Table of Contents
The Issue in Brief
Ann Fam Med 15: 502.
The Issue in Brief
Randomized Controlled Trial of Text Message Reminders for Increasing Influenza Vaccination
Annette K. Regan , and colleagues
Background Although seasonal influenza vaccine is recommended for people at high risk of serious infection, they get the vaccine at low rates. This randomized controlled trial in Western Australia investigates the impact of text message reminders for influenza vaccination.
What This Study Found Text message reminders are a low-cost effective strategy for increasing rates of influenza vaccination. Among 12,354 eligible patients at high risk of serious influenza illness who had a mobile phone number on record in their medical practice, half were randomly assigned to an intervention group, which received a vaccination reminder by text message, while the other half (control group) received no text message reminder. Three months after the messages were sent, 12 percent (n=768) of the intervention group and 9 percent (n=548) of the control group were vaccinated during the study period. For every 29 messages sent, at a cost of $3.48 (USD), one additional high-risk patient was immunized. The greatest effect was observed for children under five years of age, whose parents were more than twice as likely to have their child vaccinated if they received a text reminder. There was no significant effect among pregnant women or Indigenous Australians.
Implications
- Several factors could influence the effectiveness of text message reminders including who sends the message, reliability of contact information, content of the message, and when it is sent. The authors call for future research to examine both costs and benefits of large scale text message influenza vaccination reminders for high-risk patients.
Continuity of Primary Care and Emergency Hospital Admissions Among Older Patients in England
Peter Tammes , and colleagues
Background This study from the UK explores whether better continuity of care (seeing the same clinician over time) in older patients is associated with a lower risk of emergency hospital admission.
What This Study Found Older patients who experience more discontinuity of care in general practice are at higher risk of emergency hospital admissions. In a study of 10,000 randomly selected patients over age 65, medical records were linked with hospital episode statistics. The study used two research approaches: a prospective cohort approach, to assess the general impact of continuity of care on emergency admission, and a nested case-control approach, to test if seeing a different GP from usual increases the risk of emergency admission during the following 30 days. The prospective approach found a graded non-significant inverse relationship between continuity of care and risk of emergency hospitalization, though patients experiencing least continuity had a risk more than twice as high than those who had complete continuity. The retrospective approach found a graded inverse relationship between continuity of care and emergency hospitalization.
Implications
- Initiatives to enhance continuity of care, the authors suggest, could potentially reduce hospital admissions.
Auscultation While Standing: A Basic and Reliable Method to Rule Out a Pathological Heart Murmur in Children
Bruno Lefort , and colleagues
Background Although heart murmur in children is usually harmless (referred to as innocent murmur), in a small number of cases it is symptomatic of cardiac disease (referred to as pathological murmur). This study tests whether the disappearance of heart murmur upon standing can rule out a pathological murmur.
What This Study Found A simple tes--comparing children�s heart murmur characteristics while standing versus lying flat on their back--eliably rules out pathological heart murmurs. Using an acoustic based, non-electronic stethoscope, researchers at two French universities noted heart sound characteristics of 194 consecutive children referred to pediatric cardiologists for heart murmur, first with patients in the supine (flat on their back) position, and then for at least one minute in the standing position. After observational data were collected, an echocardiogram was performed to assess the presence or absence of cardiac anomalies that could explain the murmur. Eight-five percent of children (n=164) referred to a cardiologist for heart murmur did not have a cardiac disease. Thirty children (15 percent) had an abnormal echocardiogram that explained the heart murmur. Of 100 children (51 percent) who had heart murmur while supine but not standing, two had an organic murmur and only one required follow-up. The disappearance of heart murmur while standing, therefore, excluded a pathological murmur with a high predictive positive value of 98 percent and a specificity of 93 percent, but with a poor sensitivity of 60 percent.
Implications
- In an era of highly technical medicine, the authors state, physical examination should remain the first step in diagnosis.
- The authors conclude that the disappearance of heart murmur in children upon standing is a valuable clinical test to exclude a pathological cardiac murmur and avoid costly referral to a cardiologist.
Exploring Attributes of High-Value Primary Care
Arnold Milstein , and colleagues
Background To address criticisms that the US health system rewards service volume rather than value, Medicare and some private payers are defining and rewarding high value. However, little is known about what physicians can do to attain low per capita spending and favorable quality scores for Medicare and non-Medicare populations. This study set out to identify care delivery attributes associated with value as defined by payers.
