Table of Contents
The Issue in Brief
Sanjay Basu , and colleagues
Background Given the tenuous financial sustainability of many primary care practices, the decision to make investments in the patient-centered medical home is influenced by financial outcomes as well as the benefits to patient care. With this in mind, researchers used a microsimulation model to test the effects of new payment strategies on patient-centered medical home practices? net annual revenue and service delivery.
What This Study Found Evaluating three different funding initiatives ? increased fee-for-service payments, traditional fee-for-service with additional per-member-per-month payments and traditional fee-for-service with per-member-per-month and pay-for-performance payments ? the study found that practices gained substantial additional revenue under per-member-per-month or per-member-per-month with pay-for-performance payments ($104,000 and $113,000 per full-time physician per year, respectively) but not under increased fee for service payments (-$53,500) after accounting for the costs of meeting PCMH funding requirements. Expanding services beyond minimum levels required for PCMH requirements decreased net revenue because of lost traditional fee-for-service revenues.
Implications
- The authors conclude that achieving goals of the PCMH will likely require more radical payment reforms, including more robust non-visit-based payment mechanisms specifically targeting funding toward the delivery of desired services.
Viet-Thi Tran , and colleagues
Background This study investigates whether patients adhere to drugs considered important by their physicians. For patients under long-term drug treatment, it compares drug adherence self-reported by patients and drug importance according to their usual primary care physician.
What This Study Found There is substantial discordance between patient-reported drug adherence and physicians' assessment of drug importance with nearly 20 percent of drugs deemed important by physicians not correctly taken by patients. Comparing drug adherence reported by patients and drug importance assessed by physicians, the study found patients reported good adherence for 339 drugs (68 percent) evaluated as important by physicians, but for 94 drugs (19 percent), patients reported poor adherence even though their physicians evaluated them as important. Poor adherence involved mainly heart drugs, oral blood glucose-lowering drugs and insulin, and drugs for airway diseases. Patients intentionally did not adhere to 26 (48 percent) of the drugs for which they reported reasons for non-adherence. Notably, physicians rated 65 drugs (13 percent) as less important to patient health, raising questions about overtreatment and drug appropriateness.
Implications
- The authors conclude these findings highlight the need for better patient-physician collaboration in drug treatment, especially for patients having the poorest understanding of their medications and fewer beliefs in the need for medications.
Timothy D. H. Smith , and colleagues
Background Previous studies have shown that orally administered probiotics may prevent respiratory tract infections and associated antibiotic use.
What This Study Found The study finds no evidence to support earlier findings that probiotics may prevent respiratory tract infections. In a randomized trial of 1,302 asthmatic patients aged five years and older, researchers assessed whether advice to take probiotic treatment implemented as part of routine winter infection advice could reduce antibiotic prescription rates and respiratory tract infections. Participants in the intervention group received a leaflet that recommended taking a probiotic capsule daily, as well as free access to the supplements. Although uptake of probiotics was low--only 20 percent of patients in the intervention group accessed the recommended probiotics--outcomes were similar between the two groups.
Implications
- The authors conclude that real-world use of probiotics to prevent winter infections and reduce antibiotic use cannot yet be recommended despite earlier positive findings--at least not in older children and adults with asthma.
Primary Care Patient Experience With Naloxone Prescription
Emily Behar , and colleagues
Background Drug overdose, driven by opioids, is the leading cause of accidental death in the United States, but distribution of the opioid antagonist naloxone (which blocks or reduces the opioid's effects) has been associated with a reduction in opioid overdose mortality. This is the first study to evaluate patients' experiences receiving a co-prescription of naloxone with opioids.
What This Study Found Patients overwhelmingly responded positively to being offered a naloxone prescription, and having naloxone was associated with beneficial changes in their opioid use behaviors. Interviews with 60 patients who received naloxone prescriptions across 6 safety-net primary care clinics revealed that 90 percent of patients had never previously received a naloxone prescription, 88 percent successfully filled the prescription, 97 percent believed patients prescribed opioids should be offered naloxone, 79 percent had a positive or neutral response to being offered naloxone and 37 percent reported positive behavior change after receiving the prescription (safer dosing, safer timing and increased knowledge around opioids and overdose). Although 37 percent of patients described having previously overdosed, 17 percent of those patients described the events as ?bad reactions,? and 77 percent estimated their risk of overdose as low.
Implications
- The authors suggest that improved terminology is needed to describe opioid poisonings, as the term "overdose" may not reflect patients' perceptions.
- Since 90 percent of patients in this study had never previously received a naloxone prescription, the authors conclude that primary care prescribing appears to be reaching a population not served by community distribution. They call for future studies to investigate strategies to maximize the positive effects of on behavior change and to integrate naloxone prescribing with broader opioid stewardship efforts.
Gea A. Holtman , and colleagues
Background Guidelines recommend primary care physicians refer children with chronic diarrhea, recurrent abdominal pain, or both for specialist care if red flags are present, however the red flags are nonspecific and discriminate poorly between functional and organic gastrointestinal diseases, often leading to referral and extensive diagnostic testing. Fecal calprotectin is a simple, noninvasive diagnostic test commonly used in specialist care for ruling out inflammatory bowel disease (IBD) in children with chronic gastrointestinal symptoms. This is the first study to evaluate the use of fecal calprotectin for IBD in symptomatic children in primary care.
What This Study Found Fecal calprotectin has satisfactory discriminatory power between children with and without IBD. Among 2 groups of symptomatic children (114 children initially seen in primary care and 90 children referred to specialist care), none of the 114 children in the primary care group received a diagnosis of IBD. Among the 90 children in the cohort referred by a primary care physician to specialist care, 17 (19 percent) received a diagnosis of IBD.
