Practical recommendations for timely, accurate diagnosis of symptomatic Alzheimer's disease (MCI and dementia) in primary care: a review and synthesis.

The critical role of primary care clinicians (PCCs) in Alzheimer's disease (AD) prevention, diagnosis and management must evolve as new treatment paradigms and disease-modifying therapies (DMTs) emerge. Our understanding of AD has grown substantially: no longer conceptualized as a late-in-life syndrome of cognitive and functional impairments, we now recognize that AD pathology builds silently for decades before cognitive impairment is detectable. Clinically, AD first manifests subtly as mild cognitive impairment (MCI) due to AD before progressing to dementia. Emerging optimism for improved outcomes in AD stems from a focus on preventive interventions in midlife and timely, biomarker-confirmed diagnosis at early signs of cognitive deficits (i.e. MCI due to AD and mild AD dementia). A timely AD diagnosis is particularly important for optimizing patient care and enabling the appropriate use of anticipated DMTs. An accelerating challenge for PCCs and AD specialists will be to respond to innovations in diagnostics and therapy for AD in a system that is not currently well positioned to do so. To overcome these challenges, PCCs and AD specialists must collaborate closely to navigate and optimize dynamically evolving AD care in the face of new opportunities. In the spirit of this collaboration, we summarize here some prominent and influential models that inform our current understanding of AD. We also advocate for timely and accurate (i.e. biomarker-defined) diagnosis of early AD. In doing so, we consider evolving issues related to prevention, detecting emerging cognitive impairment and the role of biomarkers in the clinic.

Renal Transplant Arterial Stenosis Treated With Bare-Metal Versus Drug-Eluting Stents: Comparison of Treatment Outcomes.

INTRODUCTION: This study aims to evaluate outcomes of bare-metal stents (BMS) versus drug-eluting stents (DES) in patients who undergo stenting for transplant renal arterial stenosis. MATERIALS AND METHODS: We retrospectively reviewed records of renal transplantation patients who underwent transplant renal arterial stenting from September 2009 to September 2013. All stents greater than 5 mm were excluded to allow for equivalent comparison between the DES and BMS groups. Statistical comparisons were performed using a two-tailed Fischer exact test, and analysis of continuous variables was analyzed using a one-way analysis of variance. RESULTS: The final study population included a total of 18 patients who received either BMS or DES (11 and 7 patients, respectively) for transplant renal arterial stenosis. The most common indications for stenting were increasing creatinine level and abnormal Doppler velocities. There were more re-interventions with BMS (n = 4/11) than DES (n = 0/7), but the trend was not statistically significant (P = .12). Three patients who received BMS had a clinically significant decrease in blood pressure versus 4 in the DES group (P = .33). Six patients who received BMS had a clinically significant decrease in creatinine level versus 3 in the DES group (P = 1.0). CONCLUSION: There is an absolute but not statistically significant difference in the incidence of restenosis requiring repeat intervention between the BMS and DES groups. No difference was detected in clinical success as measured by decreases in blood pressure or creatinine. Future larger studies are needed to corroborate these findings.

Risk factors and recommendations for 230 adult primary care patients, based on U.S. Preventive Services Task Force guidelines.

We used a computer program based on the U.S. Preventive Services Task Force guidelines to identify recommendations for 230 adult patients who presented to an ambulatory family practice residency clinic. We entered risk factors into the computer program from sex-specific questionnaires that patients completed. On average, patients had 15.4 risk factors and 24.5 recommendations for preventive services (13.0 recommendations for screening, 10.5 for counseling, and 1.1 for immunizations). We noted a significant increase in the number of risk factors and recommendations with increasing age, except for counseling recommendations. The average patient incurs a large number of recommendations, which depend on many different risk factors, making the task of complete clinician compliance with the U.S. Preventive Services Task Force guidelines difficult. Many of these recommendations include counseling, which may take more time and require skills that clinicians may think they lack. Complete adherence may require several visits for the physician to address all recommendations. Measures to increase patient responsibility for health maintenance and innovations using comprehensive, interactive, and educational computer programs may help solve these problems.

Dissemination and implementation of Put Prevention into Family Practice.

