wharam article represents a collaboration of this sort. It is an example of the kind of thoughtful policy analysis we hope to support. We would therefore like to highlight some of the article’s key features from the point of view of SGIM

Fact or Fiction: The Need for Independent Pharmaceutical Policy Research

Fact or Fiction: The Need for Independent Pharmaceutical Policy Research

Turning and Churning: Loss of Health Insurance Among Adults in Medicaid

Turning and Churning: Loss of Health Insurance Among Adults in Medicaid

After the End of Free Fall: Geriatricizing Primary Care

After the End of Free Fall: Geriatricizing Primary Care

A Better Measure of Patients’ Need for Interpreter Services

As Karliner and colleagues discuss in their article “Identification of Limited English Proficient Patients in Clinical Care”1 in the current issue of the Journal of General Internal Medicine, the matter of knowing whether or not patients need the assistance of language access services is an important one. The limited English proficient (LEP) population in the US is large and growing2 and, as has been well documented, language barriers to access to medical care contribute to poor outcomes and health disparities in the LEP population.3,4 Unfortunately, many LEP patients still go without the help of interpreters and other language access services in their health care interactions.5 There are many reasons for this, but an important one is that many health care organizations do not know that their patients need these services and therefore cannot plan accordingly, either for the provision of interpreter services or for planning efficient use of existing services. The work by Karliner and her colleagues documents a practical, accurate method for screening patients for their need for linguistic access services that will make it easier for health care organizations to collect the data they need to adequately plan for and provide linguistic access services to their LEP populations. Their results will also likely become more valuable in the future if the Joint Commission on the Accreditation of Healthcare Organizations establishes standards regarding the provision of culturally competent patient-centered care, which is currently being explored.6 A necessary first step towards providing culturally competent care is knowing the population being served within a health care organization and the needs of that population Knowing a patient’s English proficiency prior to walking into the exam room is also valuable to individual physicians. Most physicians have had the experience where a patient “gets by” with the English that they know and somewhere in the encounter it becomes clear that the communication is not adequate. Worse yet, the physician may erroneously think the communication is adequate when it is not because the patient does not really understand what is being said. The patient may be reluctant to reveal his or her lack of understanding because of embarrassment, lack of awareness of what is being missed in the interaction, fear of being discriminated against or stigmatized because they don’t speak English, or desire to avoid a delay as an interpreter is accessed. In these situations communication is impaired and both the patient and physician are at risk. If patients needing an interpreter or other linguistic access services could be identified before an encounter, the physician could enter into that encounter with the power of that knowledge and take steps optimize communication. Research involving patients with LEP would also benefit from an accurate, practical method of identifying such patients. One of the barriers to conducting high quality studies of the impact on health and health care of language barriers and interpreter services is the lack of good data on who is LEP, especially patients identified through large clinical and administrative databases.7 Two short questions together have high specificity and sensitivity in identifying patients who would benefit from interpreter and other linguistic access services. These questions could be easily incorporated into surveys and clinical and administrative database, creating valuable resources for research. Clearly, knowing the language proficiency of patients is important and the two-question combined measure of English proficiency described in this issue of JGIM is an important contribution. This measure could be used at the policy, administrative, and health care delivery levels to plan for and improve the care delivered to LEP patients and, if incorporated into clinical and administrative databases, could enhance our ability to conduct quality research in LEP populations. This does not mean that the research is not without limitations. It would be important to see how well this measure holds up against patients’ actual English proficiency when tested, rather than their reported quality of communication and understanding, but it is an important first step towards the development of practical, short tools to identify LEP patients and those who would benefit from linguistic access services. Such a tool will go a long way in efforts to provide adequate care to the growing LEP population in the US and to evaluate the quality of that care.

