Table of Contents

The Issue in Brief

Prevalence of Prediabetes and Abdominal Obesity Among Healthy-Weight Adults: 18-Year Trend

Arch G. Mainous III , and colleagues

Background Detection and treatment of prediabetes is a fundamental strategy in preventing diabetes. Conventional thinking suggests that the obesity epidemic is driving the epidemic in diabetes, and that abdominal obesity is a particularly good marker of those at risk. This study examines the prevalence of prediabetes and abdominal obesity among healthy weight adults.

What This Study Found One-third of non-obese people have prediabetes. In the first study to examine trends in prediabetes prevalence among individuals with a body mass index in the healthy range, researchers find the prevalence of prediabetes and abdominal obesity has increased markedly since 1988. The prevalence of prediabetes in healthy-weight adults aged 20 years and older without diagnosed or undiagnosed diabetes increased from 10 percent in 1988-1994 to 19 percent in 2012. Among people aged 45 years and older, the prevalence of prediabetes increased from 22 percent to 33 percent. The percentage of adults aged 20 years and older with an unhealthy waist circumference increased from 5 percent in 1988-1994 to 8 percent in 2012, and the percentage with an unhealthy waist-to-height ratio increased from 27 percent in 1988-1994 to 34 percent in 2012. Based on further analyses, abdominal obesity does not appear to be the primary cause of the increase in prediabetes.

Implications

• These findings are an important wake-up call. The authors call for additional research to determine the primary cause of the rise and alternative ways to detect prediabetes in primary care among healthy weight adults.

A Randomized Clinical Trial of a Tailored Lifestyle Intervention for Obese, Sedentary, Primary Care Patients

Charles B. Eaton , and colleagues

Background Tailored interventions that match individual patient characteristics with treatment may help patients lose weight and increase physical activity. Such programs implemented by print, telephone, and/or video, without extensive face-to-face counseling, may be an effective model for primary care patients. This study uses weekly telephone counseling calls, individually tailored educational materials and DVDs focused on diet and physical activity over the first year, with a tapered maintenance phase during the second year.

What This Study Found A home-based weight loss and physical activity intervention for obese, sedentary adult primary care patients is effective in promoting weight loss and increasing physical activity, with effects peaking at 12 months but waning at 24 months. In this study, by the end of the active treatment phase, almost half of the enhanced intervention group lost more than 5 percent of baseline weight � a clinically significant amount � and one-third maintained the loss at 24 months. The enhanced intervention group also reported significantly more minutes of moderate to vigorous physical activity over time than the standard intervention group. Similar trends were found for absolute weight loss and the percentage reaching national guidelines for physical activity. Overall, the benefits appear to peak at 12 months for both weight loss and increasing physical activity, with no statistically significant difference in benefit between the groups at 24 months.

Implications

• These findings suggest that referral by a primary care physician to a home-based program with limited face-to-face contact can lead to weight loss and increases in moderate to vigorous physical activity.
• The authors call for research to examine the use of ancillary health care staff or peer counselors in combination with computerized tailoring software, as well as technology such as web e-mails, text messages or smart phone apps, to provide support and tailored content.

Inadequate Hydration, BMI, and Obesity Among US Adults: NHANES 2009-2012

Tammy Chang , and colleagues

Background People who want to lose weight are often counseled to first drink water when they have the urge to eat, as they may actually be thirsty rather than hungry. However, studies of water intake as a weight loss tool have shown mixed results. This study assesses the relationship between adequate hydration, as measured by urine concentration (also called urine osmolality) and obesity (measured by body mass index).

What This Study Found The findings suggest that inadequate hydration is associated with higher body mass index and obesity. In a nationally representative sample, 33 percent of adults were inadequately hydrated and had a higher average body mass index than hydrated individuals. The odds of being obese were 1.59 times higher for inadequately hydrated individuals compared with hydrated individuals.

Implications

• Although causality and directionality cannot be established with the study design, these findings raise the possibility that drinking more water could be part of a solution to the obesity problem. The authors call for additional investigation to examine the relationship between inadequate hydration and weight status.

Improving the Diagnosis and Treatment of Urinary Tract Infection in Young Children in Primary Care: Results from the DUTY Prospective Diagnostic Cohort Study

Alastair D. Hay , and colleagues

Background Up to 50% of urinary tract infections (UTIs) in young children are missed in primary care. In addition, although urine culture is essential for diagnosis, urine collection is often difficult. This study aims to develop a two-step clinical rule using symptoms and signs to select children for urine collection; and symptoms, signs and dipstick testing to guide antibiotic treatment.

