How Low is Too Low? Relatively Lower Blood Pressure is Associated with Cognitive Decline
In people age 75 and older who are being treated for hypertension, systolic blood pressure less than 130 mm Hg is associated with additional cognitive decline, particularly in individuals with complex health problems. Researchers in The Netherlands analyzed data for 1,266 participants in the Integrated Systematic Care for Older Persons study. Patients were stratified by systolic blood pressure in the year before baseline, and change was evaluated from baseline to one-year follow-up in outcome measures evaluating cognitive function (the Mini-Mental State Examination), activities of daily living, and quality of life. For participants being treated for hypertension, there was a clear trend across categories of systolic blood pressure: with lower systolic blood pressure, cognitive declined worsened at one-year follow-up. For participants being treated for hypertension and with systolic blood pressure less than 130 mm Hg, cognitive decline in one year averaged 0.90 points on the Mini-Mental State Examination, compared to 0.14 points for those with systolic blood pressure greater than 150 mm Hg, a 0.76-point less decline. The results were similar for participants with complex health problems (n=674) Compared to the reference group (systolic blood pressure less than 130 mm Hg), participants showed less cognitive decline after one year by 0.99 points on the Mini-Mental State Examination when systolic blood pressure was 130-150 mm Hg and by 1.39 points when systolic blood pressure was greater than 150 mm Hg. Daily functioning and quality of life were the same across the strata of systolic blood pressure and antihypertensive treatment. The authors call for more studies to determine if there is a causal relationship between systolic blood pressure and cognitive decline and to understand the mechanism of the association observed. Until the results of new trials are available, they state, clinicians must decide on the appropriate treatment for hypertension in older patients.
Systolic Blood Pressure and Cognitive Decline in Older Adults With Hypertension
Prof Jacobijn Gussekloo, MD, PhD, et al.
Leiden University Medical Center, Leiden, The Netherlands
Loneliness is Common in Primary Care Patients
Twenty percent of adult patients making routine primary care visits report being lonely, according to a new study, and the prevalence is higher in younger patients. A survey of 1,235 primary care patients in Colorado and Virginia found that 246 (20 percent) reported lack of companionship, feeling left out, and feelings of isolation from others. The prevalence of loneliness decreased with age, with 33 percent (18/58) of respondents less than 25 years old reporting loneliness compared to 11 percent (34/307) of those over 65 years old. Loneliness was significantly associated with relationship status and employment status. Respondents who were divorced, separated, widowed or never married, as well as those who were unemployed or disabled, had a significantly higher prevalence of loneliness than other respondents. People in poor health were more likely to report loneliness, and a high level of loneliness was positively associated with three measures of health care utilization: number of visits to the primary care office, number of hospitalizations, and number of emergency room or urgent care visits. These findings contribute to the growing body of evidence that loneliness is widespread and associated with poor health. The authors call on primary care clinicians to prioritize social connections as they consider the risks and needs of lonely patients.
Loneliness in Primary Care Patients: A Prevalence Study
Rebecca A Mullen, MD, MPH, et al
University of Colorado School of Medicine, Denver, Colorado
Living in a Socioeconomically Disadvantaged Community is Associated With Loneliness
There is growing evidence of the effects of loneliness on aspects of health, but little is known about whether loneliness is associated with where we live. New research finds associations between community factors and loneliness. Specifically, living in zip codes with higher unemployment, poor access to health care, lower income, and poor transportation are associated with higher mean loneliness scores. The findings were based on responses to the Three-Item Loneliness Scale screening tool. Of 1,235 survey respondents, 20 percent were identified as lonely. Higher mean loneliness scores were associated with a number of neighborhood characteristics: greater poverty, higher social deprivation, higher proportions of unemployment, more one-person households, more female and black residents, higher mean travel time to work, higher percentage of households with no vehicle, and higher percentage of residents without health insurance and without a usual source of medical care. Given the associations between loneliness and other community-level factors, screening for loneliness may be a proxy for other social needs, the authors suggest. They call on primary care practices to take a leading role in developing and testing interventions for loneliness and to consider loneliness as an important social need for their patients.
Geographic Characteristics of Loneliness in Primary Care
Sebastian Tong, MD, MPH, et al.
Virginia Commonwealth University, Richmond, Virginia
Older Adults Often Don’t Recognize Adverse Effects of Medication
Older adults often do not recognize a medical symptom as an adverse effect of their medication. This is according to research evaluating a patient-reported instrument for identifying adverse drug events in older adults with multiple medical conditions in the community setting. Patients 70 years of age or older were asked if they had experienced a list of 74 symptoms in the previous six months and if, 1) they believed the symptom was related to their medication; 2) the symptom had bothered them; 3) they had discussed it with their family physician and 4) they required hospital care due to the symptom. Self-reported symptoms were independently reviewed by two clinicians who determined the likelihood that the symptom was an adverse drug event. Family physician medical records were also reviewed for any report of an adverse drug event. Among 859 participating patients, 674 (78 percent) were classified as having at least one adverse drug event during the study period. Antithrombotic drugs (intended to reduce the formation of blood clots) were most frequently associated with adverse drug events, with 86 percent of patients prescribed aspirin and warfarin reporting bruising, bleeding and indigestion. Patients were most bothered by muscle pain and weakness (75 percent), dizziness or lightheadedness (61 percent) and unsteadiness on their feet (52 percent), but did not associate these symptoms with their medication. Patients were less bothered by more prevalent adverse drug events; only 21 percent were bothered by minor hemorrhages from antithrombotic therapy. On average, patients reported 39 percent of adverse drug events to their family physician. Patients who did not do so felt the symptoms were the result of old age and did not want to bother their doctors. According to the authors, technology and education to help patients and clinicians consider medications as a cause of adverse symptoms, and to differentiate adverse drug symptoms from those related to chronic disease or frailty, may help efforts to monitor and reduce medication use.
