Richard G. Roberts

The Future of Family Medicine: A Collaborative Project of the Family Medicine Community

BACKGROUND Recognizing fundamental flaws in the fragmented US health care systems and the potential of an integrative, generalist approach, the leadership of 7 national family medicine organizations initiated the Future of Family Medicine (FFM) project in 2002. The goal of the project was to develop a strategy to transform and renew the discipline of family medicine to meet the needs of patients in a changing health care environment. METHODS A national research study was conducted by independent research firms. Interviews and focus groups identified key issues for diverse constituencies, including patients, payers, residents, students, family physicians, and other clinicians. Subsequently, interviews were conducted with nationally representative samples of 9 key constituencies. Based in part on these data, 5 task forces addressed key issues to meet the project goal. A Project Leadership Committee synthesized the task force reports into the report presented here. RESULTS The project identified core values, a New Model of practice, and a process for development, research, education, partnership, and change with great potential to transform the ability of family medicine to improve the health and health care of the nation. The proposed New Model of practice has the following characteristics: a patient-centered team approach; elimination of barriers to access; advanced information systems, including an electronic health record; redesigned, more functional offices; a focus on quality and outcomes; and enhanced practice finance. A unified communications strategy will be developed to promote the New Model of family medicine to multiple audiences. The study concluded that the discipline needs to oversee the training of family physicians who are committed to excellence, steeped in the core values of the discipline, competent to provide family medicine’s basket of services within the New Model, and capable of adapting to varying patient needs and changing care technologies. Family medicine education must continue to include training in maternity care, the care of hospitalized patients, community and population health, and culturally effective and proficient care. A comprehensive lifelong learning program for each family physician will support continuous personal, professional, and clinical practice assessment and improvement. Ultimately, systemwide changes will be needed to ensure high-quality health care for all Americans. Such changes include taking steps to ensure that every American has a personal medical home, promoting the use and reporting of quality measures to improve performance and service, advocating that every American have health care coverage for basic services and protection against extraordinary health care costs, advancing research that supports the clinical decision making of family physicians and other primary care clinicians, and developing reimbursement models to sustain family medicine and primary care practices. CONCLUSIONS The leadership of US family medicine organizations is committed to a transformative process. In partnership with others, this process has the potential to integrate health care to improve the health of all Americans.

Validation of an overactive bladder awareness tool for use in primary care settings.

Overactive bladder (OAB)—a syndrome characterized by urinary urgency, with or without urge incontinence, urinary frequency and nocturia—is estimated to affect 10% to 20% of the US and European populations. This study was carried out to validate a patient-administered screening awareness tool to identify patients with bothersome OAB symptoms. Patients were recruited from 12 primary care and 1 gynecology practice during regularly scheduled appointments. Enrollees completed an 8-item questionnaire assessing the amount of “bother” they associated with OAB symptoms. Clinicians then asked the patients 4 questions regarding urinary frequency, urgency, nocturia, and incontinence. If the screening was positive for symptoms of OAB or if the patient provided positive responses to the urinary symptom questions, the clinician asked additional questions regarding lifestyle and coping behaviors. The clinician then diagnosed the patient, placing him or her in the “No OAB,” “Possible OAB,” or “Probable OAB” category. Multivariable logistic regressions controlling for age and sex were performed to assess the applicability of the tool for identifying patients with OAB. A total of 1299 patients were enrolled, and 1260 provided complete data. Patients were aged 51.6±17.0 years, 62% were female, most (89%) were Caucasian, 22% experienced urinary urgency, and 18% experienced urge incontinence. The prevalence of Probable OAB was 12%. The c-index of the model identifying patients with a diagnosis of Probable OAB was 0.96, with a sensitivity and specificity of 98.0 and 82.7. For OAB-V8 scores ≥8, the odds ratio for Probable OAB was 95.7 (95% Cl: 29.3; 312.4). The OAB-V8 performed well in helping clinicians identify patients with bothersome OAB symptoms in a primary care setting and will assist clinicians in identifying patients who may benefit from treatment.