Teaching Tips—A new series in JGIM

Teaching Tips—A new series in JGIM

Creating a More Resilient Safety Net for Persons with Chronic Disease: Beyond the “Medical Home”

Mega-disasters the scale and scope of Hurricane Katrina have been exceedingly rare in the USA. Nonetheless, careful study of such disasters can provide lessons learned that can lend essential insights to guide planning for future events of any size.1 Such disasters can also expose previously under-recognized frailties in society that, like the under-built levees of New Orleans, readily buckle under stress. One such frailty exposed by the storm was the health care safety net. Katrina was in many ways the “perfect storm” not only because of her meteorological characteristics but because she struck a portion of the world with high prevalence of chronic conditions, high rates of uninsured, and a geographically and financially consolidated safety net system.2 At the heart of the devastated area was the Medical Center of Louisiana at New Orleans (formerly known as Charity Hospital), the primary source of first-contact and chronic disease care for hundreds of thousands of uninsured and underinsured persons in the Greater New Orleans area. Katrina’s devastating flood rendered this Center completely inoperable. This confluence of events left hundreds of thousands of vulnerable patients with chronic conditions in the most densely populated hurricane-affected areas suddenly with no access to care. In this issue of JGIM, the Hurricane Katrina Community Advisory Group present the findings of their telephone survey assessing the impact of Hurricane Katrina of survivors with chronic disease among a sample from New Orleans and other affected areas.3 In their large representative sample, one in five persons reported having cut back or terminated treatment for a major chronic illness after the hurricane. Characteristics independently associated with treatment disruption included age younger than 65, having fewer relatives within and beyond hurricane-affected areas, and suffering two or more geographic relocations by early 2006, roughly 4–6 months after the disaster. Insurance was not an independent predictor in multivariable analysis, but this variable may have been difficult to disentangle from age, given the role of Medicare. Their complementary listing of respondents’ self-reported reasons for treatment interruption highlighted limited access to physicians and medications, insurance/payment issues, and competing demands for patient’s time and attention. These factors are strikingly similar to those reported in research among Americans experiencing homelessness in the absence of major humanitarian disasters.4,5 Minimizing disruption to the care of persons with chronic disease requires weaving a health care safety net resilient to the stress of disasters and to the more personalized disasters such as job loss or loss of one’s home.6 The design of a resilient health care safety net should pivot on recognition that continuing care for patients with chronic illness and their associated complex needs requires sufficiently nuanced policies. We posit that a health care safety net, capable of caring for patients with chronic disease during routine times and disasters, must take account not one, but three types of “homes”, each interdependent and supporting the other. Health care policies to shore up the safety net should drive the development of a web-enabled “medical home”,4,5 a portable financing mechanism for their care, an “insurance home”, and sufficient social support and resources to allow for self-care and management sufficient to help them respond to life’s challenges, a “social home”.

R-E-S-P-E-C-T: Even More Difficult to Teach than to Define

“Respect” is a word like “empathy”, “love”, and “compassion”, that everyone agrees connotes a positive attribute; however, there are innumerable ideas about what respect means. Perhaps the reason it is so difficult to define is because it can mean different things to different people, depending on whether it is being used as a verb or as a noun, on the person’s cultural background, and the context in which it is being discussed. For instance, when a parent tells a teenager “to show some respect” the meaning is somewhat different than when philosophers talk about “respect for persons”. Aretha1 put it very simply: “R-E-S-P-E-C-T, find out what it means to ME!” Still, it is useful to examine why and how a physician can show respect to patients. After all, the American Board of Internal Medicine’s Medical Professionalism in the New Millennium: A Physician Charter mentions “respect for patient autonomy” as a core principle and the Project Professionalism states that “Respect for others (patients and their families, other physicians, and professional colleagues such as nurses, medical students, residents, and subspecialty fellows) is the essence of humanism, and humanism is both central to professionalism and fundamental to enhancing collegiality among physicians.”2,3 In this issue of JGIM, Beach et al attempt to define the object of physicians’ respect and what respect requires4. They believe autonomy is too limited as the object of our respect because it seems to make respect conditional on whether we admire a patient’s values, and because it limits our obligation to those patients who lack autonomy. They propose that it is a physician’s moral duty to respect all patients equally as persons, as a professional extension of one’s universal duty to respect all people because of their “unconditional intrinsic value as human beings.” They go on to describe this respect as bidimensional; that is, the concept of respect is both an attitude and a set of behaviors that one ought to have as a physician. Both dimensions, they argue, are morally required of physicians. This article is likely to be widely read and discussed. Whereas philosophers may argue about whether their concept of autonomy is biased, we agree that respect should not be contingent on a patient’s lifestyle or health decisions. For medical educators who are charged with training respectful physicians for the future, the article raises questions about the barriers to respect, how to teach respect, whether a focus on behavior is sufficient, and what behaviors constitute respect. We will focus our attention on these issues.