INTRODUCTION: The Put Prevention into Practice (PPIP) program was developed and disseminated to address patient, clinician, and office barriers that result in less than optimal delivery of preventive services in the United States. METHODS: To study the dissemination of PPIP by the American Academy of Family Physicians (AAFP), pre- and post-dissemination surveys of knowledge about PPIP and purchase order data were obtained from the AAFP. In addition, a mail questionnaire was sent to a random sample of purchasers to study their use of PPIP. RESULTS: After two years of active promotion, 27% of AAFP members had heard about PPIP, and PPIP components were purchased by 2,004 individuals during its inital dissemination. Flow sheets, health guides, exam room wall charts, and the Clinician's Handbook of Preventive Services were the PPIP items most frequently purchased and used. Excluding the Clinician's Handbook of Preventive Services, 58% of purchasers used one or more parts of the kit with an average of less than four items used per purchaser. CONCLUSIONS: Initial dissemination and implementation of PPIP among family physicians was limited; continued promotion will likely improve dissemination of PPIP. However, this study, and others suggest that the simple availability of a kit of materials is not sufficient to enhance the delivery of preventive services as envisioned by clinicians or policy makers. Additional strategies for dissemination and implementation of preventive services will be required, such as providing external consultation services to practices, incorporation of preventive services into HMO organizations, and training of residents in strategies for change in their future practices.

Recommendations to institutions.

Results from the Interdisciplinary Generalist Curriculum (IGC) Project support current ideas of management within a chaotic environment. Important aspects of building support for educational innovation included the following. The trend toward primary care and request for proposal process were important catalysts for change. Buy-in from the dean and key opinion leaders was essential. Early identification of champions for the proposal and ability to achieve broad consensus helped shape coherent projects. Being able to read the culture of the institution and accede to pragmatic changes were important for bridging the initial implementation and maintenance of the change. IGC Project leaders were quick to identify key leverage points, both internal and external. The recommendations of key school committees and licensing bodies were used to foster ongoing change. A respected home for the project on neutral ground was sought. Dedicated coordinators helped sustain daily details, while developing rewards and recognition for collaboration supported faculty involvement. New relationships fostered new systems, which the projects used to continue after funding lapsed and to successfully apply for other grants and contracts.

Family medicine residency directors' perceptions of the position of chief resident.

This report describes a survey that explored the selection, training, duties, skills, and evaluation of chief residents as perceived by the program directors of the 381 family medicine residencies in the United States in 1989. A response rate of 79% (300 programs) was achieved. In 70% of the programs the chief resident received no formal training, and in 41% no formal evaluation. The program directors believed the most important duties and skills of a chief resident were acting as a liaison and advocate for residents, scheduling, and leadership. The directors thought that the most exciting aspects of being a chief resident included the development of leadership skills and the ability to influence curriculum; the aspects that caused the most concern included time pressures and demands that detract from clinical learning. The authors suggest that more attention should be directed to the nurturing and development of chief residents, who are the future leaders in academic medicine.

Integrated clinical experience: University of Nebraska Medical Center.

The Integrated Clinical Experience (ICE) at the University of Nebraska College of Medicine is a required, two-year course of study for first- and second-year students. It provides early clinical experiences in primary care settings in metropolitan and rural areas, and related instruction in the social, behavioral, and ethical foundations of medicine. The authors describe the course goals, teaching format, topics, and evaluation of students and faculty. ICE is based on the assumptions that medicine is an applied behavioral science as well as an applied biological science, that critical reflection is important in professional education, and that early exposure to primary care will promote interest in primary care careers. The authors also describe some of the challenges associated with the implementation of this new course of study. These include student dissatisfaction with behavioral and ethical topics, resistance to critical reflection about their personal attitudes and values, and discomfort with "subjective" grading. ICE has also been controversial with some basic science faculty who feel they have had to sacrifice curriculum time to make room for this new program. Also, recruiting the large number of faculty, particularly physicians, needed to run the program has been difficult. Finally, the organization of the curriculum, with basic sciences in the morning and the ICE in the afternoon, may inadvertently reinforce the conceptual split between the biomedical and psychosocial dimensions of medicine. Efforts are under way to address this problem by exploring ways to intergrate the curriculum better.

The Interdisciplinary Generalist Project at the University of Nebraska Medical Center.

