Stephen J. Spann

Management of type 2 diabetes in the primary care setting: A practice-based research network study

PURPOSE We wanted to describe how primary care clinicians care for patients with type 2 diabetes. METHODS We undertook a cross-sectional study of 95 primary care clinicians and 822 of their established patients with type 2 diabetes from 4 practice-based, primary care research networks in the United States. Clinicians were surveyed about their training and practice. Patients completed a self-administered questionnaire about their care, and medical records were reviewed for complications, treatment, and diabetes-control indicators. RESULTS Participating clinicians (average age, 45.7 years) saw an average of 32.6 adult patients with diabetes per month. Patients (average age, 59.7 years) reported a mean duration of diabetes of 9.1 years, with 34.3% having had the disease more than 10 years. Nearly one half (47.5%) of the patients had at least 1 diabetes-related complication, and 60.8% reported a body mass index greater than 30. Mean glycosylated hemoglobin (HbA1c) level was 7.6% (SD 1.73), and 40.5% of patients had values <7%. Only 35.3% of patients had adequate blood pressure control (<130/85 mm Hg), and only 43.7% had low-density lipoprotein cholesterol (LDL-C) levels <100 mg/dL. Only 7.0% of patients met all 3 control targets. Multilevel models showed that patient ethnicity, practice type, involvement of midlevel clinicians, and treatment were associated with HbA1c level; patient age, education level, and practice type were associated with blood pressure control; and patient ethnicity was associated with LDL-C control. CONCLUSIONS Only modest numbers of patients achieve established targets of diabetes control. Reengineering primary care practice may be necessary to substantially improve care.

Patient Education for Informed Decision Making About Prostate Cancer Screening: A Randomized Controlled Trial with 1-Year Follow-Up

PURPOSE The efficacy of prostate cancer screening is uncertain, and professional organizations recommend educating patients about potential harms and benefits. We evaluated the effect of a videotape decision aid on promoting informed decision making about prostate cancer screening among primary care patients. METHODS A group of 160 men, 45 to 70 years of age, with no history of prostate cancer, were randomized to view or not to view a 20-minute educational videotape before a routine office visit at a university-based family medicine clinic. The subjects were contacted again 1 year after their visit to assess their receipt of prostate cancer screening (digital rectal examination [DRE] or prostate-specific antigen [PSA] testing), their satisfaction with their screening decision, and knowledge retention since the baseline assessment. RESULTS Follow-up assessments were completed for 87.5% of the intervention subjects and 83.8% of the control subjects. The rate of DRE did not differ between the 2 groups. Prostate-specific antigen testing was reported by 24 of 70 (34.3%) intervention subjects and 37 of 67 (55.2%) control subjects (P = .01). African American men were more likely to have had PSA testing (9 of 16, 56.3%) than were white men (13 of 46, 28.3%) (P = .044). Satisfaction with the screening decision did not differ between the study groups. Intervention subjects were more knowledgeable of prostate cancer screening than were control subjects, although these differences declined within 1 year (P < .001). CONCLUSIONS Decision aids for prostate cancer screening can have a long-term effect on screening behavior and appear to promote informed decision making.

Entertainment Education for Prostate Cancer Screening: A Randomized Trial among Primary Care Patients with Low Health Literacy

OBJECTIVE To evaluate an entertainment-based patient decision aid for prostate cancer screening among patients with low or high health literacy. METHODS Male primary care patients from two clinical sites, one characterized as serving patients with low health literacy (n=149) and the second as serving patients with high health literacy (n=301), were randomized to receive an entertainment-based decision aid for prostate cancer screening or an audiobooklet-control aid with the same learner content but without the entertainment features. Postintervention and 2-week follow-up assessments were conducted. RESULTS Patients at the low-literacy site were more engaged with the entertainment-based aid than patients at the high-literacy site. Overall, knowledge improved for all patients. Among patients at the low-literacy site, the entertainment-based aid was associated with lower decisional conflict and greater self-advocacy (i.e., mastering and obtaining information about screening) when compared to patients given the audiobooklet. No differences between the aids were observed for patients at the high-literacy site. CONCLUSION Entertainment education may be an effective strategy for promoting informed decision making about prostate cancer screening among patients with lower health literacy. PRACTICE IMPLICATIONS As barriers to implementing computer-based patient decision support programs decrease, alternative models for delivering these programs should be explored.

