A participatory model of the paradox of primary care.

PURPOSE: The paradox of primary care is the observation that primary care is associated with apparently low levels of evidence-based care for individual diseases, but systems based on primary care have healthier populations, use fewer resources, and have less health inequality. The purpose of this article is to explore, from a complex systems perspective, mechanisms that might account for the effects of primary care beyond disease-specific care. METHODS: In an 8-session, participatory group model-building process, patient, caregiver, and primary care clinician community stakeholders worked with academic investigators to develop and refine an agent-based computer simulation model to test hypotheses about mechanisms by which features of primary care could affect health and health equity. RESULTS: In the resulting model, patients are at risk for acute illness, acute life-changing illness, chronic illness, and mental illness. Patients have changeable health behaviors and care-seeking tendencies that relate to their living in advantaged or disadvantaged neighborhoods. There are 2 types of care available to patients: primary and specialty. Primary care in the model is less effective than specialty care in treating single diseases, but it has the ability to treat multiple diseases at once. Primary care also can provide disease prevention visits, help patients improve their health behaviors, refer to specialty care, and develop relationships with patients that cause them to lower their threshold for seeking care. In a model run with primary care features turned off, primary care patients have poorer health. In a model run with all primary care features turned on, their conjoint effect leads to better population health for patients who seek primary care, with the primary care effect being particularly pronounced for patients who are disadvantaged and patients with multiple chronic conditions. Primary care leads to more total health care visits that are due to more disease prevention visits, but there are reduced illness visits among people in disadvantaged neighborhoods. Supplemental appendices provide a working version of the model and worksheets that allow readers to run their own experiments that vary model parameters. CONCLUSION: This simulation model provides insights into possible mechanisms for the paradox of primary care and shows how participatory group model building can be used to evaluate hypotheses about the behavior of such complex systems as primary health care and population health.

Evaluation of the Solitary Pulmonary Nodule.

A solitary pulmonary nodule is a common radiologic finding that is often discovered incidentally and may require significant workup to establish a definitive diagnosis. A solitary pulmonary nodule is a well-circumscribed round lesion measuring up to 3 cm in diameter and surrounded by aerated lung. Once a nodule is discovered, clinical and radiologic features and quantitative models can be used to determine the likelihood of malignancy. Evaluation is guided by nodule size and assessment of probability of malignancy. Surgical resection or nonsurgical biopsy should be performed in patients with solid or subsolid solitary pulmonary nodules that show clear growth on serial imaging. Solid solitary pulmonary nodules that have been stable for at least two years typically do not need further evaluation. The workup for patients with solid solitary pulmonary nodules measuring 8 mm or greater in diameter, nodules measuring less than 8 mm in diameter, and subsolid nodules should be guided by the probability of malignancy, imaging results, and the risks and benefits of different management strategies. Management should be individualized according to patient values and preferences. Medicare now covers lung cancer screening with low-dose computed tomography for high-risk patients 55 to 77 years of age at institutions that can provide a comprehensive approach to the management of solitary pulmonary nodules.

Prevalence of metabolic syndrome among urban community residents in China.

BACKGROUND: Metabolic risk factors and abnormalities such as obesity and hypertension are rapidly rising among the Chinese population following China's tremendous economic growth and widespread westernization of lifestyle in recent decades. Limited information is available about the current burden of metabolic syndrome (MetS) in China. METHODS: We analyzed data on metabolic risk factors among 22,457 adults aged ≥ 32 years participating in the "Zhabei Health 2020" survey (2009-2010), a cross-sectional study of a representative sample of community residents in Zhabei District. We defined MetS using Chinese-specific cut-off points for central obesity according to consensus criteria recently endorsed by several international and national organizations in defining MetS in different populations worldwide. We used a multiple logistic regression model to assess the associations of potential risk factors with MetS. RESULTS: The unadjusted prevalence of the MetS was 35.1% for men and 32.5% for women according to the consensus criteria for Chinese. The prevalence increased progressively from 12.1% among participants aged 32-45 years to 45.4% among those aged ≥ 75 years. Age, smoking, family history of diabetes, and education are significantly associated with risk of MetS. CONCLUSIONS: The MetS is highly prevalent and has reached epidemic proportion in Chinese urban adult community residents.

An overview of pediatric dysphagia.

