Table of Contents

The Issue in Brief

Use of Asthma APGAR Tools in Primary Care Practices: A Cluster-Randomized Controlled Trial

Barbara P. Yawn , and colleagues

Background Implementation of asthma guidelines is challenging and the burden of the condition remains high. This study tests the effects of Asthma APGAR tools, including an asthma control assessment completed by patients and linked to an asthma management algorithm, on patient outcomes and practices� adherence to asthma guidelines.

What This Study Found The Asthma APGAR tools help decrease asthma-related visits to the emergency department, urgent care or hospital and improve patients' asthma control. A randomized controlled study of 18 family medicine and pediatric practices across the United States compared outcomes in more than 1,000 patients with persistent asthma aged five to 45 years using Asthma APGAR tools versus usual care. The proportion of patients reporting an asthma-related emergency department, urgent care or hospital visit in the final six months of the study differed significantly between groups: 11 percent for intervention groups and 21 percent for usual care groups. Between baseline and one year, the percentage of patients whose asthma was in control increased significantly in the intervention group (14 percent) compared to the usual care group (3 percent), with a trend toward better control scores and asthma-related quality of life in the intervention group at 12 months. Intervention practices also significantly increased their adherence to three or more elements of the National Asthma Education and Prevention Program guidelines compared to usual care practices. Participating practices reported that changing practice to incorporate the Asthma APGAR tools was challenging, but the tools themselves were perceived as useful and efficient.

Implications

• The authors suggest that the Asthma APGAR tools are effective for asthma management in the primary care practice setting.

Treating Subthreshold Depression in Primary Care: A Randomized Controlled Trial of Behavioral Activation With Mindfulness

Samuel Y. S. Wong , and colleagues

Background Subthreshold (minor) depression is common among primary care patients. The aim of this study was to evaluate the effectiveness of group behavioral activation focused on mindfulness training to treat subthreshold depression in primary care.

What This Study Found Among primary care patients with subthreshold depression, mindfulness meditation training reduces the incidence of major depression and improves depression symptoms. A randomized controlled trial of adults with subthreshold depression compared a usual care group in which there was no psychological intervention (n=116) with a behavioral activation group focused on mindfulness training (n=115). Intervention participants were invited to attend weekly two-hour mindfulness training sessions for eight consecutive weeks. At 12 months, there was a statistically significant difference in the incidence of major depressive disorder between groups (11 percent in the mindfulness group compared to 27 percent in usual care). Mindfulness training also had a small effect in reducing depression symptoms. Other secondary outcomes demonstrated no significant change.

Implications

• The authors suggest that, for patients with subthreshold depression who have not had a major depressive episode in the past six months, mindfulness training is a feasible method of preventing major depression.
• The authors plan future research into the cost-effectiveness, health service use implications, and acceptability of mindfulness training.

Sustainability of a Primary Care-Driven eConsult Service

Clare Liddy , and colleagues

Background Excessive wait times for specialist appointments pose a significant barrier to patient care. To improve access to specialist care and reduce wait times, the Champlain BASE (Building Access to Specialists through eConsultation) eConsult service was launched in Ontario, Canada in April 2011. This study reports on the impact of the service during its first five years.

What This Study Found The Champlain BASE eConsult service experienced exponential growth during its first five years. The electronic consultation system was created to provide primary care clinicians in Ontario, Canada with a range of high quality and timely (up to one week) specialty input. Electronic consultation is an alternate, complimentary approach to usual face-to-face referrals. The primary care clinician can submit a patient-specific question (usually for a patient who would have otherwise needed an in-person referral) to a specialty service via a secure web-based portal. The system, created in 2010, had four completed eConsult cases in April, 2011 compared to 769 cases in April, 2016, with primary care clinicians submitting 14,105 cases to 56 specialties during the 5-year period. Specialties receiving the highest number of eConsults were dermatology (17 percent); endocrinology, obstetrics/gynecology, and hematology (7 percent each); cardiology (6 percent); and neurology (6 percent). Specialists responded in a median of 21 hours; in 75 percent of cases they responded within three days. Self-reported billing time for specialists ranged from less than 10 minutes (in 48 percent of cases) to more than 20 minutes (4 percent of cases). By the end of the study period, approximately 80 percent of primary care clinicians in the region had adopted the eConsult service, which is poised for expansion across Canada.

Implications

• The study demonstrates that, once integrated into a practice's specialty referral workflow, the eConsult service has the potential to reduce wait times for specialty care.

Multimorbidity and Socioeconomic Deprivation in Primary Care Consultations

Stewart W. Mercer , and colleagues

Background Patients with multimorbidit--two or more long-term medical condition--have complex health care needs, often requiring higher levels of care than other patients, but the influence of multimorbidity on the clinical encounter is not well understood. This study examines the effects of multimorbidity on primary care visits in affluent areas compared to areas of socioeconomic deprivation.