The Interdisciplinary Generalist Curriculum (IGC) Project at the University of Nebraska College of Medicine (Nebraska) had three goals: (1) to increase first- and second-year students' exposure to primary care practice in the community; (2) to develop specific educational programs introducing these students to the principles and practices of primary care medicine; and (3) to establish a generalist coordinating council to provide leadership and to nurture generalist educational initiatives in the College of MEDICINE: Students at Nebraska were already required to spend three half-days a semester in a longitudinal clinical experience (LCE) and to complete a three-week primary care block experience in the summer between the first and second years. IGC Project funds were used increase the number of required LCE visits to five a semester and to develop curricular enhancements that would maximize the educational potential of community-based clinical experiences for first- and second-year students. Curricular elements developed included a focus on faculty development for preceptors and development of the Primary Care Introduction to Medicine Curriculum, an eight-week, interdisciplinary module scheduled late in the first year to help prepare students for intensive summer rotations. Other developments were the implementation of a pediatric physical examination experience for first-year students and the implementation of instruction in community-oriented primary care in the second year. Lessons learned are related to: (1) the value and power of early clinical experiences; and (2) the enhancing effect of a holistic, longitudinal view of the curriculum on the planning of early clinical experiences.

Disability, stigma and deviance.

An important contribution social science research makes to understanding the experiences of disabled individuals in the U.S. is to illuminate the influence of stigma and deviance on those experiences. Because perceptions of negative difference (deviance) and their evocation of adverse responses (stigma) have been and continue to be widespread, it is these with which alternate perceptions and responses vie in the construction of disability's symbolic and practical meanings. While some research demonstrates a regrettable imposition of stigma/deviance into the lives and minds of disabled people, some of it shows disabled people resisting stigma/deviance imputations; and some of it suggests that such imputations are losing force as new ways of thinking about the meaning of disability gain sway.

Disclosure of traumas and psychosomatic processes.

Results from a series of studies are summarized in support of a general theory of inhibition and psychosomatics. According to this view, to inhibit thoughts, feelings, or behaviors is associated with physiological work. In the short term, inhibition results in increased autonomic nervous system activity. Over time, inhibition serves as a cumulative stressor that increases the probability of psychosomatic disease. Actively avoiding thoughts and feelings surrounding a trauma and/or not discussing a trauma is a particularly insidious form of inhibition. The results from recent surveys and experiments indicate: (a) childhood traumatic experiences, particularly those never discussed, are highly correlated with current health problems; (b) recent traumas that are not discussed are linked with increased health problems and ruminations about the traumas; (c) requiring individuals to confront earlier traumas in writing improves health and immune system functioning; (d) actively talking about upsetting experiences is associated with immediate reductions in selected autonomic activity. Implications of these findings for our understanding of disclosure, trauma, and disease are discussed.

Do program directors and their chief residents view the role of chief resident similarly?

BACKGROUND: The chief resident plays an important role in family practice residencies and is positioned at the nexus of the relationship between the faculty and the residents. It is unknown if program directors and their respective chief residents view this position and the role of training and faculty development similarly. METHODS: Parallel surveys were sent to all family practice residency program directors and their respective chief residents to explore their perceptions of the importance of the tasks and roles of the chief resident and the effects that perceived training, feedback, and support have on the chief resident's satisfaction. RESULTS: Fifty-one percent of chief residents and their program directors returned surveys that could be analyzed in parallel. Program directors placed relatively greater importance on the administrative role of chiefs. Mentioned most frequently as problems were balancing administrative duties with other tasks, dealing with personnel issues, and working with the lack of a clear job description. Chiefs who participated in formal training programs and who perceived better burnout prevention were more satisfied with their position. CONCLUSIONS: A large number of chief residents perceived gaps in the preparation for their position, particularly with regard to administrative skills. These deficiencies are particularly ironic in light of program directors' perceptions that administrative duties are of the highest importance among the tasks assigned to chief residents. Faculty development strategies and a program of burnout prevention for chief residents should be incorporated into each residency.

Continuity of care and outcome in nursing home patients transferred to a community hospital.

This study prospectively investigated the effect of continuity of primary physician care on functional ability and outcome of nursing home patients transferred to a community hospital. Evaluated were 335 consecutive transfers with concurrent chart review and a standardized functional rating scale on admission and discharge from the hospital. Continuity of care by the primary physician was more likely with a greater length of stay. There was no association of continuity with age, sex, initial functional status or mental status of the patient, type of admission, or payment source. No significant relationship was found between outcome and continuity of care by the primary physician. Logistic regression analysis indicated that emergency admission to the hospital conferred an increased risk of mortality but that the level of primary physician continuity did not.