What This Study Found Six attributes of primary care delivery are associated with high value: decision support for evidence-based medicine, risk-stratified care management, careful selection of specialists, coordination of care, standing orders and protocols, and balanced physician compensation. Researchers analyzed commercial health insurance claims data from 2009 to 2011 for more than 40 million PPO patients and 53,000 primary care practice sites and found that the six statistically significant attributes relate to three themes: the need for "care traffic control" to help patients with complex conditions navigate the fragmented US health care system (risk-stratified care management, careful selection of specialists, and coordination of care), the need for tools to ease the cognitive burden of physicians and staff (decision support for evidence-based medicine and standing orders and protocols), and the importance of reimbursement based on value rather than volume (balanced compensation).
Implications
- According to the authors, awareness of care delivery attributes associated with high value may help physicians respond successfully to incentives from Medicare and private payers intended to lower healthcare spending and improve quality of care.
General Practitioner-Performed Compression Ultrasonography for Diagnosis of Deep Vein Thrombosis of the Leg: A Multicenter, Prospective Cohort Study
Nicola Mumoli , and colleagues
Background Compression ultrasonography has many advantages as a tool to identify deep-vein thrombosis. This study assesses the diagnostic accuracy of compression ultrasonography performed by general practitioners who receive vascular ultrasound training in diagnosing suspected deep vein thrombosis of the lower limbs.
What This Study Found General practitioners trained in compression ultrasonography have excellent accuracy and agreement in diagnosing symptomatic proximal deep vein thrombosis. In a study of more than 1,000 outpatients with clinically suspected deep vein thrombosis, diagnosis was performed by physician experts in vascular ultrasonography and GPs trained in the technique. Expert physicians diagnosed deep vein thrombosis in 200 patients, corresponding to an overall prevalence of 18 percent. Compression ultrasonography performed by GPs had sensitivity of 90 percent and specificity of 97 percent with diagnostic accuracy for deep vein thrombosis of 96 percent. Because sensitivity achieved by GPs appeared suboptimal, the authors call for future studies to evaluate the implementation of proper training strategies to maximize skill.
Implications
- The authors suggest that more rapid diagnosis, directly obtained by GPs in primary care, could improve appropriate management of deep vein thrombosis and help address the growing need for professionals trained in compression ultrasonography.
An Autoethnographic Examination of Postpartum Depression
Tara L. Frankhouser , and colleagues
Background A physician shares her experience with post-partum depression in a qualitative study using autoethnography (a method of self-reflection and analysis of personal and cultural experiences).
What This Study Found After the birth of her first child, the author found that the reality of post-partum depression was much different than what she thought as a physician. She identifies issues that shape the experience of postpartum depression including standards of intensive mothering, feelings of guilt, and the stigma of mental illness. The author encourages physicians to let patients know that postpartum depression does not define them, that there is healing ahead, and that, as her story exemplifies, they are not alone.
Multimorbidity and Decision-Making Preferences Among Older Adults
Winnie C. Chi , and colleagues
Background Shared decision-making, which is important in caring for people with multiple medical conditions, requires participation from both patient and clinician. This study explores preferences for health care decision-making among older adults and identifies multimorbidity profiles for those who prefer less active roles in decision-making.
What This Study Found Although most older Americans prefer to actively participate in making health care decisions, those with four or more chronic conditions are less likely to prefer active decision making. Researchers analyzed a random sample of 2,017 older adults who, with sample weights, represented approximately 33 million Medicare beneficiaries aged 65 and older. They found that eighty-five percent of older Americans in a community setting preferred to actively participate in medical decision making, but approximately one in every seven older Americans preferred a passive role, leaving health care decisions to doctors (15 percent, n=4.9 million). Approximately one quarter of older adults with four or more chronic conditions preferred a passive role, which was more than twice the odds of those that did not have multiple conditions after controlling for socio-demographic characteristics. Older adults with multiple condition clusters were relatively less likely to prefer active decision-making compared to those with none or a single condition cluster.
Implications
- The authors encourage primary care clinicians to invite older adults with four or more conditions or multiple condition clusters to participate in decision-making and to elicit goals and outcome preferences in those older adults who prefer less active participation.
Trends in Patient-Perceived Shared Decision Making Among Adults in the United States, 2002-2014
David M. Levine , and colleagues
Background This study explores how shared medical decision making between patient and clinician has changed over time.