Entertainment education for breast cancer surgery decisions: a randomized trial among patients with low health literacy.

OBJECTIVE To evaluate an entertainment-based patient decision aid for early stage breast cancer surgery in low health literacy patients. METHODS Newly diagnosed female patients with early stage breast cancer from two public hospitals were randomized to receive an entertainment-based decision aid for breast cancer treatment along with usual care (intervention arm) or to receive usual care only (control arm). Pre-decision (baseline), pre-surgery, and 1-year follow-up assessments were conducted. RESULTS Patients assigned to the intervention arm of the study were more likely than the controls to choose mastectomy rather than breast-conserving surgery; however, they appeared better informed and clearer about their surgical options than women assigned to the control group. No differences in satisfaction with the surgical decision or the decision-making process were observed between the patients who viewed the intervention and those assigned to the control group. CONCLUSIONS Entertainment education may be a desirable strategy for informing lower health literate women about breast cancer surgery options. PRACTICE IMPLICATIONS Incorporating patient decision aids, particularly computer-based decision aids, into standard clinical practice remains a challenge; however, patients may be directed to view programs at home or at public locations (e.g., libraries, community centers).

Task Force 1. Report of the Task Force on Patient Expectations, Core Values, Reintegration, and the New Model of Family Medicine

BACKGROUND To lay the groundwork for the development of a comprehensive strategy to transform and renew the specialty of family medicine, this Future of Family Medicine task force was charged with identifying the core values of family medicine, developing proposals to reform family medicine to meet consumer expectations, and determining systems of care to be delivered by family medicine in the future. METHODS A diverse, multidisciplinary task force representing a broad spectrum of perspectives and expertise analyzed and discussed published literature; findings from surveys, interviews, and focus groups compiled by research firms contracted to the Future of Family Medicine project; and analyses from The Robert Graham Center, professional societies in the United States and abroad, and others. Through meetings, conference calls, and writing, and revision of a series of subcommittee reports, the entire task force reached consensus on its conclusions and recommendations. These were reviewed by an external panel of experts and revisions were made accordingly. MAJOR FINDINGS After delivering on its promise to reverse the decline of general practice in the United States, family medicine and the nation face additional challenges to assure all people receive care that is safe, effective, patient-centered, timely, efficient, and equitable. Challenges the discipline needs to address to improve family physicians’ ability to make important further contributions include developing a broader, more accurate understanding of the specialty among the public and other health professionals, addressing the wide scope and variance in practice types within family medicine, winning respect for the specialty in academic circles, making family medicine a more attractive career option, and dealing with the perception that family medicine is not solidly grounded in science and technology. The task force set forth a proposed identity statement for family medicine, a basket of services that should be reliably provided in family medicine practices, and an itemization of key attributes and core values that define the specialty. It also proposed and described a New Model of family medicine for people of all ages and both genders that emphasizes patient-centered, evidence-based, whole-person care provided through a multidisciplinary team approach in settings that reduce barriers to access and use advanced information systems and other new technologies. The task force recommended a time of active experimentation to redesign the work and workplace of family physicians; the development of revised financial models for family medicine, and a national resource to provide assistance to individual practices moving to New Model practice; and cooperation with others pursuing the transformation of frontline medicine to better serve the public. CONCLUSIONS Unless there are changes in the broader health care system and within the specialty, the position of family medicine in the United States will be untenable in a 10- to 20-year time frame. Even within the constraints of today’s flawed health care system, there are major opportunities for family physicians to realize improved results for patients and economic success. A period of aggressive experimentation and redevelopment of family medicine is needed now. The future success of the discipline and its impact on public well-being depends in large measure on family medicine’s ability to rearticulate its vision and competencies in a fashion that has greater resonance with the public while substantially revising the organization and processes by which care is delivered. When accomplished, family physicians will achieve more fully the aspirations articulated by the specialty’s core values and contribute to the solution of the nation’s serious health care problems.