Identifying Adverse Drug Events in Older Community Dwelling Patients
Caitriona Cahir, PhD, et al.
Royal College of Surgeons in Ireland, Dublin, Ireland
Symptoms Can Help Identify Bacterial Sinus Infection
Although acute rhinosinusitis (sinus inflammation) is the most common reason for outpatient prescription of antibiotics, only about one-third of patients with sinus symptoms have a confirmed bacterial pathogen that is amenable to antibiotics. An analysis of existing research identifies three symptoms that can help clinicians identify patients with the bacterial form of rhinosinusitis. These symptoms include clinical impression (the clinician’s preliminary or working diagnosis), pain in the teeth, and cacosmia. Acute rhinosinusitis, which may be viral or bacterial, is significantly less likely in patients without nasal discharge, without a complaint of purulent nasal discharge (yellow to green mucus), and in those with normal transillumination (light can be transmitted through the sinuses and is not blocked by secretions). Clinical decision rules for the diagnosis of both acute and bacterial rhinosinusitis have not yet been prospectively validated.
Accuracy of Signs and Symptoms for the Diagnosis of Acute Rhinosinusitis and Acute Bacterial Rhinosinusitis
Mark H. Ebell MD, MS, et al.
The University of Georgia, Athens, Georgia
Training in Communication, But Not in CRP Testing, Can Reduce Unnecessary Antibiotics Over Time
Training physicians in communication skills and in testing for C-reactive protein have been shown to have short-term effectiveness in reducing antibiotic prescriptions, but only communication training remains effective over time. In a six-country study designed to reduce antibiotic prescribing for lower respiratory tract infections, 246 general practices received internet-based training in patient-centered communication, including use of an interactive patient booklet and point-of-care testing for C-reactive protein. Participants were cluster-randomized to one of four groups: usual care (n=61), training for C-reactive protein point of care testing (n=62), training in communication skills and use of patient booklet (n=61), or combined interventions (n=62). At 12 months, antibiotic prescribing was reduced in usual care (51 percent, 613/1194), but increased in the C-reactive protein testing group (43 percent, 456/1052). When compared to three-month data, reductions in prescribing for communication training were maintained at 40 percent (465/1166). Despite being freely provided, C-reactive protein testing was rarely used, and patient booklets were used only sparingly. The authors suggest that, in routine primary care practice, training clinicians to use CRP testing is likely to yield short-term benefits. Training in enhanced communication skills provides the most useful long-lasting effects.
Antibiotic Prescribing for Acute Respiratory Tract Infections 12 Months After Communication and CRP Training: A Randomized Trial
Professor Paul Little, FRCGP, et al.
University of Southampton, Southampton, The United Kingdom
Fewer Primary Care Services Provided Outside of Physicians’ Offices and AfterHours
During a six-year period, there was a significant decline in the provision of primary care services outside of regular office hours and at alternative locations, such as facilities for urgent after-hours or long-term care. An analysis of physician-level payments for all primary care physicians practicing in British Columbia between 2006 and 2012 (n=6531 physicians) found that the proportion of physicians providing care in non-office locations and after hours declined significantly in rural, urban and metropolitan practice locations. Declines ranged from five percent for long-term care visits to 22 percent for after-hours care. Female physicians and those in the oldest age category had lower odds of providing care at alternative locations or in urgent after-hours care. Rural physicians had significantly higher odds of providing care in alternative locations and after hours compared to those practicing in metropolitan areas. The authors note that these declines occurred in the context of significant financial incentives intended to promote full service family practice. This trend, they state, points to increasing challenges in primary care accessibility, both within Canada and elsewhere.
Trends in Providing Out-of-Office, Urgent After-Hours, and On-Call Care in British Columbia
Lindsey Hedden, PhD, et al
Vancouver General Hospital, Vancouver, British Columbia, Canada
Waiting Room Tool Improves Communication But Not Gaps in Care
A health information technology tool in waiting rooms of primary care practices helped patients prepare questions and express their concerns to their doctors, but did not reduce gaps in clinical care. The “Visit Planner” tool, which was placed in eight primary care practices, was designed to help adult patients identify priorities for their visit and effectively express them to their clinician. Eligible patients had at least one clinical care gap (e.g., not meeting diabetes goals). Of 359 patients in the intervention group, 59 percent (n=198) reported that they “definitely” prepared questions for their doctor, compared to 45 percent (n=160) of control patients. A high percentage of intervention group patients also reported “definitely” expressing their top concerns at the beginning of the doctor visit (91 percent vs. 83 percent of control group patients). Patients in both arms of the study reported high levels of satisfaction with their care. Overall, half of study patients (394/747, 53 percent) had all baseline care gaps closed by the end of the 6-month follow-up period. The prevalence of clinical care gaps was reduced by a similar amount in both groups. The Visit Planner successfully guided patients to begin primary care visits by communicating their top care priorities, an important gap in visit interactions. Improving this crucial first step of prioritization, the authors state, can be a building block for the next generation of tools that address communication barriers related to care planning with the ultimate goal of improving clinical care outcomes.
