Table of Contents
The Issue in Brief
Family Physician Participation in Maintenance of Certification
Jason C. B. Rinaldo , and colleagues
Background Maintenance of Certification (MOC) is the process by which the American Board of Family Medicine (ABFM) continually assesses the clinical performance of its Diplomates. It is also intended as a means to improve quality of care. This study explores family physician participation in Maintenance of Certification and the geographic, demographic, and practice characteristics associated with variations in certification of family physicians by the ABFM.
What This Study Found The great majority of family physicians in the United States have current board certification and are actively engaged in the voluntary Maintenance of Certification process. Family physicians practicing in poorer and underserved areas were more likely to have lapsed board certification and to have missed initial MOC certification requirements. Family physicians older than 55 years were twice as likely as their younger colleagues to have allowed their certification to lapse and were less likely to participate in MOC.
Implications
- Widespread participation in MOC suggests it is a viable mechanism for disseminating information, with the potential to influence US health care quality.
- The authors note that as more studies link quality of medical care to board certification, it is troubling that physicians who have not maintained certification tend to be practicing in underserved areas or caring for underserved populations. High levels of health care disparities and the need for high-quality care in those areas make it even more pressing to understand the barriers to participation in MOC by these physicians.
Anna Kiessling , and colleagues
Background This study is one of the first to evaluate the impact of physician continuing medical education on patient outcomes. Specifically, the study examined whether case-based training, designed to help general practitioners manage patients with hyperlipidemia (high levels of fat in the blood, such as cholesterol and triglycerides), increased 10-year survival in patients with coronary heart disease.
What This Study Found Patients of physicians who participated in case-based training had a 10-year mortality rate one-half that of patients whose physicians who didn�t take the training. In addition to a standard lecture and mailing of new evidence-based treatment guidelines received by all physicians who participated in the study, the physicians in the intervention group participated in small-group seminars, facilitated by a cardiologist, which encouraged the discussion of cases and active problem solving. After 10 years, 22 percent of the patients in the intervention group had died compared with 44 percent of patients in the control group, a difference mainly attributed to reduced cardiovascular mortality. The 22 percent mortality rate in the intervention group was comparable to the rate of 23 percent seen in patients treated by a comparison group of cardiology and internal medicine specialists.
Implications
- Based on these findings, the authors call for case-based training to be tested in other areas of clinical practice.
Racial Differences in Primary Care Opioid Risk Reduction Strategies
Barbara J. Turner , and colleagues
Background Previous research has found that doctors are less likely to prescribe opioid analgesics for pain to black patients when compared with white patients, in spite of findings that whites are more likely than blacks to misuse prescription opioids. This study looked at racial differences in risk reduction strategies, designed to minimize misuse of prescription pain medications, for patients receiving long-term opioids for chronic pain.
What This Study Found Black patients are significantly more likely than white patients to receive recommended opioid risk reduction strategies. Analyzing health records for 1,612 patients prescribed opioid analgesics for chronic noncancer pain, researchers found black patients were more likely than white patients to receive urine drug testing (10 percent vs 4 percent), regular office visits (56 percent vs 39 percent) and restricted early refills (80 percent vs 72 percent). After adjustment for patient and health care factors, the odds of urine drug testing for blacks was still higher, but no longer significantly so.
Implications
- The racial differences found in this study contradict evidence that the risk of prescription drug abuse is greater in whites than in other racial/ethnic groups.
- The authors call for clinical and educational initiatives to ensure that all patients are appropriately monitored for opioid use and that patient race does not affect opioid monitoring strategies.
Aaltien Brinks , and colleagues
Background Greater trochanteric pain syndrome (GTPS), also known as trochanteric bursitis, is a common cause of hip pain. This study compared usual care (analgesic pain medicines as needed) and corticosteroid injection in primary care patients with GTPS.
What This Study Found For patients with GTPS, corticosteroid injections offer better short-term pain relief than pain medicines. At the 3-month follow-up, 34 percent of patients in the usual care group had recovered compared with 55 percent in the injection group. At 3 months, pain severity at rest and on activity decreased in both groups, but the decrease was greater in the injection group. At the 12-month follow-up visit, the differences in outcomes were no longer present.
