Table of Contents
The Issue in Brief
March/April 2013
Long-Term Psychosocial Consequences of False-Positive Screening Mammography
John Brodersen, and colleagues
Background False-positive results are a common, unintended, harmful effect of breast cancer screening mammography. The aim of this study is to measure the long-term psychosocial consequences of false-positive screening mammography.
What This Study Found Among 1,310 women, 454 of whom had abnormal findings on screening mammography, those who had a false-positive result reported greater negative psychosocial consequences compared with women with normal test findings, even 3 years after being declared free of suspected cancer. Specifically, 6 months after the final diagnosis, women with false-positive findings reported changes in existential values and inner calmness as great as those reported by women with a true diagnosis of breast cancer. Three years after being declared free of cancer, women with false-positive results reported greater negative psychosocial consequences compared with women who had normal findings in all 12 psychosocial outcomes. The pattern of the 12 psychosocial outcomes was consistent at the time of screening and at 1, 6, and 18 months after screening and final diagnosis: women with breast cancer experienced greater negative psychosocial consequences than women with false-positive findings, and these women experienced greater negative psychosocial consequences than women with normal findings.
Implications
- That women with false-positives reported changes just as great in existential values and inner calmness as women with breast cancer in the first half-year after final diagnosis indicates the significant psychological harm caused by false-positive diagnoses.
Screening for Hypertension Annually Compared With Current Practice
Gregory M. Garrison, and colleagues
Background This study examines whether checking blood pressure annually, instead of at every outpatient office visit, may improve the screening test's ability to correctly identify those without hypertension (specificity) without sacrificing its ability to identify those with hypertension (sensitivity).
What This Study Found Comparing the usual screening practice of checking blood pressure at every visit with a second strategy that uses only annual blood pressure measurements in a group of 440 adults over a 5-year study period, researchers found the reduced frequency of screening produced a significant decrease in the false-positive rate from 30 percent to 18 percent of nonhypertensive patients. They found no statistically significant difference in sensitivity between the 2 methods. When applied to the roughly 2,000 healthy adults cared for by a typical family physician, the annual screening strategy results in 232 fewer patients needing further workup over 5 years.
Implications
- In addition to improving the false-positive rate, reducing the number of unnecessary blood pressure screenings in healthy adults provides other benefits, including increased clinic efficiency, reduced clerical burdens, and more clinical staff time to more accurately measure blood pressures.
Osteopathic Manual Treatment and Ultrasound Therapy for Chronic Low Back Pain: A Randomized Controlled Trial
John C. Licciardone, and colleagues
Background Low back pain is responsible for more than 20 million ambulatory medical care visits and $100 billion in costs annually in the United States. Research has not conclusively demonstrated efficacy of osteopathic manual treatment (OMT) in relieving low back pain. This study examines the efficacy of OMT and ultrasound therapy (UST) for treatment of chronic low back pain.
What This Study Found OMT is effective for short-term pain relief when used to complement other co-treatments for chronic low back pain. OMT met or exceeded the Cochrane Back Review Group criterion for a medium effect size for both moderate and substantial improvements in low back pain. Thus, low back pain reductions with OMT were statistically significant and clinically relevant. The less frequent use of prescription drugs for low back pain reported by OMT patients further corroborates the clinical relevance of these results. The OMT regimen was safe, parsimonious, and well accepted by patients as demonstrated by high levels of treatment adherence and satisfaction with back care. By contrast, UST was not efficacious in relieving chronic low back pain.
Implications
- The authors suggest that these results may begin to explain why one-third of ambulatory, chronic problem visits for low back pain in the United States are provided by osteopathic physicians, and why they less frequently prescribe medications, such as nonsteroidal anti-inflammatory drugs, than allopathic physicians during such visits.
New York City Physicians' Views of Providing Long-Acting Reversible Contraception to Adolescents
Susan E. Rubin, and colleagues
Background Despite their safety and efficacy, only 3 percent of adolescents who use contraceptives use an intrauterine device (IUD), and far fewer use implantable contraception. Yet increasing use of such long-acting reversible contraceptives (LARC) could decrease unintended adolescent pregnancy rates. This study explores primary care physicians' experiences, attitudes, and beliefs about LARC counseling and provision to adolescents with a focus on enablers and barriers to access.