Visit Planning Using a Waiting Room Health IT Tool: The Aligning Patients and Providers Randomized Controlled Trial
Richard W. Grant, MD, MPH, et al.
Kaiser Permanente Northern California, Oakland, California
Should I Disclose My Breast Cancer To My Patients?
Following her diagnosis of breast cancer in 2016, family physician Heather Thompson Buum wondered, “Is it ever appropriate to disclose my situation, my diagnosis, any details about my cancer journey to my patients?” As a member of the medical profession, in which privacy is highly valued, she recognized the need for boundaries and objectivity. As a patient, however, she learned the importance of personal connection and support. “I have no easy answers,” she states, “but I do see potential benefits to (h)elping patients cope with the nature of an illness, a new diagnosis, and potentially frightening or confusing treatment plans—that’s what I spent years of my life training to do, and continue to do, every day. I just never thought I would accomplish any of it in quite this way.”
Sharing My Diagnosis: How Much is Too Much?
Heather A. Thompson Buum, MD
University of Minnesota, Minneapolis, Minnesota
Primary Care Clinicians Follow Specialist Advice in E-Consults
Electronic consultations can improve access to specialist advice, but do primary care clinicians follow the advice they receive? Yes, according to a new study. In a retrospective chart audit of 291 eConsults, primary care clinicians adhered to specialist advice in 82 percent of cases. Questions asked of specialists most often related to diagnosis (63 percent). Other questions addressed management (27 percent), drug treatment (10 percent) and procedures (1 percent). The eConsult’s results were communicated to patients in 79 percent of cases, most often by face-to-face meeting (38 percent), phone call (32 percent) or use of patient portal (9 percent). Communication occurred in a median of 5 days. The most consulted specialties were dermatology (32 percent), orthopedics (8 percent) and neurology (7 percent). In light of the high primary care clinician adherence to specialist recommendations and primary care clinician-to- patient communication, the authors conclude that eConsult delivers good quality care and improves patient management.
Primary Care Clinician Adherence to Specialist Advice in Electronic Consultation
Clare Liddy MD, MSc, et al
Bruyère Research Institute, Ottawa, Ontario, Canada
Practice Gap in Screening for Tobacco, Alcohol and Physical Activity
Tobacco use, lack of physical activity, poor diet and alcohol consumption are leading causes of death in the United States, but there is significant room for improving the delivery of clinical preventive services in these areas. Based on a nationally representative survey of 2,186 adults, researchers estimated screening and counseling rates for tobacco use, obesity and alcohol misuse. They found that receipt of recommended levels of services ranged from nearly two-thirds (64 percent for obesity and 62 percent for tobacco use) to less than half (41 percent for alcohol misuse). The authors note that while there is significant room for improving screening and counseling rates, primary care practices will likely need additional resources to effectively do so. For example, counseling can be provided within primary care or referred from primary care, and numerous strategies are available. Because solutions may vary, the authors call for approaches that take into account the local environment in order to balance the many competing demands of primary care.
The Practice Gap: National Estimates of Screening and Counseling for Alcohol, Tobacco and Obesity
Paul R. Shafer, MA, et al.
University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
Innovations in Primary Care
Innovations in Primary Care are brief one-page articles that describe novel innovations from health care’s front lines. In this issue:
Increasing Naloxone Availability in Rural Communities – A rural practice redesigned its workflow and collaborated with local police to increase naloxone availability.
Empowering Community Health Workers with Mobile Technology to Treat Diabetes – A clinical decision support smartphone application enables lay community health workers to manage diabetes in rural Guatemala.
Embedding an Immigration Legal Navigator in a Primary Care Clinic – In light of the impact of immigration status on patients’ health, a pilot program embedded an Immigration Legal Navigator in a primary care practice with a high population of immigrant, refugee and asylum-seeking patients.
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Annals of Family Medicine is a peer-reviewed, indexed research journal that provides a cross-disciplinary forum for new, evidence-based information affecting the primary care disciplines. Launched in May 2003, Annals is sponsored by seven family medical organizations, including the American Academy of Family Physicians, the American Board of Family Medicine, the Society of Teachers of Family Medicine, the Association of Departments of Family Medicine, the Association of Family Medicine Residency Directors, the North American Primary Care Research Group, and The College of Family Physicians of Canada. 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. Complete editorial content and interactive discussion groups for each published article can be accessed free of charge on the journal’s website, www.AnnFamMed.org.
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