March 2005
March/April 2005 Annals of Family Medicine tip sheet
Consumption of High Levels of Dietary Iron Linked to Increased Cancer Risk for Patients Predisposed to Iron Overload
High-protein diets that include a lot of iron-containing foods, such as the increasingly popular Atkins diet, may not be the best choice for everybody, according to a new study out of the Medical University of South Carolina. Analyzing population-based data from U.S. National Health and Nutrition Examination Surveys, Mainous and colleagues found that people with elevated levels of serum transferrin saturation – an indicator of iron overload – who consume high levels of dietary iron, have an increased risk of cancer and cancer mortality.
Specifically, they found that people with elevated levels of transferrin saturation who ingest more than 18 mg of iron per day have a 2.24 times greater relative risk of cancer than those who have normal transferrin saturation levels and report low dietary iron intake. Having high transferrin saturation with a normal diet did not carry increased risk. The authors point out that a substantial proportion of adults in the United States – approximately 7 percent of the adult U.S. population – has transferrin saturation levels greater than 41 percent, and are at increased risk.
The authors suggest that simple dietary restrictions may help to reduce the cancer risk associated with high transferrin saturation. They add that these findings call into question the strategy of the addition of iron to food by manufacturers.
Transferrin Saturation, Dietary Iron Intake, and Risk of Cancer
By Arch G. Mainous III, et al
Family-level Influences Have a Significant Impact on Individuals' Health
With health care systems increasingly focusing on the individual, new research out of the University of Texas Health Science Center shows the need for a concurrent focus on the family's role in health. Analyzing data from more than 35,000 people who participated in the national Community Tracking Survey, researchers found that a significant proportion of general health status can be attributed to family-level influences. Depending on the family configuration, the data indicate that between 4.5 and 26.1 percent of the variance in individual health status was derived from the family, with the shared characteristics of income and health insurance accounting for only a modest portion of the effect. While the study does not seek to disentangle the contribution of specific family-level determinants to health status, because of the study design, the authors conclude that most of the family-level effects derive not from shared genetics but from shared features of the family environment, such as health beliefs and behaviors, physical environments, common stresses, and interpersonal relations that can be either beneficial or harmful to health. The authors and two editorialists suggest that health policy interventions should place more emphasis on the family's role in health.
The Family Contribution to Health Status: A Population-Level Estimate
By Robert L. Ferrer, M.D., M.P.H., et al
Physicians, Families, and Population Health By Jim House, Ph.D., et al
U.S. Preventive Services Task Force Updates Glaucoma Screening Recommendations
In a new Recommendation Statement and accompanying evidence review, the U.S. Preventive Service updates its 1996 recommendations for glaucoma screening, finding insufficient evidence to recommend for or against screening adults for glaucoma. Despite some evidence that treatment to lower intraocular pressure may delay the progression of visual field deficits in some patients, a long-term health benefit of early recognition and treatment of glaucoma in preventing severe vision loss and disability in asymptomatic patients was not found. Thus, the new statement represents no change from the Task Force's 1996 recommendation. In its recommendation, the Task Force notes that the potential benefits of screening and treatment must be weighed against the known harms, which include local eye irritation and an increased risk for cataracts. Primary open-angle glaucoma, the most common type of glaucoma, is a leading cause of blindness and vision-related disability, affecting an estimated 2.5 million people in the United States.
Screening for Glaucoma: Recommendation Statement
U.S. Preventive Services Task Force
Screening for Primary Open-Angle Glaucoma in the Primary Care Setting: an Update for the U.S. Preventive Services Task Force
By Craig Fleming, M.D., et al
Blacks and Latinos Prefer and Are More Satisfied with Physicians of the Same Race
Latino and black patients who perceive racism in the health care system prefer and are more satisfied with physicians from the same race or ethnicity, according to a new study. Analyzing a national survey of more than 3,800 blacks, Latinos and whites, Chen and colleagues find that nearly one quarter of blacks and one third of Latinos prefer that their personal physician is of their same race or ethnicity. In turn, those patients who have racial preferences for their physicians are more likely to rate their physician highly if they are in a race-concordant relationship. Blacks who prefer a black physician and have a black physician are nearly three times as likely to rate their physician as excellent than are blacks who prefer a black physician and have a non-black physician (57 percent vs. 20 percent). Though not statistically significant, Latinos who prefer and have a Latino physician rate their physician higher than Latinos who prefer a Latino physician but have a non-Latino physician (40 percent vs. 29 percent). The authors suggest that these findings may point to ways to address racial and ethnic disparities in health care. Addressing discrimination in the health care system, increasing access to minority physicians and improving the ways patients can choose physicians may be more potent options for reducing disparities than simply increasing the number of minority physicians and attempting to teach cultural competence.