What This Study Found Through in-depth interviews with 28 New York City-based family physicians, pediatricians and obstetrician-gynecologists, researchers identify multiple factors affecting their likelihood of prescribing long-acting reversible contraception to adolescents, and they find numerous barriers, including financial concerns, the clinical environment, and physicians' knowledge, attitudes, and beliefs. In short, the authors found physicians rarely counsel about implantable contraception because of knowledge gaps (capability) and limited access to the devices (opportunity). Notably, many physicians, in particular pediatricians, did not know that girls who have not previously given birth can be appropriate candidates for IUDs and consequently never counsel about this option. Specific enablers to counseling included the availability of the device in the clinic, a "culture" within the clinic supportive of adolescent contraception provision, and the ability to insert IUDs or easy access to someone able to insert the device. Factors enabling motivation included a belief in the positive consequences of IUD use, which was particularly influenced by physicians' perception of adolescents' risk of pregnancy and sexually transmitted disease.
Implications
- The authors assert that a concrete step to addressing the persistent public health issue of adolescent pregnancy is optimizing access to reliable, forgettable forms of reversible contraception, and they call for future research to explore strategies to increase adolescents' LARC access in primary care.
Impact of Peer Health Coaching on Glycemic Control in Low-Income Patients With Diabetes: A Randomized Controlled Trial
David H. Thom, and colleagues
Background Many primary care practices have no one available to provide the time-consuming counseling and teaching of self-management skills that have been shown to improve diabetes. Peer educators and coaches are trained patient volunteers who themselves have diabetes and can provide ongoing support for self-management to a small group of clients. This study tests the impact of individual peer coaching on glucose control for patients with poorly controlled diabetes seen in public clinics.
What This Study Found Clinic-based peer health coaching improves the glycemic control of patients with poorly controlled diabetes seen in urban public health clinics. A randomized controlled trial involving almost 300 low-income patients with poorly controlled type 2 diabetes found patients who receive one-on-one coaching and self-management support from volunteer peer coaches saw a greater reduction in HbA1c levels than those in the usual care arm at 6 months' follow-up. HbA1c levels decreased 1 percent or more in 50 percent of coached patients vs 32 percent of usual care patients, and levels at 6 months were less than 7.5 percent for 22 percent of coached vs 15 percent of usual care patients. The authors note that because peer coaches experience similar challenges of living with the same chronic condition as the patients they assist, they are uniquely poised to engage and motivate them in self-management.
Implications
- Peer coaches represent a potential resource to increase primary care capacity and remove some of the burdens of patient-self management support from primary care clinicians and staff.
Improved Outcomes in Diabetes Care for Rural African Americans
Paul Bray, and colleagues
Background Rural, low-income African American patients with diabetes traditionally have poorer clinical outcomes and limited access to state-of-the-art diabetes care. This study tests the effectiveness of a model of redesigned care on intermediate and long-term glycemic, blood pressure, and lipid levels for African American primary care patients with type 2 diabetes.
What This Study Found Redesigning diabetes care to incorporate interprofessional care management results in significantly improved glycemic control among rural, low-income African-American patients. Analyzing data on 727 diabetic patients at 3 rural primary care practices, researchers found patients in the intervention group who received point-of-care education, coaching, and medication intensification from a care management team comprised of a nurse, pharmacist, and dietician had significantly greater reduction in mean hemoglobin A1c levels than those receiving usual care at the 18-month and 36-month follow-ups . Moreover, a significantly greater percentage of patients in the intervention practices achieved a hemoglobin A1c value of less than 7.5 percent at the final assessments, and the proportion achieving a systolic blood pressure of less than 140 mm Hg was also substantially greater in the intervention group.
Implications
- The findings suggest that a portion of chronic diabetes management can be accomplished with an interprofessional team, potentially making clinicians more available for acute problems.
Initial implementation of a Web-Based Consultation Process for Patients With Chronic Kidney Disease
Nynke D. Scherpbier-de Haan, and colleagues
Background A Web-based consultation system (telenephrology) enables family physicians to consult a nephrologist on a patient with chronic kidney disease: relevant data are exported from the electronic patient file to a protected digital environment from which advice can be formulated by the nephrologist. This study assesses the potential of telenephrology to reduce in-person referrals.
What This Study Found A Web-based consultation system between family physicians and nephrologists reduces the number of referrals and appears to improve treatment appropriateness among patients with chronic kidney disease. Analyzing 122 telenephrology consultations involving 116 patients, researchers found that in the absence of telenephrology, 43 patients (35 percent) would have been referred by their family physicians, whereas the nephrologist considered referral necessary in only 17 patients (14 percent) -- an 84 percent reduction. The opposite was seen in 10 patients, who according to clinicians could be treated in primary care but for whom the nephrologist deemed referral necessary. The time investment per consultation, most of which were performed during office hours, amounted to less than 10 minutes, and nephrologists' average response time was 1.6 days.
Implications
- The authors assert these findings support the introduction of telenephrology in primary care as a means of delivering higher quality, more convenient care at a lower cost. They conclude that on a broader scale, e-consultation has the potential to break down walls between primary and specialty care.
