Table of Contents
The Issue in Brief
Nadine E. Foster , and colleagues
Background Back pain can be difficult to resolve and may lead to disability. This study used stratified care, in which a prognostic screening tool classifies patients by level of risk for disability and matches them with appropriate treatment. In particular, the study examines whether the use of stratified care in a primary care setting is clinically effective, leads to more targeted use of healthcare resources by changing physician referral behavior, and reduces healthcare costs.
What This Study Found Risk-stratified care for low back pain in primary care results in significant improvements in patient disability outcomes and reductions in work absence without an increase in health care costs. Patients with low back pain who received stratified care had modest improvements in physical function, fear avoidance beliefs, satisfaction with care and time off work. Average time off work was 50 percent shorter (four vs. eight days) and the proportion of patients given sickness certifications was 30 percent lower (9 percent vs. 15 percent) in the post-intervention group. Significant changes to physician clinical behavior included increased numbers of risk-appropriate referrals to physical therapy, reduced prescribing of nonsteroidal medications and fewer sickness certifications. There was also a small overall reduction in health care resource use and large societal cost savings due to fewer periods of pain-related work absence.
Implications
- The authors recommend widespread implementation of stratified care based on its association with benefits for patients and more targeted use of health care resources without increasing health care costs.
Five-Week Outcomes From a Dosing Trial of Therapeutic Massage for Chronic Neck Pain
Karen J. Sherman , and colleagues
Background Neck pain is a common and debilitating condition, and massage therapy is commonly used to treat it. This study evaluates the optimal dose of massage for persons with chronic neck pain.
What This Study Found Two hundred twenty-eight patients with chronic neck pain were randomized to 5 groups receiving various doses of massage for a 5-week period. The study found that the benefits of massage treatments for chronic neck pain increase with dose. Specifically, patients who received 30-minute treatments 2 or 3 times weekly were not significantly better than a wait-listed control group in terms of achieving a clinically meaningful improvement in neck dysfunction or pain. In contrast, patients who received 60-minute treatments 2 or 3 times weekly showed significant improvement in neck dysfunction and pain intensity compared to the control group. Compared with their control counterparts, massage participants were 3 times more likely to have clinically meaningful improvement in neck function if they received 60 minutes of massage twice a week and 5 times more likely if they received 60 minutes of massage 3 times a week.
Implications
- Patients who receive massage treatment for chronic neck pain may not be realizing benefits from treatment because they are not receiving an effective treatment dose.
Azithromycin and Levofloxacin Use and Increased Risk of Cardiac Arrhythmia and Death
Gowtham A. Rao , and colleagues
Background Azithromycin is an antibiotic commonly prescribed for treatment of respiratory infections, urinary tract infections, and sexually transmitted diseases. In 2013, the Food and Drug Administration issued a warning on azithromycin use and the risk of potential fatal heart rhythms. This study of a national cohort of veterans investigates whether cardiac arrhythmia and mortality risks are observed in older male patients receiving azithromycin and 2 other antibiotics: amoxicillin and levofloxacin.
What This Study Found In this analysis of more than 1.6 million unique antibiotic dispensations of amoxicillin, levofloxacin, and azithromycin, there was a higher risk of death associated with azithromycin and levofloxacin therapies as compared with amoxicillin. A short-course of azithromycin therapy was associated with statistically significant hazard ratios of 1.48 for mortality risks and 1.77 serious arrhythmia risks within the first five days of treatment. The risk of these events was not significantly increased for days 6 to 10, likely due to the traditional 5-day dispensation of azithromycin. Treatment with levofloxacin, also when compared with amoxicillin, had statistically significant hazard ratios of 2.49 for mortality risk and 2.43 for serious arrhythmia risk; however, the increased risk with levofloxacin continued to be statistically significant during days 6 to 10. Levofloxacin is predominantly dispensed for a minimum of 10 days.
