Table of Contents

The Issue in Brief

An Early Look at Rates of Uninsured Safety Net Clinic Visits After the Affordable Care Act

Heather Angier , and colleagues

Background The Affordable Care Act supports significant expansions in Medicaid coverage in the United States. This study explores the number of patient visits to uninsured safety net clinics in states that implemented Medicaid expansion compared with states that did not expand Medicaid.

What This Study Found Medicaid expansions appear to have successfully decreased the number of uninsured safety net patients in the US Community health centers in states that expanded Medicaid had a 40 percent decrease in the rate of uninsured visits and a 36 percent increase in the rate of Medicaid-covered visits. In contrast, clinics in non-expansion states had a 16 percent decline in the rate of uninsured visits but no change in the rate of Medicaid-covered visits.

Implications

• This study confirms other reports showing increased health insurance coverage rates following state Medicaid expansion and adds new information demonstrating a measurable effect on community health center visits in Medicaid expansion states.

Sustaining "Meaningful Use" of Health Information Technology in Low-Resource Practices

Lee A. Green , and colleagues

Background Implementation of electronic health records (EHRs) has been studied extensively, but less is known about maintenance of EHRs once implemented. This study explores potential barriers to maintaining meaningful use of EHRs in primary care practices with limited financial, technical, and organizational resources. (Under "meaningful use," medical practices must show that they use certified EHR technology in ways that can be measured in quality and quantity.)

What This Study Found Primary care practices with limited financial, technical and organizational resources, especially those in rural areas, are at high risk for falling on the wrong side of a "digital divide," as payers and regulators enact increasing expectations for EHR use and information management. Maintaining EHR technology will require ongoing expert technical support indefinitely, beyond implementation, to address upgrades and security needs. Maintaining meaningful use of quality improvement will require ongoing support for leadership and change management. This is a particular challenge for rural practices, because expertise is often not available locally.

Implications

• Without long-term support solutions, the many challenges of maintaining health information technology will likely overwhelm low-resource practices.
• The operational and financial consequences of falling behind in EHR maintenance could mean lower quality of care for patients or possibly no care at all.

Geographic and Specialty Distribution of Physicians Trained to Provide Office-Based Treatment of Opioid Use Disorder in the United States

Roger A. Rosenblatt , and colleagues

Background The United States is experiencing an epidemic of opioid-related deaths due to excessive prescribing of opioids, misuse of prescription drugs, and increased use of heroin. Buprenorphine-naloxone is an effective treatment for opioid use disorder. It can be prescribed by office-based physicians who complete training to obtain a waiver to treat opioid use. This study examines the extent to which the US population has local access to waivered clinicians who can provide effective treatment for opioid use disorder.

What This Study Found Only 3.6 percent of American primary care physicians have obtained the waiver required to dispense buprenorphine. Ninety percent of those physicians practice in urban counties, leaving the majority of US counties (53 percent)--most of them rural--with no physician who can dispense buprenorphine. Although primary care physicians are the predominant providers of health care in rural America, very low percentages of family physicians and general internists have obtained a waiver. Most US counties, therefore, have no physicians with waivers to prescribe buprenorphine-naloxone and, as a result, more than 30 million people live in counties without access to buprenorphine treatment.

Implications

• The low numbers of rural physicians trained to provide office-based treatment of opioid use disorder, the authors conclude, is a major barrier to office-based outpatient treatment for opioid use disorder.

General Practitioners Recognizing Alcohol Dependence: A Large Cross-Sectional Study in 6 European Countries

Jakob Manthey , and colleagues

Background Alcohol consumption is a major risk factor for death and disability. This study examines the rate of identification of patients with alcohol dependence in 6 European countries using 2 different methods: identification by general practitioners and identification by semistructured interview using the Composite International Diagnostic Interview (CIDI) tool for assessing alcohol use disorders.

What This Study Found The 2 methods discover about the same number of alcohol dependent people, but there is little overlap between the people identified. The 12-month prevalence of alcohol dependence was 5.1 percent when assessed by the physician and 5.5 percent when assessed by the CIDI interview. Although physician assessment and the CIDI yielded a similar prevalence, they identified different patient populations, with fewer than one-fifth of the cases identified by both methods. Both methods identified alcohol dependence in 8.7 percent of patients, confirming that in Europe, alcohol dependence is common and disabling among primary care patients. Compared with the CIDI, general practitioners identified more patients with severe alcohol dependence. The CIDI was not as successful as a physician in identifying alcohol dependence in older patents.