Enhanced Communication Skills and C-Reactive Protein Point-of-Care Testing for Respiratory Tract Infection: 3.5-Year Follow-up of a Cluster Randomized Trial
Jochen W. L. Cals, and colleagues
Background Reducing overprescribing of antibiotics for respiratory tract infections (RTIs) is essential in an era of increasing antimicrobial resistance. This study assesses the long-term effects of 2 interventions on office visit rates and antibiotic prescribing for patients with RTIs; the interventions are family physicians' use of C-reactive protein point-of-care testing, a widely used means of diagnosing and monitoring infections, and physician training in communication skills.
What This Study Found What This Study Found The study found mixed results. An office visit with a family physician who used C-reactive protein point-of-care testing and/or who was trained in enhanced communication skills had no effect on the rate of office visits for respiratory tract infection episodes during the next 3.5 years. However, patients managed by a family physician trained in enhanced communication skills were less likely to receive antibiotics for RTI episodes during the 3.5-year follow-up. Specifically, family physicians trained in communication skills treated 26 percent of all episodes of respiratory tract infection with antibiotics compared with 39 percent treated by family physicians without such training. The cluster-randomized controlled trial included 379 patients at 20 family practices in the Netherlands.
Implications
- The authors call for implementation of both interventions on a larger scale, noting that training physicians in the use of enhanced communication skills may have a wider longer-term effect on the treatment of respiratory tract infections beyond acute cough to include reduced antibiotic prescribing.
Risks and Benefits Associated With Antibiotic Use for Acute Respiratory Infections: A Cohort Study
Sharon B. Meropol, and colleagues
Background Antibiotics are frequently prescribed for acute respiratory infections (ARIs), although research has failed to demonstrate a clear benefit from antibiotics for these conditions. This study uses outpatient ARI visits to estimate the risks of serious adverse drug events and community-acquired pneumonia among patients who have and have not received antibiotics.
What This Study Found In this study, there is a small reduction in subsequent hospitalization for pneumonia and no increase in severe adverse drug reactions for patients prescribed antibiotics. Analyzing data on more than 1.5 million patient visits, researchers found antibiotics were prescribed in 65 percent of cases. The adjusted risk difference for treated vs untreated patients per 100,000 visits was 1.07 fewer adverse events and 8.16 fewer pneumonia hospitalizations within 15 days following the visit. The number needed to treat was 12,255 patients to prevent 1 hospitalization.
Implications
- The authors conclude this small benefit from antibiotics for a common diagnosis creates a persistent tension; at the societal level, physicians are compelled to reduce antibiotic prescribing, thus minimizing future resistance, whereas at the visit level, they are compelled to optimize the benefit-risk balance for that patient.
The Primary Care Extension Program: A Catalyst for Change
Robert L. Phillips, Jr, and colleagues
Background The US Affordable Care Act of 2010 provides unprecedented support for primary care, placing it at the core of a health care system that seeks to improve the experience of care, improve the health of populations, and reduce health care costs. This article describes how critical the Primary Care Extension Program (PCEP) is to enhancing primary care effectiveness, to the integration of primary care and public health, and to translating research into practice in order to achieve the goals described above.
What This Study Found Much as the Cooperative Extension Program of the US Department of Agriculture sped the modernization of farming a century ago, the PCEP could speed the transformation of primary care through local deployment of community-based Health Extension Agents. The authors call for $120 million in annual federal funding for the PCEP, with a target of $500 million for future appropriations. They conclude that the rapid pace of change in health care demands that a PCEP be viewed as an essential, not optional, ingredient for transformation of primary care and improvement of population health.
Should Authors Submit Previous Peer-Review Reports When Submitting Research Papers? Views of General Medical Journal Editors
Jochen W. L. Cals, and colleagues
Background Publishing research can be time consuming, as papers are often submitted and reviewed by multiple journals before final acceptance. In this study, the authors assess the views of medical journal editors about whether attaching previous peer-review reports when submitting the paper to a different journal could decrease the workload for both reviewers and editors and could shorten the time from final draft to actual publication.
What This Study Found Among 51 general medical journals surveyed online, a quarter at least occasionally receive previous peer review reports from authors submitting manuscripts, and about one-half have an interest in the idea. Editors reported both pros and cons. They reasoned that including previous reviews may reduce reviewers' workload, improve transparency, prevent duplication of efforts, and shorten the decision process; however, they expressed concerns about the introduction of bias and reluctance of authors to submit unfavorable reviews. They also expressed concerns that the practice of using previous peer reports could create lazy reviewers and editors and prohibit the manuscript from receiving an objective fresh start.
Implications
- Editors of general medical journals have diverging views on the use of peer-review reports in submission of scientific papers.
- The authors call for debate on how to improve the peer-review system.