Established in 1927 by the American College of Physicians


3 November 2009 Annals of Internal Medicine Tip Sheet

Annals of Internal Medicine is published by the American College of Physicians on the first and third Tuesday of every month. These highlights are not intended to substitute for articles as sources of information. For a copy of an article, call 1-800-523-1546, ext. 2656, or 215-351-2656, or visit Past highlights are accessible as well.

Early Releases:

1. Report Questions Whether Family Health History Disclosure Improves Clinical Decision Making

Systematic collection of family history is a potentially important step in personalizing healthcare. Family health history can reveal important information about a patient, and may prompt specialist investigation or positive lifestyle changes. However, the accuracy of patient-provided information is limited by the individual’s awareness, understanding, recollection, and willingness to disclose family health issues. For example, researchers found that patients were more accurate when reporting lack of disease in a family history than in reporting the presence of disease. Researchers reviewed all available studies published between 1995 and March 2009 to clarify the role of family history, its validity in the primary care setting, and its effect on individual and population health outcomes on common illnesses. They found insufficient evidence that family health history improves clinical decision making. Many questions remain regarding whether information gained from family history assessment improves risk prediction and chronic disease management. In addition, there is no standard method for capturing family health history. Tools are in development to allow family history information to be effectively incorporated into health information technology systems.

In this Issue:

2. Community-based Interventions Effective at Reducing Blood Pressure for Patients in Developing Countries

Cardiovascular disease is the leading cause of death in adults worldwide. There is convincing evidence that lowering blood pressure decreases cardiovascular morbidity and mortality. However, blood pressure control rates remain poor in developing countries. Poor health literacy, unhealthy lifestyles, and lack of awareness contribute to the problem. Researchers sought to assess how physician training and home health care education could affect blood pressure in patients with hypertension living in Karachi, Pakistan. Researchers randomly assigned 1,341 patients in 12 communities to general practitioner education, home health visits by trained lay workers, both, or neither. Patients in communities assigned to a combination of both interventions had the greatest improvements in systolic blood pressure after two years.

3. Primary Care Physician Pap Screening Practices Not Consistent with Major Guidelines

In 2002 and 2003, three prominent heath organizations modified their cervical cancer screening recommendations to reflect new information about human papillomavirus. The guidelines recommended decreasing the frequency of cervical cancer screening in some risk groups. To assess the impact of these guideline revisions, researchers conducted a survey of 1,212 primary care physicians about current cervical cancer screening recommendations and practices. Researchers used clinical vignettes describing women by age and by sexual and screening history to elicit physicians’ recommendations for Pap screening. Less than one fourth of physicians reported guideline-consistent recommendations for Pap screening. In general, physicians overused Pap screening, which is expensive for the health care system, and may result in unnecessary follow-up testing and distress for patients. Gynecologists were least likely and internists were most likely to report care that agreed with recommendations.

4. Biologics Effective, But Not Cost-Effective for Very Early Treatment of Rheumatoid Arthritis

Evidence suggests that very early treatment may lead to long-term control or remission of rheumatoid arthritis (RA). However, medical science has yet to identify the optimal first therapeutic strategy. Researchers reviewed published data and actual hospital costs to assess the potential cost-effectiveness of major therapeutic strategies for very early RA. The researchers compared three management strategies: a “pyramid” strategy with initial nonsteroidal anti-inflammatory drugs, patient education, pain management, low dose glucocorticoids, and disease-modifying antighumatic drugs (DMARDs) only at one year; early DMARD therapy with methotrexate; and early therapy with biologics and methotrexate. The analysis showed that early initiation of conventional DMARDs or early biologics was preferred, but the additional costs of early biologics may not be justified for all patients. The most rational use of resources is prompt initiation of conventional DMARD therapy for patients with very early RA.