What This Study Found Between 2002 and 2014, reports of shared decision making increased significantly among adult Americans. Analyses of data from a nationally representative survey found that the mean shared decision making composite increased from 4.4 to 5. In multivariable modeling, blacks reported more shared decision making, while Asians, those without insurance, and those in poor health reported less. When a respondent and their clinician were of the same race/ethnicity, the respondent reported improved shared decision making.
- The authors suggest that efforts to improve shared decision-making target Americans who do not share race/ethnicity with their clinician and those with poor perceived health.
Factors Influencing Allopurinol Initiation in Primary Care
Lorna E. Clarson , and colleagues
Background Although medication to reduce uric acid, such as allopurinol, can reduce the complications of gout, it is prescribed for only a minority of gout patients. This study investigates factors associated with time to initiation of allopurinol treatment.
What This Study Found Managing gout as a chronic, rather than an acute, condition could help prevent recurrences. A study of more than 8,000 medical records found a positive association between starting treatment with allopurinol and recurring doctor visits for the condition. Clinicians may therefore be more likely to offer allopurinol, or patients may be more likely to accept it, after multiple acute gout attacks.
Implications
- The authors suggest that more frequent chronic disease reviews to evaluate patients' preferences and eligibility for allopurinol could reduce barriers to successfully treating gout.
Comparative Associations Between Measures of Anticholinergic Burden and Adverse Clinical Outcomes
Fei-Yuan Hsiao , and colleagues
Background Anticholinergic burden is the cumulative effect of using multiple medications that block the effects of acetylcholine in the body. Medications with anticholinergic properties comprise 30 to 50 percent of all medications commonly prescribed to older adults. This is the first study to examine the association between long-term (10 years) anticholinergic burden and adverse clinical outcomes by comparing different measurement scales of anticholinergic burden.
What This Study Found Anticholinergic burden assessed with the Anticholinergic Cognitive Burden Scale consistently shows dose-response relationships with a variety of adverse outcomes. In a study of long-term associations between adverse clinical outcomes in older adults and three scales for anticholinergic burden, the ACB scale showed the strongest, most consistent dose-response relationships with risk of all four adverse outcomes studied: emergency department visits, all-cause hospitalizations, hospitalizations for fractures, and incident dementia.
Implications
- The authors suggest that the ACB scale may be a useful tool to identify high-risk populations for future research.
The Foundations Framework for Developing and Reporting New Models of Care for Multimorbidity
Jonathan Stokes , and colleagues
Background Researchers set out to identify models of care relevant to managing multiple chronic conditions (multimorbidity) and develop and apply a framework to describe models of care.
What This Study Found The new framework for reporting and designing models of care for multimorbidity describes each model in terms of its theoretical basis and target population (the foundations of the model), and elements of care implemented to deliver the model. Elements of care, including clinical focus, organization of care, and support for model delivery, have changed over time, with a decrease in models implementing home care and an increase in models offering extended appointments. Nearly half of all models lacked a mental health focus (although mental health focus increased over time) and few models directly focused on treatment burden.
Implications
- As health systems begin to implement new models of care for multimorbidity, careful design, implementation and reporting can assist in the development of an evidence base. The authors offer the framework as a tool for standardized reporting and research on multimorbidity interventions and the contributions and interactions of different elements that provide cost-effective care and support health system redesign.
Caring for the Tribe: From Addiction to Zen
David Loxterkamp
Background How can medical practices create and sustain healthy cultures at a time of rapid and often stressful change? The answer, according to family physician David Loxterkamp, MD, lies in human connection.
What This Study Found Based on the book "Tribe: On Homecoming and Belonging," by Sebastian Junger, Loxterkamp suggests that both medical professionals and their patients need to feel useful and connected. For physicians, however, a feeling of connection is increasingly hard to find, as medical practice focuses more on productivity and guidelines and less on relationships. By adopting such values as connection, egalitarianism, and loyalty, practices could strengthen their cultures in creative ways including viewing the practice (rather than teams or individuals) as the unit of care, encouraging employees to apply their ingenuity and problem-solving skills, and sharing both sacrifice and decision making. Loxterkamp calls on medical professionals to demand the kind of practice community that patients long for: one characterized by deeper connection and sense of purpose.
Hatpins
Irene Koplinka-Loehr
What This Study Found When a patient dies in the early years of a resident's training, the resident gains insights into the complicated relationships that can mark patients� lives and deaths. Although the resident had a conflicted relationship with her insensitive patient, she finds that the experience taught her to reach toward rather than away from the people she treats.