An overview of clinical policies with implications for clinical practice, medical education, and research.

Clinical policies, also known as practice parameters or practice guidelines, are gaining notoriety out of a desire to control escalating medical costs, lessen wide practice variations, and improve quality of care. The clinical policies are supposed to influence medical decision making by summarizing scientific data about a clinical problem in a format that is easily understood by patient and physician alike. Developing an evidence-based policy involves: a clearly defined clinical problem, a comprehensive literature review, a summary table of the data (known as an evidence table), a presentation of this data as outcome possibilities from alternative decisions (in the form of a balance sheet), and creation of clinical recommendations that incorporate both financial costs and patient preferences. Well-developed policies can be used by family physicians as guides in areas of clinical uncertainty and by medical educators as up-to-date literature syntheses for teaching critical appraisal and for outlining approaches to common problems. Explicit policy formulation also highlights the shortcomings of existing literature and can suggest more appropriate future research. The future of the clinical policy movement rests on its ability to reduce costs of care and improve patient outcomes. Explicit clinical policy formulation incurs significant development and implementation costs and the evidence on which many policies are based is lacking. Nevertheless, clinical policies in some form are likely to play an increasing role in medical care.

Benign intracranial hypertension.

Benign intracranial hypertension (pseudotumor cerebri) is a syndrome of intracranial hypertension that classically presents with headaches and visual disturbance. Physical examination discloses papilledema. Diagnosis is confirmed by a normal cranial computed tomographic scan or magnetic resonance image and the presence of a markedly increased opening pressure on lumbar puncture. Treatment is directed to underlying causes, hypertension, and withdrawal of offending medications. Repeated lumbar puncture, diuretic therapy, and surgery are occasionally used. Careful follow-up and visual testing are imperative.

Postpartum depressive disorders.

Despite the high prevalence of postpartum depressive disorders, many signs and symptoms of this illness are dismissed as normal physiologic changes associated with childbirth. Prompt recognition and treatment are imperative in order to limit the negative impact on both the mother and infant. Mood disturbances may have a minor functional impact that respond well to social support (eg. postpartum blues) or cause significant functional compromise requiring more aggressive therapy (eg. postpartum depression). The most extreme case of postpartum depressive disorder, postpartum psychosis, occurs when patients develop psychosis, mania, or thoughts of infanticide. Depression during pregnancy or the presence of risk factors suggests the need for careful follow-up. If postpartum depression develops, psychotherapy is the first-line treatment. Antidepressant treatment may be warranted for some patients, and the risks and benefits to both the mother and infant should be considered in the decision to institute pharmacotherapy.

Sleep in the elderly: a practical approach.

The elderly commonly complain about the quality and quantity of their sleep. The family physician can assess accurately such symptoms in the office. It is important for the physician to recognize age-related changes in sleep and obtain an accurate history. The correction of environmental disruptions and transient psycho-physiologic problems, the critical evaluation of drug use, and the treatment of underlying medical conditions are important first steps in addressing the complaint of insomnia. Appropriate sleep hygiene and pharmacologic therapy can be helpful in many instances. The family physician, however, must remember that primary sleep disorders are more common in the elderly, and sleep-center referral should be considered if such a disturbance is suspected or if problems persist after conservative therapy.

Physician counseling for smoking cessation: is the glass half empty?

BACKGROUND: Professional groups urge physicians to aggressively counsel their patients who smoke, but research evaluating the effectiveness of physician counseling has produced mixed results. METHODS: Four hundred ten smokers identified in a previous study were contacted 1 year later to determine whether they had quit smoking. In both studies, smokers were asked whether their physicians had counseled them in any of six specific ways (eg, advising the patient of personal health risks and the need to stop smoking, or discussing cessation methods). RESULTS: Seventy-nine percent of patients reported that their physician counseled them either at the initial visit or at some time during the following year; 42% reported having tried to quit at least once during the year, but only 5.9% were nonsmokers at 1-year follow-up. Physician counseling had no effect on the rate of successful attempts to quit. Patients with serious health problems were more likely to be counseled and to attempt to quit (P < .02). Non-Hispanic white patients were more likely to be counseled but less likely to attempt to quit (P < .01). CONCLUSIONS: Counseling by physicians appears to motivate some patients to attempt to quit, but this study did not show significant improvement in actual quit rates in patients who were counseled by a physician.