Implications
- While fecal calprotectin showed good sensitivity and specificity, the authors question whether it can add to the diagnostic information that is already available from a thorough history and physical examination. They call for further research to determine the cost-effectiveness of fecal calprotectin and whether it should be incorporated in to the routine diagnostic evaluation of pediatric patients with chronic gastrointestinal symptoms and red flags in primary care.
- A pragmatic approach may be to monitor children with an initial calprotectin value between 50 ?g/g and 250 ?g/g feces, and later refer children whose symptoms persist and whose calprotectin values remain high.
Hostility During Training: Historical Roots of Primary Care Disparagement
Joanna Veazey Brooks
Background In light of the growing shortage of primary care physicians, a researcher illuminates the historical roots of primary care disparagement by analyzing primary care physician oral histories collected between 1995 and 1996.
What This Study Found Examining 52 oral histories, the authors finds 64 percent of respondents reported experiencing discouragement and disparagement about primary care across 5 decades. Analysis revealed that hostility toward primary care was embedded in the culture and structure of medical training, creating barriers to the portrayal of primary care as appealing and important. While some respondents reported support for primary care choice, it was uncommon.
Implications
- The author concludes that for policy responses to be most effective in meeting the primary care workforce shortage, they must address the presence and power of persistent and deeply rooted hostility against primary care during training.
Nifedipine vs Placebo for Treatment of Chronic Chilblains: A Randomized Controlled Trial
Ibo H. Souwer , and colleagues
Background The drug nifedipine is commonly prescribed for the treatment of chilblains, a condition with painful or itching lesions on the fingers, feet, ears or thighs due to exposure to cold. This study compared nifedipine to placebo for the treatment of patients with chronic chilblains in a primary care setting.
What This Study Found In this study, the drug nifedipine was no more effective than placebo for treating chronic chilblains and may even cause harm. Researchers randomized 32 patients with chronic chilblains to receive either nifedipine or placebo and found after 6 weeks of treatment, the nonsignificant difference in patient-reported symptoms tended to favor nifedipine, while the nonsignificant difference in patient-reported disability tended to favor placebo. Nifedipine was associated with a lower systolic blood pressure and a higher incidence of edema.
Implications
- The authors conclude that these findings underscore the importance of rigorous evaluation of treatments with adequate numbers of patients and control for potential cofounders before widespread adoption of nifedipine.
Family Physician Support for a Family with a Mentally Ill Member
J. LeBron McBride
Background A mental health professional and educator asserts that family physicians are positioned to intervene in powerful ways to support mentally ill patients and their families because of the specialty's family systems orientation.
What This Study Found Even though family physicians do not manage severe mental illness, they may manage the physical care of the patient and family members and play a major role in their psychological support, helping them to access available resources and offering compassion and coping strategies.
Implications
Elizabeth Ford , and colleagues
Background With approximately 13 percent of mothers experiencing postnatal depression during the first year after delivery and 90 percent of cases managed in primary care, this study analyzed existing research to assess the efficacy of psychological therapies for postnatal depression in primary care. While antidepressant medication is commonly used as a first-line treatment for postnatal depression, potential adverse effects of medication are worrisome to both mothers and clinicians, making it important to evaluate the efficacy of non-drug therapies.
What This Study Found The study, which included 10 clinical trials involving 1,324 depressed new mothers, found that psychological interventions delivered in community settings are effective treatment for postnatal depression. Compared with treatment as usual or a wait-list control, psychological interventions resulted in lower levels of depressive symptoms and higher levels of remission immediately after treatment. Improvements in symptoms at four to six months of follow-up were still significant but less robust. No particular type of therapy emerged as the most effective, but interpersonal therapy and cognitive behavioral therapy showed promising results. There were also improvements in anxiety and stress, marital relationships, adjustment to parenthood, and perceived social support.
Implications
- The small number of studies available means that caution is required when interpreting the secondary results and longer-term follow-up.
- The authors recommend that primary care clinicians make psychological therapies available to their patients.
Bipolar Disorder: A Daughter's Experience
Satya Rashi Kahre
Background This essay describes the author's experience as the daughter of a father with bipolar disorder and the enormous strain his illness placed on their relationship
What This Study Found The author relates her father's destructive cycling of mania, rage and depression, as well as her emotions that resulted from the experience. She explains how her experience led her to understand that mental illness is not a patient illness but rather a family illness--one that requires a whole family approach to treatment. While she was equally affected by her father?s mental disorder, she received no treatment from the family physician who saw all the members of her immediate family. Despite numerous routine check-ups, the author's family physician never asked how she was coping with her father's bipolar disorder. Consequently, she managed her feelings in isolation, never truly learned how to effectively cope and struggled with feelings of sadness, confusion, anger and injustice, all of which culminated in intense guilt.
Implications
Ruth Kannai , and colleagues
Background A family physician tells the story of a young female patient who had 4 siblings diagnosed with full-blown schizophrenia and the woman's all-consuming fear that the mental illness that afflicted her siblings would touch her as well.
What This Study Found Although the patient's family seemed like any other family, the patient (Hope) was keenly aware that the statistics were against her, and she worked tirelessly to create a fortress of sorts to protect her family from her past and her fears of the future. She describes the unsettling anxiety that consumed her patient whenever she or her children experienced any difficulties--shyness, provocative behavior, hostility, or isolation. The author reflects on how she feels she isn't able to offer much to the patient other than to hold close her darkest, most painful secrets and offer reassurance and a safe, nonjudgemental, and accepting environment. As a family physician practicing in a small community, the author concludes that psychiatric, social, and family issues are family medicine concerns.