What This Study Found Among young children, having a previous UTI, increasing pain/crying on passing urine, increasingly smelly urine, absence of severe cough, increasing clinician impression of severe illness, abdominal tenderness on examination, and normal findings on ear examination are associated with UTI. These factors can be used for selecting children for whom a urine sample (step 1) and dipstick results would improve specificity for antibiotic treatment (step 2). Clinician preference should determine how these findings are used; some may use the risk factors to supplement clinical judgement while others may use a checklist approach and the points-based clinical rule.

Implications

• The authors call for further research to distinguish pathogens from contamination and asymptomatic bacteriuria.

A High Sense of Coherence as Protection Against Adverse Health Outcomes in Patients Aged 80 Years and Older

Pauline Boeckxstaens , and colleagues

Background Sense of coherence (SOC) refers to a feeling of confidence that one's environment is predictable and that things will work out as well as can reasonably be expected. High SOC scores have been shown to protect patients from negative health outcomes including perceived health, quality of life, mortality, and disability. This study explores whether a high sense of coherence protects patients aged 80 years and older who have multiple chronic diseases from adverse health outcomes.

What This Study Found Very elderly patients who have a high sense of coherence have lower mortality rates and less functional decline. Patients with high SOC scores show a higher cumulative survival than other patients, independent of other conditions. A high SOC is also protective against functional decline in the performance of daily activities.

Implications

• Given the protective effects of SOC, the authors conclude, it may be important to further explore interventions for increasing SOC in people with low scores in order to improve their capacity to cope with life stressors and maintain their health.

When Do Primary Care Physicians Retire? Implications for Workforce Projections

Stephen M. Petterson , and colleagues

Background Retirement of primary care physicians (PCPs) is becoming a matter of increasing concern in light of physician shortages. This study examines the ages at which the majority of PCPs retire and compares retirement ages across primary care specialties.

What This Study Found The average retirement age of about 65 years varies little by specialty, practice location, or gender. These findings suggest that changes in the composition of the primary care workforce will not have a remarkable impact on overall retirement rates in the near future. Females have a median retirement about one year earlier than males. There is no substantive difference in retirement ages between rural and urban primary care physicians.

Implications

• The authors suggest that strategies to lengthen careers, including quality-of-life accommodations such as a reduction in full-time work, weekend work, or on-call requirements, would be worthwhile for policymakers to explore.

Interconception Care for Mothers During Well-Child Visits With Family Physicians: An IMPLICIT Network Study

Stephanie E. Rosener , and colleagues

Background Interconception Care (ICC)--care provided to mothers between pregnancies--can improve health outcomes for women, newborns and children. Well-child visits are an opportunity for interconception care of mothers prior to their next pregnancy. This study investigates ICC practices by family physicians at well-child visits.

What This Study Found A substantial portion of mothers accompanying their children to well-child visits have risk factors for adverse subsequent birth outcomes. Family physicians routinely provide key elements of interconception care at well-child visits, and mothers are highly receptive to advice from their child's physician even if they receive primary care elsewhere. Seventeen percent of mothers surveyed reported a previous preterm birth, 19 percent reported a history of depression, 25 percent were smoking, 26 percent were not using contraception, and 58 percent were not taking folic acid. Regarding advice, 80 percent of mothers who smoked were counseled to quit, 59 percent reported depression screening, 71 percent discussed contraception, and 44 percent discussed folic acid. Most mothers were willing to accept health advice from their child's physician regardless of whether they shared a medical home.

Implications

• The authors call for routine integration of interconception care at well-child visits.

Seasonality of Ankle Swelling: Population Symptom Reporting Using Google Trends

Scott Garrison , and colleagues

Background It appears that complaints of ankle swelling are more common in summer, however, this observation has not been reported. This study seeks evidence of seasonality based on the public�s Google Internet searches for ankle swelling.

What This Study Found Internet searches for ankle swelling and related terms are highly seasonal, with public interest peaking in midsummer. Analyzing Google Trends data of searches for "ankle swelling," "swollen ankles," "swollen feet," or "swollen legs" originating in the US between 2004 and 2016, seasonality explained 86 percent of the variability in search volume, with the peak of searches occurring in mid-June and the low point in mid-December. To confirm these findings, an identical analysis was conducted for Australia where the seasons are reversed, and found the same pattern. Heart failure admissions have been shown to exhibit the opposite seasonal trend, peaking in winter, which is consistent with the authors' clinical observation that these patients seldom go on to develop cardiovascular disease.

Implications

• The authors call for research on patients with summertime ankle swelling to establish whether such patients have, or go on to develop, cardiovascular pathology. Further research is also needed to establish the mechanism behind the findings, which could potentially include seasonality in contributing factors, such as diet (including salt and water intake) increased activity in summer, or widening of blood vessels due to temperature.