What This Study Found Patients with multimorbidity in affluent areas receive longer doctor visits, greater perceived empathy, and more patient-centered care than comparable patients in socioeconomically deprived areas. Researchers in Scotland analyzed 659 routine visits to general practitioners in deprived and affluent areas, as well as patient ratings of general practitioner empathy. In affluent areas, multimorbid patients received longer consultations than other patients (13 minutes versus 9 minutes) while in deprived areas, consultation length was about the same for both groups (10 minutes). Similarly, patients with multimorbidity in affluent areas found GPs to be more empathetic and, according to video analysis, more attentive to their disease and illness experience. There were no such differences between similar groups in deprived areas.

Implications

• If primary care is to succeed in narrowing health inequalities, the authors state, action is needed to ensure that patients with multimorbidity in lower socioeconomic areas receive the same level of care and attention as patients in affluent areas.

A Core Outcome Set for Multimorbidity Research (COSmm)

Susan M. Smith , and colleagues

Background Core outcome sets represent the minimum that should be measured and reported in a clinical trial of a specific condition. In this study, an international panel of experts established a core outcome set for research of multimorbidity (two or more chronic conditions in an individual).

What This Study Found Clinical trials of multimorbidity should measure and report, at minimum, quality of life, mortality, and mental health outcomes. Twenty-six multimorbidity researchers, clinicians, and patients from 13 countries participated in a Delphi Panel and reached consensus on 17 core outcomes for multimorbidity research. The highest ranked outcomes were health related quality of life, mental health outcomes and mortality. Other outcomes were grouped into overarching themes of patient-reported impacts and behaviors (treatment burden, self-rated health, self-management behavior, self-efficacy, adherence); physical activity and function (activities of daily living, physical function, physical activity); outcomes related to the medical visit (communication, shared decision making, prioritization); and health systems outcomes (healthcare utilization, costs, quality of healthcare).

Implications

• The authors suggest that, when designing studies to capture important domains in multimorbidity, researchers consider the full range of outcomes based on study aims and interventions.

Recent Patterns in Shared Decision Making for Prostate-Specific Antigen Testing in the United States

Stacey A. Fedewa , and colleagues

Background There is consensus that the decision to undergo prostate-specific antigen testing for prostate cancer screening should be shared by patients and clinicians, but rates of shared decision making are low. This study examines whether there have been recent changes in shared decision-making for PSA testing.

What This Study Found Although there has been no increase in shared decision-making for PSA testing, the content of discussions has become more comprehensive. The study compared responses to the National Health Interview Survey in 2010 and 2015 among men age 50 and older (n=9598). In this nationally representative sample, a similar proportion (approximately 60 percent) of men with recent PSA testing reported one or more elements of shared decision-making in both 2010 and 2015. They also reported a modest shift away from discussions limited to the advantages of PSA testing toward full shared decision-making in which advantages, disadvantages, and uncertainties were discussed (12 percent of recently-tested men in 2010 compared to 17 percent in 2015). One in 10 men who did not receive PSA testing reported receiving one or more elements of shared decision-making, a number which did not change during the study period.

Implications

• The results suggest that, contrary to guideline recommendations, many men receiving PSA testing still do not receive shared decision-making and a limited number of men without PSA testing receive one or more shared decision-making elements.
• The authors call for new and innovative strategies to achieve more widespread application of shared decision-making for men considering PSA testing.

The Relationship Between Oseltamivir and Suicide in Pediatric Patients

James W. Antoon , and colleagues

Background Reports from the early 2000�s raised concerns about the potential for psychiatric problems in children using oseltamivir. an antiviral drug used to treat influenza Type A and B. Previous research examining the association between oseltamivir exposure and neuropsychiatric issues (including suicide) in children have had mixed findings and were limited by small sample size, older data or potential confounding. This study examines the oseltamivir - suicide association using recent data and a study design that minimizes confounding.

What This Study Found Use of oseltamivir does not increase risk of suicide in children. Researchers identified 21,047 children between one and 18 years of age who attempted suicide during the 2009-2013 influenza seasons. Of those, 251 had been exposed to oseltamivir. Mean age was approximately 15 years, and underlying mental health diagnoses were common (65 percent). Because the observed association between oseltamivir and suicide could potentially be confounded by underlying influenza infection, the analysis was repeated with influenza diagnosis alone (without oseltamivir use) as the exposure. Using this novel study design, which reduced statistical concerns found in previous studies, researchers did not find an association between oseltamivir or influenza diagnosis (only) and suicide.

Implications

Digital Rectal Examination for Prostate Cancer Screening in Primary Care: A Systematic Review and Meta-Analysis

Jason Profetto , and colleagues

Background Although digital rectal examination is commonly used to screen for prostate cancer, there is limited data to support its use in primary care. This analysis of existing research aims to evaluate the diagnostic accuracy of the digital rectal exam in screening for prostate cancer in primary care settings.

What This Study Found There is limited data to support the effectiveness of digital rectal examination in primary care. The study found that the quality of available evidence was very low and that existing studies were at risk of bias. Pooled sensitivity of the digital rectal exam among primary care physicians was 0.51 and pooled specificity was 0.59.