Difficulty swallowing or dysphagia can be present in children and adults alike. Pediatric dysphagias have long been recognized in the literature. Certain groups of infants with specific developmental and/or medical conditions have been identified as being at high risk for developing dysphagia. Still others may present with a swallowing or feeding problem as their primary symptom. Left untreated, these problems in infants and children can lead to failure to thrive, aspiration pneumonias, gastroesophageal reflux, and/or the inability to establish and maintain proper nutrition and hydration. Awareness of the prevalence of pediatric dysphagia in today's population and the signs and symptoms of this condition aids in its treatment. Early detection of dysphagia in infants and children is important to prevent or minimize complications. This article provides a review of symptoms, etiologies, and resources available regarding management of this condition to help the primary care physician and the families of young children and infants in its management.

Stuttering: an overview.

Speech dysfluency (stuttering) is common in children. Although stuttering often resolves before adulthood, it can cause significant anxiety for children and their families. Stuttering speech patterns are often easily identifiable; when a child is learning to talk, repetition of sounds or words, prolonged pauses, or excessively long sounds in words usually occur. Secondary behaviors (e.g., eye blinking, jaw jerking, involuntary head or other movements) that accompany stuttering can further embarrass the child, leading to a fear of speaking. The etiology of stuttering is controversial, but contributing factors may include cognitive abilities, genetics, sex of the child, and environmental influences. Research has shown that more than 80 percent of stuttering cases are classified as developmental problems, although stuttering can also be classified as a neurologic or, less commonly, psychogenic problem. The initial assessment of patients who stutter addresses the severity of dysfluency; secondary behaviors; and the impact of stuttering, such as patient distress. Further testing is useful in assessing the need for therapy. Pharmacologic therapy has not been shown to improve stuttering. Encouraging patients to talk slowly and the use of fluency-shaping mechanisms such as delayed auditory feedback devices to slow the speech rate can help minimize or eliminate stuttering. For patients with persistent stuttering, controlled fluency or stuttering modification therapy may be effective.

Antiplatelet therapy for atherothrombotic disease: an update for the primary care physician.

Atherothrombosis is a progressive and generalized pathologic process that affects the vascular system. Clinical manifestations of atherothrombosis depend on the affected vascular bed and include acute coronary syndromes, stroke, and peripheral arterial disease. Ischemia associated with atherothrombosis is highly prevalent, affecting millions of people each year. Many patients experience multiple ischemic events within the first year of an initial event. The mainstay for prevention includes risk factor management through lifestyle modification and treatment of underlying disease. Guidelines have been published for secondary prevention of atherothrombosis-related cardiovascular disease, including use of various long-term pharmacotherapies, such as antiplatelet agents, statins, and angiotensin-converting enzyme inhibitors. Implementation of effective treatment strategies requires an awareness of the guidelines by physicians to ensure that both acute therapy and long-term management are addressed. This review is based on treatment guidelines and selected peer-reviewed publications identified through a MEDLINE and PubMed literature search, primarily from January 1996 to December 2006, that relate to clinical trials of antiplatelet therapy in patients with atherothrombotic disease. Secondary prevention strategies for patients with atherothrombosis are discussed, highlighting current guideline recommendations and programs designed to encourage a continuum of care from the acute to the ambulatory setting.

A comparison of ambulatory services for patients with managed care and fee-for-service insurance.

OBJECTIVES: To determine whether family physicians provide different ambulatory care to patients with health insurance from managed care organization (MCO) versus fee-for-service (FFS) plans. STUDY DESIGN: Multimethod cross-sectional observational study. PATIENTS AND METHODS: A total of 4454 patients made office visits to 138 family physicians in northeastern Ohio. Direct observation with the Davis Observation Code and a structured checklist were used to assess the process of care. Patient satisfaction was measured with the Medical Outcomes Study 9-Item Visit Rating Form. RESULTS: Among 1588 patients with MCO insurance and 876 with FFS insurance, no differences were noted in the number of visits per year, length of visits, percentage of visits for well care, or the percentage of visits in which medicines were prescribed in analyses controlling for patient mix. Visits by patients with MCO insurance were more likely to involve referrals to another physician than visits by patients with FFS insurance. Patient satisfaction and time use during visits were comparable for the 2 groups. CONCLUSIONS: Managed care insurance appears to increase involvement of the primary care provider in the referral process. However, in a healthcare market with moderate managed care penetration in which the same physicians see patients with different types of insurance, the process of care is affected little by type of insurance coverage.