A framework for understanding visits by frequent attenders in family practice.

OBJECTIVE: Our purpose was to develop a typology of outpatient visits between family physicians and adult "frequent attender" patients. STUDY DESIGN: This was a cross-sectional observational study using qualitative analysis of family physician visits. Three family physician researchers reviewed detailed field notes for each patient based on direct observation of a single office visit to determine major themes and characteristics of physician-patient encounters. POPULATION: Non-pregnant adults in the top 5% for visit frequency, and age-and sex-mated non-frequent attenders were identified from among 1194 adult patients in 18 Midwestern family practice offices as part of The Prevention and Competing Demands in Primary Care Study. RESULTS: Visits by 62 patients who had made at least 25 visits in the previous 2 years were selected (frequent attender visits). Three major dimensions emerged to distinguish different encounter types: (1) biomedical complexity, (2) psychosocial complexity, and (3) the degree of dissonance between the patient and the physician. These 3 dimensions were used in a descriptive framework to characterize visit types as: simple medical, ritual visit, complicated medical, the tango, simple frustration, psychosocial disconnect, medical disharmony, and the heartsink visit. CONCLUSIONS: The discovery of a wide variation of encounter types among adult frequent attenders and the resulting descriptive framework laid a foundation for defining the appropriateness of outpatient health care utilization, for designing interventions to reduce inappropriate utilization, and for educating physicians regarding effective management of frequent attender patients.

Primary care physicians' perceptions of diabetes management. A balancing act.

BACKGROUND: Studies demonstrate significant shortfalls in the quality of care for diabetes. Primary care physicians' views of the management of diabetes have been inadequately explored. The objective of our study was to describe primary care physicians' attitudes toward diabetes, patients with diabetes, and diabetes care. METHODS: In-depth interviews were conducted by a trained research interviewer with a sample of 10 family physicians and 9 internists in Connecticut. Interviews lasted an average of 60 minutes and were audiotaped and transcribed. Data were interpreted by a multidisciplinary team using a standard qualitative text analysis methodology. Themes from each interview were used to identify and develop overall themes related to the areas of inquiry. RESULTS: Physicians' goals were congruent with current guidelines emphasizing the importance of good glycemic control and prevention of complications. However, physicians noted the challenge of balancing the multiple goals of ideal diabetes care and the realities of patient adherence, expectations, and circumstances. The majority of physicians described a patient-centered management style, but a substantial minority described a more paternalistic approach. Physicians did not identify or describe office systems for facilitating diabetes management. Differences between family physicians and internists did not emerge. CONCLUSIONS: The complexity of diabetes care recommendations coupled with the need to tailor recommendations to individual patients produces wide variation in diabetes care. Improvement in care may depend on (1) prioritizing diabetes care recommendations for patients as individuals, (2) improving physicians' motivational counseling skills and enhancing their ability to deal with challenging patients, and (3) developing office systems and performance enhancement efforts that support cost-effective practice and patient adherence.

Technician, friend, detective, and healer: family physicians' responses to emotional distress.

OBJECTIVE: We sought to develop a typology of physicians' responses to patients' expressed mental health needs to better understand the gap between idealized practice and actual care for emotional distress and mental health problems. STUDY DESIGN: We used a multimethod comparative case study design of 18 family practices that included detailed descriptive field notes from direct observation of 1637 outpatient visits. An immersion/crystallization approach was used to explore physicians' responses to emotional distress and apparent mental health issues. POPULATION: A total of 379 outpatient encounters were reviewed from a purposeful sample of 13 family physicians from the 57 clinicians observed. OUTCOMES MEASURED: Descriptive field notes of outpatient visits were examined for emotional content and physicians' responses to emotional distress. RESULTS: Analyses revealed a 3-phase process by which physicians responded to emotional distress: recognition, triage, and management. The analyses also uncovered a 4-quadrant typology of management based on the physician's philosophy (biomedical vs holistic) and skill level (basic vs more advanced). CONCLUSIONS: Physicians appear to manage mental health issues by using 1 of 4 approaches based on their philosophy and core set of skills. Physician education and practice improvement should be tailored to build on physicians' natural philosophical proclivity and psychosocial skills.