Prostate Cancer Screening and Beliefs about Treatment Efficacy: A National Survey of Primary Care Physicians and Urologists

PURPOSE To describe practice patterns and beliefs of primary care physicians and urologists regarding early detection and treatment of prostate cancer. SUBJECTS AND METHODS National probability samples of primary care physicians (n=444) and urologists (n=394) completed mail survey instruments in 1995. Physicians were asked about their use of prostate-specific antigen (PSA) testing for men of different ages and their beliefs about the value of radical prostatectomy, external-beam radiation therapy, and watchful waiting for men with differing life expectancies. RESULTS Most primary care physicians report doing PSA tests during routine examination of men older than 50 years of age. The majority say they continue to do them on patients over 80 years and to refer men with abnormal values for biopsy. In contrast, only a minority of urologists would recommend PSA tests or biopsy for abnormal values for men over 75 years of age. More than 80% of primary care physicians and urologists doubt the value of radical prostatectomy for men with < 10 years of life expectancy; more primary care physicians than urologists see probable survival benefit in radiation therapy for patients with life expectancy < 10 years (48% versus 36%) or > 10 years (67% versus 53%). Thirteen percent of primary care physicians and only 3% of urologists consider watchful waiting to be as appropriate as aggressive therapy for men with > 10 years of life expectancy. CONCLUSIONS Primary care physicians are more aggressive about PSA testing and referral for biopsy than most urologists recommend. Both groups recommend PSA testing and believe that aggressive treatment is more beneficial than existing evidence indicates.

Tackling NCDs: a different approach is needed.

www.thelancet.com Vol 379 May 19, 2012 1873 Submissions should be made via our electronic submission system at http://ees.elsevier.com/ thelancet/ The view by Jan De Maeseneer and colleagues that the priority in relation to non-communicable diseases (NCDs) is a health-service response is deeply fl awed. Non-governmental organisations have been struggling, in the current debate stimulated by the UN High-Level Meeting on NCDs, to shift the focus to environmental change to reduce exposure to the drivers of risk behaviours that contribute so strongly to NCDs. Do we really want to continue to live in a world where the oversupply and marketing of tobacco, alcohol, unhealthy processed foods, and soft drinks is tolerated simply to allow continuing profi ts for the shareholders of the transnational corporations producing and distributing them, while the taxpayer funds the health services and pharmaceutical response to the ensuing disease and injury?

THE DEVELOPMENT OF JOINT PRINCIPLES: INTEGRATING BEHAVIORAL HEALTH CARE INTO THE PATIENT-CENTERED MEDICAL HOME

The world of primary care was galvanized in 2007 by the publication of the Joint Principles of The Patient-Centered Medical Home (PCMH) that spells out the fundamental features of a primary health care setting in which a team of clinicians offers accessible first-contact primary care.[1][1] This

Joint principles: integrating behavioral health care into the patient-centered medical home.

The Patient-centered Medical Home (PCMH) is an innovative, improved, and evolving approach to providing primary care that has gained broad acceptance in the United States. The Joint Principles of the PCMH, formulated and endorsed in February 2007, are sound and describe the ideal toward which we

Depression and diabetes : the role and impact of models of health care systems

OBJECTIVES Depression and diabetes often occur together and their comorbidity has a significant and detrimental impact on health outcomes. The aims of this paper are to review the existing international literature on approaches to health care for comorbid depression and diabetes and draw out the key conclusions for both research and future development in health care delivery. METHODS Narrative review of the literature with synthesis by an international team of authors. RESULTS The synthesized findings are discussed under four main headings: specialty and generalist care; models for co-ordinating and integrating care; community approaches to service delivery; and the role of health policy. LIMITATIONS The review only included literature published in English. CONCLUSIONS Translating basic and clinical research findings into improved treatment and outcomes of those with depression and diabetes remains a substantial challenge. There is little research on the difficulties of identifying and implementing best practice into routine health care. Systems need to be designed so that evidence-based interventions are provided in a timely way, with appropriate professional expertise where required.