Implications
- These results, the authors conclude, provide support for the FDA?s recent safety announcement. They caution physicians to carefully consider the risks and benefits of antibacterial therapies when making prescription decisions.
- This study only investigated three specific antibiotics and does not determine which alternative antibiotics might be safer.
Barriers to Primary Care Physicians Prescribing Buprenorphine
Roger A. Rosenblatt , and colleagues
Background Buprenorphine-naloxone is a highly effective outpatient treatment for opioid addiction, yet few physicians offer it. In an earlier project, 120 physicians were trained to prescribe buprenorphine. This study determined what proportion of the trainees began prescribing it and identified barriers to incorporating this approach into outpatient practice
What This Study Found Of the 78 physicians interviewed, 22 (28%) reported prescribing buprenorphine, though almost all reported positive attitudes toward the treatment. Commonly-cited barriers included a lack of mental health and psychosocial support, time constraints, and a lack of specialty, institutional and partner support.
Implications
- Interventions before and after training could help increase the number of physicians who offer buprenorphine for treatment of addiction.
- Targeting physicians in clinics that agree in advance to institute services, coupled with technical assistance after training is completed, could help more physicians become active providers of buprenorphine.
Effect of Raw Milk on Lactose Intolerance: A Randomized Controlled Pilot Study
Christopher Gardner , and colleagues
Background Unpasteurized raw milk consumption has increased in popularity and emerged into a nationwide movement. This pilot study aimed to determine whether raw milk reduces lactose malabsorption and/or lactose intolerance symptoms associated with pasteurized milk.
What This Study Found Raw milk did not reduce lactose malabsorption or lactose intolerance symptoms when compared with pasturized milk. Data on 16 adults with lactose intolerance and lactose malabsorption who underwent three eight-day milk phases (raw vs 2 controls: pasteurized milk and soy) in randomized order separated by 1-week washout periods were analyzed. Hydrogen breath testing showed higher lactose malabsorption for raw vs pasteurized milk on day 1 and comparable degrees of lactose malabsorption on day 8. Self-reported symptom severities were similar for raw and pasteurized milk on day 7. Compared to soy milk, both dairy milks caused significantly greater degrees of lactose malabsorption and intolerance symptoms.
Implications
- The evidence supporting raw milk consumption remains anecdotal, as do other health benefit claims for raw milk. The authors call for larger trials to confirm these findings and examine potential ethnic and racial differences.
Staffing Patterns of Primary Care Practices in the Comprehensive Primary Care Initiative
Deborah N. Peikes , and colleagues
Background Team-based care is a cornerstone of new care models designed to deliver high-quality, comprehensive care efficiently, but little is known about appropriate staffing composition for team-based primary care. This report describes the size and staffing composition of 496 technologically-advanced practices in the Centers for Medicare and Medicaid Services Comprehensive Primary Care Initiative.
What This Study Found There is a significant gap between where practices are and where policy makers expect them to be in order to implement new models of care. While most practices reported having administrative staff (98%) and medical assistants (89%), most did not have dedicated staff integral to providing team-based primary care ? staff who provide health education, care coordination, behavioral health care, nutrition counseling and medication adherence and reconciliation. Fifty-three percent reported having nurse practitioners or physicians assistants; 47% reported having licensed practical or vocational nurses; 36% reported having registered nurses; 24% reported having care managers and/or coordinators; and 7% or fewer reported having pharmacists, social workers, community service coordinators, health educators, or nutritionists.
Implications
- Without such staff and payment for their services, practices are unlikely to deliver comprehensive, coordinated and accessible care to patients at a sustainable cost.
- The restricted staff composition found in this study may be a result of the current fee-for-service payment environment, which does not provide incentives for the delivery of comprehensive coordinated care.
Patterns of Relating Between Physicians and Medical Assistants in Small Family Medicine Offices
Nancy C. Elder , and colleagues
Background Medical assisting is one of the fastest growing professions in the United States, and MAs are vital to new primary care practice models, yet little is known about their relationships to the clinicians with whom they work. This study aimed to understand MA roles and describe the clinician-MA relationship.