Using Best-Worst Scaling to Understand Patient Priorities: A Case Example of Papanicolaou Tests for Homeless Women

Eve Wittenberg , and colleagues

Background Best-Worst Scaling (BWS) is a survey method for assessing individuals' priorities: what is best and worst among a set of items. This report applies the BWS method to cervical cancer screening priorities for homeless women.

What This Study Found Best-Worst Scaling quantifies patients' priorities in a way that is transparent and accessible. To demonstrate the use of BWS in primary care, participants were asked to evaluate attributes of Pap services. The biggest influence on participants' decision about whether to have a Pap test was the availability of support for issues beyond health, followed by no-cost testing. Least important was the availability of accommodations for hygiene and participants' familiarity with the clinician.

Implications

• The authors conclude that BWS can be easily understood by patients and is relatively easy to administer. This approach can be applied to other areas of health care where prioritization is helpful in guiding decisions.

A Comparison of the Male Osteoporosis Risk Estimation Score (MORES) and the FRAX in Identifying Men at Risk for Osteoporosis

Alvah R. Cass , and colleagues

Background This study compares the Male Osteoporosis Risk Estimation Score (MORES) and the Fracture Risk Assessment Tool (FRAX) in screening men for osteoporosis.

What This Study Found Compared to the MORES, the FRAX under-performs as a screening strategy for osteoporosis using the threshold score suggested by the US Preventive Services Task Force. Among men aged 50 years and older, based on the MORES, 42 percent of men in the sample would be referred for a follow-up dual-energy x-ray absorptiometry (DXA) scan, of whom 10 percent had osteoporosis. In comparison, based on the FRAX, 12 percent of men would be referred for DXA, of whom 14 percent had osteoporosis. Agreement between the two screening tools was poor. When the MORES and FRAX were integrated, they identified 82 percent of men who were candidates for treatment.

Implications

• An integrated approach, which uses the MORES to identify men who should undergo a diagnostic DXA scan and the FRAX to guide treatment decisions, may be optimal.

Concept Mapping as a Method to Engage Patients in Clinical Quality Improvement

Marianna Lanoue , and colleagues

Background Patient engagement is a priority in primary care research and practice, but there is little guidance on how best to engage patients in practice improvement or how to measure the impact of their involvement. Group concept mapping, a process where concepts in a particular subject area and their interrelationships are visually represented in a map, may be a means to engage patients in primary care practice improvement.

What This Study Found Group concept mapping is a promising method with several potential applications in primary care including practice improvement, research, and evaluation. A quality improvement project with patients and staff found that concept mapping offers a feasible patient engagement technique that can also illustrate and quantify the convergence and divergence of ideas from patients and other stakeholders, highlight the perspective that patients bring to practice improvement, and provide a basis for patient-centered practice improvements. Concept mapping may also be a powerful method for stakeholder engagement in other types of clinical research because it demonstrates and quantifies the effect of patient involvement in the process.

Implications

• Group concept mapping appears to be a viable method of engaging stakeholders. The authors call for research to measure engagement as an outcome of group concept mapping.

The Critical Role of Clerks in the Patient-Centered Medical Home

Samantha L. Solimeo , and colleagues

Background Interdisciplinary teams are a key element of healthcare delivery in patient-centered medical homes (PCMHs). Little attention has been given, however, to the role and training of primary care clerks. This essay describes the important but largely underutilized contributions of clerical staff to patient-centered medical home outcomes.

What This Study Found Based on a prior study of PCMH implementation in a large integrated delivery system, the authors suggest that PCMHs can be strengthened by enabling clerks to use administrative tasks to establish long-term personalized relationships with patients. Such relationships, which can develop trust in the PCMH and the broader health care organization, are engendered through care coordination activities clerks perform and may be bolstered by organizational investment in clerks as skilled health care team members.

Implications

• The authors conclude that the integration and support of clerks will make it possible for team-based initiatives, such as medical homes, to optimize their true potential of transforming how patient care is delivered.

A Dance with Mrs. Chan

Abraar Karan

Background n/a

What This Study Found In this essay, a medical student reflects on the most important lesson he learned during his internal medicine clerkship -- that a patient is more than his disease. While much of medicine is spent evaluating patients' vital signs and laboratory results, the sign most vital to care is how much time clinicians actually spend caring. The author asserts that physicians cannot fully appreciate how a patient is doing if they don�t first appreciate who patients are and what matters to them. Relating a story of how this important lesson later guided him to help another patient who was emotionally overcome by his disease, the author writes that paying attention to the little things is one of the most important things a physician can do to truly change how patients feel � and that is a very big thing.