Preferences of Husbands and Wives for Outcomes of Prostate Cancer Screening and Treatment

OBJECTIVE: To explore the preferences of male primary care patients and their spouses for the outcomes of prostate cancer screening and treatment, and quality of life with metastatic prostate cancer.DESIGN: Cross-sectional design.SETTING: Primary care clinics in Galveston County, Texas.PATIENTS: One hundred sixty-eight couples in which the husband was a primary care patient and a candidate for prostate cancer screening.MEASUREMENTS AND MAIN RESULTS: Preferences were measured as utilities for treatment outcomes and quality of life with metastatic disease by the time trade-off method for the husband and the wife individually and then conjointly for the couple. For each health state considered, husbands associated lower utilities for the health states than did their wives. Couples’ utilities fell between those of husbands and wives (all comparisons were significant at P<.01). For partial and complete impotence and mild-to-moderate incontinence, the median utility value for the wives was 1.0, indicating that most wives did not associate disutility with their husbands having to experience these treatment complications.CONCLUSIONS: Male primary care patients who are candidates for prostate cancer screening evaluate the outcomes of prostate cancer treatment and life with advanced prostate cancer as being far worse than do their wives. Because the choice between quantity and quality of life is a highly individualistic one, both the patient and his partner should be involved in making decisions about prostate cancer screening.

Psychological benefits of prostate cancer screening: the role of reassurance.

Objectives  The role of reassurance in decision‐making about screening for health problems is largely unknown. We examined the reassurance value of prostate cancer screening in primary care patients.

Report on Financing the New Model of Family Medicine

PURPOSE To foster redesigning the work and workplaces of family physicians, this Future of Family Medicine task force was created to formulate and recommend a financial model that sustains and promotes a thriving New Model of care by focusing on practice reimbursement and health care finances. The goals of the task force were to develop a financial model that assesses the impact of the New Model on practice finances, and to recommend health care financial policies that, if implemented, would be expected to promote the New Model and the primary medical care function in the United States for the next few decades. METHODS The members of the task force reflected a wide range of professional backgrounds and expertise. The group met in person on 2 occasions and communicated by e-mail and conference calls to achieve consensus. A marketing study was carried out using focus groups to test the concept of the New Model with consumers. External consultants with expertise in health economics, health care finance, health policy, and practice management were engaged to assist the task force with developing the microeconomic (practice level) and macroeconomic (societal level) financial models necessary to achieve its goals. Model assumptions were derived from the published medical literature, existing practice management databases, and discussions with experienced physicians and other content experts. The results of the financial modeling exercise are included in this report. The initial draft report of the findings and recommendations was shared with a reactor panel representing a broad spectrum of constituencies. Feedback from these individuals was reviewed and incorporated, as appropriate, into the final report. RESULTS The practice-level financial model suggests that full implementation of the New Model of care within the current fee-for-service system of reimbursement would result in a 26% increase in compensation (from

Population-based time preferences for future health outcomes

167,457 to

Aspirin for primary prevention of cardiovascular events

210,288 total annual compensation) for prototypical family physicians who maintain their current number of work hours. Alternatively, physicians could choose to decrease their work hours by 12% and maintain their current compensation. This result is sensitive to physician practice group size. The societal level financial model shows that modifications in the current reimbursement system could lead to further improvements in compensation for family physicians practicing the New Model of care. Reimbursement for e-visits and chronic disease management could further increase total annual compensation to