Patients' Beliefs about Racism, Preferences for Physician Race, and Satisfaction with Care
By Frederick M. Chen, M.D., M.P.H., et al
Continuity of Care Associated with Improved Health Care Outcomes
While the discipline of family medicine has always been predicated on a core assumption that interpersonal continuity of care – the ongoing relationship between an individual doctor and patient – is important, individual studies measuring its impact on health care outcomes and cost have yielded conflicting results. In a critical review that synthesizes the findings of 41 research studies, researchers found a significant association between interpersonal continuity and improved preventive care and lower rates of hospitalization. Although even fewer studies addressing the association between continuity and cost exist, a review of 20 studies found an association between interpersonal continuity and lower cost variables.
Interpersonal Continuity of Care and Care Outcomes: A Critical Review
By John W. Saultz, M.D., et al
Contrary to Common Physician Perceptions, Care Coordination Does Not Increase Liability Risks
Although the coordination of care for patients with multiple chronic conditions is a fundamental function of primary care, many physicians are reluctant to take on expanded care coordination for fear of increased exposure to medical liability. In fact, a representative sample of 1,238 practicing physicians found that 49 percent listed legal liability as one of the two main barriers to care coordination. In a new study that combines legal research with key informant interviews, Hall and colleagues find no strong basis for these reservations; instead, they find that care coordination done well may lower liability risks. Liability insurers interviewed as part of the study indicated no reluctance to insure physicians who coordinate care for patients with multiple chronic conditions and no strong tendency to attribute higher risk to this role.
Liability Implications of Physician-Directed Care Coordination
By Mark A. Hall, J.D., et al
OTHER STUDIES IN THIS ISSUE:
Outpatient Colonoscopies Can be Performed Safely and Competently by Trained Family Physicians
Analyzing data from 731 colonoscopies performed by two rural family physicians, researchers find that colonoscopies can be performed safely and competently by properly trained family physicians in the outpatient setting. With the increasing demand for colonoscopy screening outstripping the capacity of gastroenterologists, these findings should encourage more family physicians to seek training in this procedure.
Outpatient Colonoscopy by Rural Family Physicians
By Robert J. Newman, M.D., et al
Study Offers Insight into the Services Provided by Acupuncturists
Given the increasing popularity of acupuncture in the United States, this study describes the range of conditions treated by acupuncturists and their approach to patient care, with the aim of helping physicians and patients understand what services acupuncturists provide.
The Practice of Acupuncture: Who Are the Providers and What Do They Do?
By Karen J. Sherman, Ph.D., et al
Patient Earth: A Call for Physicians to Adopt a Broader Perspective on Health and Disease
In a thoughtful essay, a family physician calls for caregivers to adopt an ecosystem health perspective – helping people avoid unwanted pregnancies, using resources prudently, staying engaged in the natural world – to help prevent the collapse of the biological systems upon which all we all depend.
Ecological Change and the Future of the Human Species: Can Physicians Make a Difference
By Roger A. Rosenblatt, M.D., M.P.H., M.F.R., et al
Effectiveness of Cancer Screening Intervention Still Evident Though Diminished Over Time
Reporting the 24-month follow-up data on an intervention to foster increased cancer screening in community centers, researchers found the intervention had a persistent, although modest, effect on screening after two years. Patients who received care at an intervention clinic were up-to-date on a greater number of targeted screening tests and had 26 percent greater odds of mammography screening compared to patients at control clinics. Although still apparent, intervention effects on screening at 24 months had clearly diminished relative to effects observed at 12 months.
Long-term Results from a Randomized Controlled Trial to Increase Cancer Screening Among Attendees of Community Health Centers
By Richard G. Roetzheim, M.D., M.S.P.H., et al
Unsedated Ultrathin Esophagoscopy Feasible in Primary Care
The first to examine the use of a new technology – ultrathin esophagoscopy – to examine unsedated patients for Barrett's esophagus in a primary care setting, this study found that most patients (95 percent) tolerated the procedure. These findings demonstrate the feasibility of primary care physicians performing this procedure on unsedated outpatients.
Office-Based Unsedated Ultrathin Esophagoscopy in a Primary Care Setting
By Thad Wilkins, M.D., et al
Study Examines Family Physicians' Decision-Making Styles
Analyzing how 18 family physicians made decisions during patient visits, this study found that family physicians have specific, highly individualized, task-structuring styles. Moreover, researchers found commonalities between their study of family physicians and previous analyses of expert decision makers in other fields. They call for tailoring practice improvement efforts to the different cognitive styles of physicians.
Opening the Black Box: Cognitive Strategies in Family Practice
By Robert E. Christensen, M.D., et al
Annals of Family Medicine is a peer-reviewed research journal that provides a cross-disciplinary forum for new, evidence-based information affecting the primary care discipline. Launched in May 2003, the journal is sponsored by six family medical organizations, including the American Academy of Family Physicians, the American Board of Family Practice, the Society of Teachers of Family Medicine, the Association of Departments of Family Medicine, the Association of Family Practice Residency Directors and the North American Primary Care Research Group. Annals is published six times each year and contains original research from the clinical, biomedical, social and health services areas, as well as contributions on methodology and theory, selected reviews, essays and editorials. A board of directors with representatives from each of the sponsoring organizations oversees Annals. Complete editorial content and interactive discussion groups for each published article can be accessed free of charge on the journal's Web site, www.annfammed.org.