Task Force Report 5. Report of the Task Force on Family Medicine’s Role in Shaping the Future Health Care Delivery System

BACKGROUND Recognizing that the implementation of needed changes within family medicine will be enhanced through a concurrent effort to transform the broader health care system, this Future of Family Medicine task force was charged with determining family medicine’s leadership role in shaping the future health care delivery system. METHODS After reviewing the changes taking place within family medicine and the broader health care system, this task force identified 6 priorities for fostering necessary modifications in the health care system. In addressing the leadership challenge facing the discipline, the task force presents a 3-dimensional matrix that provides a useful framework for describing the audiences that should be targeted, the strategic priorities that should be pursued, and the specific recommendations that should be addressed. Noting that leadership is part of the heritage of family medicine, the task force reviewed past successes by the discipline as important lessons that can be instructive as family physicians begin advocating for needed changes. MAJOR FINDINGS Effective leadership is an essential ingredient that will determine, to a large extent, the success of family medicine in advocating for needed change in the health care system overall and in the specialty. It is vitally important to groom leaders within family medicine and to create venues where policy makers and influence leaders can look beyond their usual constituencies and horizons to a comprehensive view of health care. A central concept being proposed is that of a relationship-centered personal medical home. This medical home serves as the focal point through which all individuals—regardless of age, gender, race, ethnicity, or socioeconomic status—receive a basket of acute, chronic, and preventive medical care services that are accessible, accountable, comprehensive, integrated, patient-centered, safe, scientifically valid, and satisfying to both patients and their physicians. CONCLUSION Family medicine has and will continue to have an important leadership role in health system change. It has been most successful when it has been able to identify a high-priority goal through consensus within the discipline, to focus and coordinate local and national resources, and to use a multipronged approach in addressing the priority. Although the Future of Family Medicine project has provided an important impetus for the identification of key priorities across the discipline, for the FFM project ultimately to be a success, implementation steps will need to be identified and prioritized. The leadership matrix presented in this report can provide a useful structuring tool to identify, understand, and coordinate change efforts more effectively. Strategic alliances with primary care groups and others also will be critical to the success of change initiatives.

The Challenges of Measuring, Improving, and Reporting Quality in Primary Care

We propose a new set of priorities for quality management in primary care, acknowledging that payers and regulators likely will continue to insist on reporting numerical quality metrics. Primary care practices have been described as complex adaptive systems. Traditional quality improvement processes applied to linear mechanical systems, such as isolated single-disease care, are inappropriate for nonlinear, complex adaptive systems, such as primary care, because of differences in care processes, outcome goals, and the validity of summative quality scorecards. Our priorities for primary care quality management include patient-centered reporting; quality goals not based on rigid targets; metrics that capture avoidance of excessive testing or treatment; attributes of primary care associated with better outcomes and lower costs; less emphasis on patient satisfaction scores; patient-centered outcomes, such as days of avoidable disability; and peer-led qualitative reviews of patterns of care, practice infrastructure, and intrapractice relationships.

Nappies and transmission of Giardia lamblia between children

Sir—Ekramul Hoque and colleagues (March 31, p 1017) report that exposure to nappies is an important risk factor for spread of Giardia spp to adults in the community. We agree that exposure to nappies represents an important risk factor for acquiring giardia infection but point out that exposure to nappies is also important for the spread of Giardia spp between children. The health risks of paddling pools have been described. We have managed the largest recorded outbreak of Giardia lamblia in the UK. At the same time we became aware of a form of water play in which children who were not toilet trained sit together in paddling pools, frequently while wearing nappies. A telephone survey of 17 local nurseries showed that this practice was allowed in ten of 16 for which data were available. Of these ten nurseries, six regularly allowed children to wear nappies while sitting together in the water. Only one of the nurseries reported the use of waterproof nappies. The outbreak centred on one nursery catering for children age 3 months to 5 years. All household contacts of microbiologically positive cases were screened. 56 individuals had confirmed Giardia lamblia infection, 37 children, three child-care workers, and 16 parents. 17 individuals had symptoms and 39 were identified by screening. The epidemiology of the cases suggested person-to-person faecal oral spread rather than spread from a point source. We did a retrospective case-control study to find out whether sitting in paddling pools was a risk factor for illness in the outbreak. Paddling was associated with a significant risk of microbiologically confirmed Giardia lamblia infection. We informed all UK environmental health departments of this common practice and the risk associated with it.