May/June 2008 Annals of Family Medicine tip sheet

The Unintended Consequences of Pay-for-Performance Programs

At a time when pay-for-performance programs are proliferating, this study finds that while such programs may succeed in improving clinical outcomes and increasing physician income, they also change the nature of patient consultations and the way doctors and nurses work together. In-depth interviews with 41 family physicians and nurses working in the United Kingdom three years after implementation of a new pay-for-performance initiative revealed that participants believed the aims of the program had been met in terms of improvements in disease-specific processes of patient care and physician income, as well as improved data capture. Participants also reported unintended consequences of the program, including reduced continuity of care and care fragmentation. While acknowledging the positive impact of the program, many physicians expressed concern that the guideline-driven process of care leaves them feeling they are becoming less skilled, are losing their sense of place in the enterprise and are less connected with patients.

The Experience of Pay for Performance in English Family Practice: A Qualitative Study
By Stephen M. Campbell, Ph.D., et al

Efficacy and Side Effects of Treatment for Restless Legs Syndrome

A meta-analysis of 14 trials involving 3,197 patients with restless legs syndrome finds that although drug therapy using nonergot dopamine agonists – the mainstay of therapy for patients with the condition – reduces the severity of symptoms, significant numbers of patients discontinue their use because of adverse side effects, including nausea, dizziness, drowsiness and fatigue. Further analysis suggests these treatments are most beneficial in the first weeks of therapy, with their effects diminishing somewhat over time. The researchers call for future research to compare directly the efficacy of individual nonergot dopamine agonists with each other, as well as to include a longer follow-up period to assess the long-term effects of these agents.

Effect of Nonergot Dopamine Agonists on Symptoms of Restless Legs Syndrome
By William L. Baker, Pharm.D., et al

Age-Related Pulmonary Crackles Often Benign

Kataoka and Matsuno describe the often benign nature of pulmonary crackles – discontinuous, interrupted, explosive respiratory sounds heard during inspiration – in many older patients. Examining a panel of 274 patients 45 to 95 years old, they found many had audible pulmonary crackles, even in the absence of apparent cardiac dysfunction and comorbid pulmonary disease. The older the age-group, the more frequently the patients had audible pulmonary crackles. In fact, the findings show that the risk for audible crackles increased approximately threefold every 10 years after 45 years of age in patients with cardiovascular disease and apparently normal heart function. They conclude that the recognition of age-related crackles is important, because such clinically unimportant crackles are so common among elderly patients that, without knowledge of this phenomenon, their existence might interfere with the physician’s management of patients with suspected heart failure or presumable pulmonary disease.