Implications

• These significant differences, the authors conclude, raise questions about the validity of the CIDI and its status as a reference standard for assessing alcohol use disorders.

Functional Trajectories in the Year Before Hospice

Thomas M. Gill , and colleagues

Background Because of restrictions on hospice (end of life) care and confusion between hospice and palliative care (treatment of stress and pain during serious illness), many older persons do not receive hospice or palliative care near the end of life. This can burden caregivers and increase patients' suffering. This study examines the course, or trajectory, of disability in older patients in the year before hospice.

What This Study Found The study found five trajectories, representing worsening disability, among patients 70 years or older who were later enrolled in hospice. Participants with neurodegenerative disease had the worst functional trajectory, whereas those with a cancer diagnosis had the most favorable. Nearly 60 percent of the study sample had progressively or persistently severe disability during the year before hospice. The median survival in hospice was only 14 days and did not differ significantly by functional trajectory.

Implications

• Late admission to hospice, as shown by patients' short survival, coupled with high levels of severe disability before hospice indicate there are potential unmet palliative care needs for many at the end of life.

Clinical Relevance of Fixed Ratio vs Lower Limit of Normal of FEV1/FVC in COPD: Patient-Reported Outcomes From the CanCOLD Cohort

Wouter van Dijk , and colleagues

Background Currently, there is no consensus on the best spirometric diagnostic criteria to be used for clinical diagnosis of chronic obstructive pulmonary disease. Failure to resolve the controversy has resulted in inappropriate treatments for many patients. This study aims to shed light on the debate by analyzing data 4,882 adults aged 40 years and older participating in the Canadian Cohort of Obstructive Lung Disease study, a large, population-based study of lung health.

What This Study Found Comparing the clinical relevance of differing cutoffs of forced expiratory volume in one second/forced vital capacity (FEV1/FVC) for airflow limitation in COPD, the study found that airflow limitation defined solely by the fixed ratio was inadequate and may misdiagnosis patients with COPD, in particular those with cardiovascular complaints, leaving them at risk for inappropriate or unnecessary treatments. Conversely, a diagnosis of COPD established by low FEV1/FVC by fixed ratio and/or by lower limit of normal, coupled with a low FEV1 (<80 percent from predicted) was strongly associated with adverse clinical outcomes.

Implications

• The authors conclude that guidelines should be reconsidered to require both spirometry abnormalities in order to reduce overdiagnosis of COPD.

Laryngeal Measurements and Diagnostic Tools for Diagnosis of Chronic Obstructive Pulmonary Disease

Veronica Casado , and colleagues

Background Laryngeal height is considered a diagnostic sign of chronic obstructive pulmonary disease (COPD). Although examinations to screen and diagnose COPD have been found valid, research on exploratory tests is scarce. This study set out to evaluate sensitivity, specificity, and positive and negative likelihood ratios of maximum laryngeal height, lung function questionnaire, and COPD diagnostic questionnaire for screening and diagnosis of primary care patients.

What This Study Found The combination of laryngeal height measurement and a lung function questionnaire is useful for screening for COPD. Combining a maximum laryngeal height of less than 4 cm with lung function questionnaire findings of less than 18 yielded a sensitivity of 76 percent, specificity of 97 percent, a positive likelihood ratio of 29.06 and a negative likelihood ratio of 0.26.

Implications

• These findings, the authors conclude, suggest that combining Lung Function Questionnaire and laryngeal height can help to confirm or rule out COPD.

Ultrasound Imaging for Tailored Treatment of Patients With Acute Shoulder Pain

Ramon P. G. Ottenheijm , and colleagues

Background Although most patients with acute shoulder pain are managed in family medicine, physical examinations used to evaluate the extensive spectrum of rotator cuff disease (RCD) are often inadequate. Ultrasound imaging of the shoulder has become an accepted method for evaluating RCD and potentially allows for more tailored treatment. This study set out to determine the frequencies of RCD disorders in family medicine patients with shoulder pain as diagnosed with ultrasound and to identify possible predictors of shoulder pain.

What This Study Found Ultrasound imaging appears to be useful in diagnosing acute shoulder pain and providing tailored treatment. Eighty-one percent of patients had rotator cuff disorders and 50 percent had multiple disorders. Age of 40 years and older was a strong predictor of RCD in patients complaining of acute should pain. Full thickness tears were found in only 3 percent of patients.

Implications

• Ultrasound imaging can help guide treatment, especially in patients who are 40 years and older, for acute shoulder pain.