Implications

• Given the considerable lack of evidence supporting its efficacy, the authors recommend against routinely performing digital rectal exams to screen for prostate cancer in the primary care setting.

Moving From Problem-Oriented to Goal-Directed Health Records

Zsolt J. Nagykaldi , and colleagues

Background When electronic health records were introduced, clinicians and patients were optimistic that computer technology would facilitate higher quality, more cost-effective and more patient-centered care. However, EHRs have not met many of these expectations. This report proposes applying the Goal-Directed Health Care model, focusing on patients' life and health goals, as an organizing framework for patient care and electronic health records.

What This Study Found Meaningful reform of primary care should not only address the provision, documentation and payment of care; it should be based on patients� goals for their lives and health, with corresponding redesign of electronic health records. This report from an international team of primary care researchers recommends that the current problem-oriented fee-for-documentation structure of EHRs be replaced by a framework built around life and health goals. This focus would not only better serve patients; it would also help refocus medical professionals on the full scope of human health. To begin the process of creating goal-directed electronic health records, the authors suggest incorporating core patient profile and health planner functions into existing EHRs and creating linkages between patient characteristics and other parts of the EHR. If patient attributes captured by EHRs are expanded to include actionable sociocultural and socioeconomic information, life and health goals, care preferences, and personal risk factors, they can be leveraged by other EHR components so that patients and clinicians can work together to develop personalized care. The authors point out that, although numerous systemic and administrative health care innovations have been tried, the problem-oriented approach to care and its conceptual image coded into the medical record remain the same across innovations. If patient life and health goals are to drive health care and medical record design, shifts will also need to occur in health care delivery, measurement, and payment.

Implications

• The authors call for research into how patients and health care teams can partner effectively using goal-directed health records.

A Narrative Approach to Healing Chronic Illness

Thomas R. Egnew

Background Clinicians do not always feel prepared to manage the suffering that can accompany a patient's chronic illness. This essay suggests that, through thoughtful exploration of suffering, clinicians can support their patients through chronic and terminal illness.

What This Study Found According to the essay, "What patients bring to their clinicians is their stories." It is through these stories that clinicians try to understand and treat patients' health. When patients experience chronic or life-threatening illness and their suffering increases, clinicians can take on the role of holistic healer by addressing the inevitable existential conflicts in patients' narratives and helping them edit their stories to promote acceptance and meaning. In this guiding role, clinicians can help patients transcend suffering, "assume the mantle of their heritage as healers," and find meaning in their work.

You Will Have a New Life

Adi Finkelstein

Background For a young woman with ulcerative colitis, a total colectomy (removal of the colon) marks the end of an illness and the beginning of a journey of personal discovery.

What This Study Found The author describes her physical illness and the decision to undergo a colectomy after which, her surgeon promised her, she would have a new life. Over time, she did indeed build a new life, although perhaps not the one her surgeon envisioned. Her journey included letting go of her desire to be an exemplary patient and embracing the liberation that came with accepting her disability, as well as a career researching and teaching medical and nursing students about chronic illness. Living with her own disability while helping others better understand chronic illness is, she writes, "a paradox that sustains me."

From Transactional Tasks to Personalized Care: A New Vision of Physicians' Roles

David B. Reuben , and colleagues

Background Changes in health care delivery have affected the work that physicians perform and, in turn, their satisfaction. This essay suggests steps that can be taken to align the current and future practice of medicine with the professional mission that motivates physicians and creates satisfaction.

What This Study Found Physicians should reduce their roles in transactional aspects of care, such as gathering and entering data, providing disease-specific patient education, and providing most preventive care. Instead, such duties should be filled by other members of the health care team with complementary skills, leaving physicians to diagnose and help patients meet personal goals and objectives. Physicians would provide personalized care by synthesizing data from diverse, often discordant sources; adjudicating the competing needs of multiple conditions; adjusting patients" treatment plans to align with their goals and preferences; and advocating for patients in a complicated, fragmented health care environment. To make this approach a reality, changes would need to occur on multiple levels including health care organization and delivery, technology, reimbursement, medical education, and practice and physician "buy-in."

Implications

• The authors state that their vision would meet the needs of patients and society while closing the gap between physicians' intended patient care mission and their current transactional roles. In the process, they explain, physicians could discover joy, purpose, and meaning in their work.

When It's Time to Retire: Notes from the Afterlife

David Loxterkamp

Background The Baby Boomer generation is now retiring. This essay describes the emotional turbulence of ending one career and contemplating the next.

What This Study Found As a family physician approaches retirement, he reflects on the next chapter of his life with feelings of freedom and fear. "To live without the vestments of a career," he realizes, "is a test of faith." He finds comfort in knowing that his community will be well cared for by a new generation of physicians. On a more personal level, he is both surprised and freed by his aging body, encouraging us to "relax our grip on life, just as our skin has relaxed its grip on us." Ultimately, he puts his faith in the knowledge that, more than three decades ago, he was called to a career in medicine. "Therein lies the hope that I will be called again."