Revisiting literacy and adherence

Revisiting literacy and adherence

Medical care for patients with severe and persistent mental illness

Medical care for patients with severe and persistent mental illness

Uncertainty, competence, and opioids

Uncertainty, competence, and opioids

Cancer screening in primary care

Determining an appropriate cancer screening regimen is one of the most important and challenging preventive care tasks in primary care. Providers must evaluate the evidence on the effectiveness of multiple screening tests, decide which tests to offer, identify patients who are eligible for screening, reach agreement with eligible patients about which tests to perform, appropriately follow up on the results of screening, and identify when the tests will need to be performed again. Some forms of screening, such as mammography for breast cancer, have reached large segments of the eligible population. However, current health care delivery models continue to have significant difficulty ensuring that eligible patients are aware of the availability of effective screening interventions and are able to take advantage of them. Two articles in this issue of JGIM illustrate how inadequate patient–provider communication limits the quality of cancer screening. Ling et al. performed a survey of patients' and providers' attitudes about different options for colorectal cancer (CRC) screening.1 They provided participants with structured educational information about 5 CRC screening options considered effective by a 1997 expert panel. Most patients preferred either fecal occult blood testing (FOBT) alone (43%) or colonoscopy (40%). Patients who attached the highest value to test accuracy most often chose colonoscopy, while patients who considered the frequency, complications, discomfort, or inconvenience of the test most important were more likely to choose FOBT. Interestingly, although patients and providers were similar in how they valued different test characteristics, physicians vastly overestimated the value patients placed on discomfort and underestimated the value they placed on accuracy. The effect of this misperception on the tests that providers recommend to patients is not clear, but raises concern that providers may be selecting tests that do not reflect patients' values. Further research is required to determine if this mismatch reduces test completion rates or patient satisfaction, and to determine if better information and communication about values and preferences will improve screening rates and satisfaction. Voss and Schectman examine another important issue in cancer screening: the use of prostate-specific antigen (PSA) screening for prostate cancer.2 PSA screening presents a different communication dilemma: how should providers and patients discuss and decide about screening in the face of uncertainty about its effectiveness in reducing mortality? Voss and Schectman present data from a longitudinal survey of physician providers from 1993 and 1998. Physicians reported ordering PSA screening as part of regular health maintenance visits 73% of the time in 1993 and 81% in 1998. Physician support for PSA testing increased over the same time period, despite the fact that over 50% of providers were either uncertain or did not believe that aggressive therapy reduced mortality. Providers in busy practices were more likely to order testing, as were those furthest from training; academic physicians were less likely to order testing than community physicians. PSA use was associated with the perception that testing represented “standard of care” practice and concerns about malpractice liability if screening were not offered; it was inversely associated with the belief that the harms of screening may outweigh the benefits. Many providers who were classified as “high testers” (i.e., reported ordering PSA in over 80% of their patients) also agreed that the harms of treatment might outweigh the benefits. The authors hypothesize that under the condition of uncertainty about treatment efficacy, but increasing public interest and awareness of PSA, busy practitioners may choose to perform testing rather than engage in a shared discussion about the pros and cons of screening. The studies by Ling et al. and Voss and Schectman both illustrate how lack of communication between providers and patients acts as a barrier to the provision of high-quality preventive care. Surveys of providers suggest that a lack of time is perceived as one of the main reasons for a failure to discuss screening.3 Recent research has suggested that decision aids, systematically developed tools that use videodiscs or computers to provide relevant information to patients about their options, can help patients who are facing screening decisions to make more informed decisions, and may also improve adherence and satisfaction.4,5 Because such tools are used before the patient sees the provider, they can help focus the discussion, reduce the perception of inadequate time, and allow better communication of patient values.

The world we live in: Health policy from a primary care perspective

The world we live in: Health policy from a primary care perspective

Populations at risk: A new section for JGIM

Populations at risk: A new section for JGIM

Veterans, Medicare, and Health Maintenance Organizations Where Is the Value?

Veterans, Medicare, and Health Maintenance Organizations Where Is the Value?