Effectiveness of Psychological Treatments for Depressive Disorders in Primary Care: Systematic Review and Meta-Analysis

Klaus Linde , and colleagues

Background Psychological interventions have a central role in treating depressive disorders. This analysis of currently available evidence looks at whether psychological treatments are effective for treating depressed primary care patients compared to usual care or placebo, taking type of therapy and its delivery method into account.

What This Study Found Overall, psychological treatments, including cognitive behavioral therapy (CBT), are superior to usual care alone, with small to moderate effect sizes. Differences between different types of psychological treatments are minor, with remote therapist-led, guided self-help and minimal-contact approaches appearing to produce effects similar to more intensive, personalized face-to-face therapies. However, the finding that remote, reduced or minimal contact CBT-based interventions seem to be similarly effective to intense face-to-face treatments should be interpreted carefully, in light of the limited number and moderate size of the identified studies.

Implications

• The authors conclude that these findings are reassuring for patients and clinicians wishing to pursue treatment options other than drugs.
• Although the available evidence for non-drug treatment of depression in primary care is promising, it is still not sufficient to guide practice and health policy. The authors call for large pragmatic trials comparing long-term outcomes and acceptability of different psychological treatment strategies in primary care patients with depression.

Efficacy and Acceptability of Pharmacological Treatments for Depressive Disorders in Primary Care: Systematic Review and Network Meta-Analysis

Klaus Linde , and colleagues

Background Most cases of depression are seen and managed in primary care, however, most research on depression treatment involves specialty settings. Antidepresssant drugs are an important element of depression treatment, but there is ongoing debate about whether their relatively small effects over placebo are clinically relevant. This study analyzes existing randomized trials of pharmacological treatments of depression in primary care to investigate whether antidepressants are more effective than placebo and whether there are differences in efficacy and acceptability between different types of depression medications.

What This Study Found Antidepressants have short-term effects over placebo in primary care. SSRI (selective serotonin reuptake inhibitors) and TCA (tetracyclic antidepressants) have a somewhat more solid evidence base than other substance classes (with SSRI having a slightly better acceptability profile). Other pharmaceuticals (Hypericum, MAO-A, SNRI, NRI, NaSSa, SARI) showed some positive results, but due to limitations of the currently available evidence, a clear recommendation on their place in clinical practice remains difficult.

Implications

• The authors call for future research prioritizing large, long-term trials and observational studies addressing clinically relevant questions, such as the best management of mild-to-moderate depression and comparison of pharmacological and psychological treatments under conditions of routine care and stepped-care strategies.

Clinical Practice Guideline Executive Summary: Labor After Cesarean/Planned Vaginal Birth After Cesarean

Bellinda K. Schoof , and colleagues

Background A clinical practice guideline summary from the American Academy of Family Physicians offers evidence-based recommendations to help guide clinicians in planning for labor and planned vaginal birth after a prior Cesarean delivery.

What This Study Found The multidisciplinary panel recommends that clinicians counsel, encourage and facilitate planned vaginal birth after cesarean (PVBAC), and offer pregnant women referrals to facilities or clinicians who can offer the service if PVBAC is not locally available. Additionally, the panel strongly recommends that clinicians inform women who have had a prior vaginal birth that they have a high likelihood of vaginal birth after cesarean (VBAC). Absent specific contraindications to a vaginal birth, they assert these women should be encouraged to plan labor and vaginal birth after cesarean. Lastly, the panel recommends that induction of labor after cesarean (LAC) is appropriate for women who have a medical indication for induction of labor and who are planning an LAC/VBAC.

Implications

• The panel calls for increased access to clinicians and facilities capable of managing LAC/VBAC in order to reduce the US cesarean rate and associated maternal morbidity while increasing choice for childbearing women and their families.

It's Time to Shine the Light on Direct-to-Consumer Advertising

Timothy K. Mackey , and colleagues

Background While pharmaceutical marketing has shifted to direct-to consumer advertising (DTCA) on the Internet, in social media and through mobile applications, new federal "sunshine" regulations require disclosure of certain marketing and industry payments to physicians. This essay calls for greater DTCA transparency, especially in emerging digital forms of DTCA, to complement forthcoming sunshine transparency data. To get a clearer picture of the overall impact of pharmaceutical promotion in the changing digital health landscape, the authors propose some initial DTCA disclosure requirements aimed at increasing transparency. This data, they assert, could lead to more targeted state and federal policy interventions leveraging existing federal transparency regulations to ensure appropriate marketing, spending and consumption of pharmaceutical products.