What This Study Found MAs' roles in small practices are determined by their career motivation and relationship with the clinician(s) with whom they work. Based on these findings, the authors propose a new model for this relationship, which they call trust and verify, characterized by different configurations of physician trust and verification of MA?s clinical activities.
Implications
- These findings may assist small offices undergoing practice transformation and guide future research to improve education, training and the use of MAs in the family medicine setting.
Prognosis of Mild Cognitive Impairment in General Practice: Results of the German AgeCoDe Study
Marion Eisele , and colleagues
Background Mild cognitive impairment, a transitional state between normal and illness-related cognitive decline, is a common condition in the elderly. As part of the German Study on Aging, Cognition and Dementia in Primary Care Patients, this study investigated determinants of the course of mild cognitive impairment (MCI) in primary care patients.
What This Study Found Among 357 primary care patients aged 75 years or older with a diagnosis of MCI without dementia, 42% had a remittent course (remission of symptoms and normal cognitive function at 1.5 and 3 years later) 21% had a fluctuating course (status changed between MCI and normal cognitive function), 15% had a stable course (impairment neither worsened to dementia nor improved to normal cognitive function), and 22% had a progressive course (developed to dementia). Patients were at higher risk of advancing from one course to the next along this spectrum if they had symptoms of depression, impairment in more than one cognitive domain, more severe cognitive impairment, and were older. Patients' performance on learning new material and the Geriatric Depression Scale helped predict a progressive versus a remittent course.
Implications
- In a 3-year period, about one-quarter of patients with MCI progress to dementia, while three-quarters of patients stay cognitively stable or improve. As a result, the authors suggest that patients should not be alarmed unnecessarily by a diagnosis of MCI.
The 10 Building Blocks of High-Performing Primary Care
Thomas Bodenheimer , and colleagues
Background A movement is underway to re-engineer primary care practices to help achieve better patient health, improved experience in the health care system, and more affordable costs. This article presents a conceptual model of 10 building blocks of high-performing primary care to assist practices as they transform.
What This Study Found The building blocks include 4 foundational elements ? engaged leadership, data-driven improvement, empanelment, and team-based care ? that assist the implementation of the other 6 building blocks ? patient-team partnership, population management, continuity of care, prompt access to care, comprehensiveness and care coordination, and a template of the future.
Implications
- The authors suggest that, while the building blocks focus on design elements largely under the control of the practice organization, external reforms are needed to support the building blocks ? principally a reformed payment model.
Value-Based Financially Sustainable Behavioral Health Components in Patient-Centered Medical Homes
Roger G. Kathol , and colleagues
Background Forty percent of primary care patients are estimated to have behavioral health problems, including mental health and substance abuse disorders, disabling psychological symptoms, and psychological stress. Yet despite this prevalence, the integration of behavioral health services into primary care is the exception rather than the rule. This article suggests seven components necessary to provide sustainable, value-added integrated behavioral health care in patient-centered medical homes.
What This Study Found The 7 components of value-added integrated behavioral health care are to: 1) combine medical and behavioral benefits into one payment pool; 2) target complex patients for priority behavioral health care; 3) use proactive onsite behavioral "teams;" 4) match behavioral professional expertise to the need for treatment escalation inherent in stepped care; 5) define, measure, and systematically pursue desired outcomes; 6) apply evidence-based behavioral treatments; and 7) use cross-disciplinary care managers in assisting the most complicated and vulnerable.
Implications
- The authors suggest that by adopting these components, medical homes will augment their ability to achieve improved health in their patients at lower cost in a setting that enhances ease of access to commonly needed services.
- Unaddressed or ineffectively addressed behavioral health conditions in the medical home predict poor medical and behavioral outcomes and continued high cost of care.