Implications
- Although local corticosteroid injections are frequently given for GTPS, this study is the first to examine the additional value of injection therapy, providing physicians with a more evidence-based rationale for offering it to patients.
Frances S. Mair , and colleagues
Background Chronic heart failure requires patients to take complicated medication regimes and enact numerous lifestyle changes. The aim of this study was to identify and understand the components of "work"�or treatment burden�in patients with chronic heart failure.
What This Study Found Patients living with heart failure have a wide-ranging and substantial treatment burden as they manage their disease. Among the components of treatment burden are the work of developing an understanding of treatments, interacting with others to organize care, attending appointments, taking medications, enacting lifestyle measures, and appraising treatments. Patients also reported several factors that increased this burden, including too many medications and appointments, barriers to accessing services, fragmented and poorly organized care, lack of continuity, and inadequate communication between health professionals.
Implications
- The authors conclude that these findings lay the foundation for a new target for treatment and quality improvement efforts toward patient-centered care.
Susan Woolhouse , and colleagues
Background This study explores family physicians' experiences of providing care to women using illicit drugs in order to better understand how to engage the women in the patient-physician relationship.
What This Study Found Exploring 10 family physicians� experiences, researchers identified a two-phase process of relationship development. First is an initial engagement phase that attempts to build relationships from a tenuous starting point of patients� difficult past experiences. This phase requires trust and presence and can lead to a maintenance phase, which requires continuity and finding common ground.
Implications
- Improving physicians� ability to engage women who use illicit drugs in the patient-physician relationship has implications for improving the women's overall health.
- Strong patient-physician relationships, the authors assert, are especially important for marginalized women, such as those who use illicit drugs.
Preventing Life-Sustaining Treatment by Default
Ursula K. Braun , and colleagues
Background Many patients receive life-sustaining treatment by default, because there are no instructions available as to what kind of care the patient prefers and because surrogate decision makers are likely to ask for �everything� when they do not know a patient�s preferences. This article identifies pathways to life-sustaining treatment by default originating with the patient�s preferred decision-making style.
What This Study Found Preventing life-sustaining treatment by default depends on increasing the frequency with which patients make clear decisions or clearly express their values and goals and then effectively communicate this information to physicians and/or surrogates.
Implications
- Preventing life-sustaining treatment by default could enable family members to report the patient�s end-of-life preferences, rather than act as surrogate decision makers, and thus reduce the burdens of making end-of-life decisions without adequate information.
- Preventing life-sustaining treatment by default would help health care professionals to better respect patients' autonomy.
Use of Acid Suppressive Drugs and Risk of Fracture: A Meta-Analysis of Observational Studies
Chun-Sick Eom , and colleagues
Background Acid suppression medications, including proton pump inhibitors (PPIs) and H2-receptor antagonists (H2RAs), are among the most widely used drugs in the world. Previous research has reported inconsistent findings about an association between use of such drugs and fracture risk. This study analyzed existing research to investigate the association between the use of PPIs and H2RAs and the risk of fracture.
What This Study Found Long-term use of proton pump inhibitors, but not H2-receptor antagonists, is associated with increased risk of fracture. The meta-analysis of 11 studies finds that PPIs are associated with a 29 percent increase of fracture, including 31 percent increased risk of hip fracture and a 54 percent increased risk of vertebral fractures. Long-term H2RA use, by contrast, was not significantly associated with fracture risk.
Implications
- Given the widespread use of acid-suppressive drugs, these findings have important implications for public health.
- The authors conclude that clinicians should carefully consider their decision to prescribe PPIs for patients, especially those who already have an elevated risk of fracture because of age or other factors.
Peter A. de Schweinitz
What This Study Found This essay explores the importance of narrative by connecting an ancient Middle Eastern fable to a contemporary story of healing. When a chronically ill patient does not respond to standard biomedical approaches, a young physician tries broader and deeper interactions with the patient. Ultimately, the patient heals herself by revisiting her past. Her story suggests that the cause of illness may sometimes be found outside the usual biomedical framework .