Table of Contents
The Issue in Brief
Social Isolation and Patient Experience in Older Adults
Takuya Aoki , and colleagues
Background Social isolation has been shown to have negative effects on health. This study explores the relationship between social isolation and the experience of elderly patients in primary care.
What This Study Found Among older people, social isolation is associated with a negative experience as a primary care patient. A cross-sectional study in 28 primary care practices in Japan utilized screening tools to assess social isolation and patients' experiences of key domains of primary care: first contact, in which the primary care clinician is the patient's usual entry point into the health care system; longitudinality or duration of the patient-physician relationship; coordination of care by the primary care clinician; comprehensiveness of services available and provided; and community orientation of care. Among 465 patients age 65 years or older, social isolation was negatively associated with overall primary care assessment scores and was significantly associated with longitudinality, comprehensiveness of services provided, and community orientation. Comprehensiveness of services provided had the strongest association with social isolation.
Implications
- These findings, the authors suggest, can contribute to our understanding of how social isolation influences health.
- The authors call for targeted interventions for socially isolated elderly patients aimed at improving their experience of primary care.
Adoption of Social Determinants of Health EHR Tools by Community Health Centers
Rachel Gold , and colleagues
Background A growing awareness that social factors--the conditions in which people live, work and play--influence health suggests that it is crucial to document such information in patients' electronic health records. This pilot study assesses the feasibility of implementing electronic health record tools for collecting, reviewing, and acting on patient-reported social determinants of health data in community health centers.
What This Study Found The study found that adopting EHR tools to systematically document social determinants of health in primary care is feasible, but substantial barriers exist. Researchers implemented social determinants data tools in three Pacific Northwest community health centers. Among 1,130 patients for whom social determinants data were collected, 97 to 99 percent (n = 1,098) had one or more social need documented in the EHR, with 210 (19 percent) receiving an EHR-documented social determinants referral. Fifteen to 21 percent of patients with a documented social need wanted help from the clinic to address the need. Although the study identified many barriers to implementing and designing tools and workflows, participating community health centers successfully documented social determinants in the EHR and continued to do so post-study.
Implications
- The authors explain that, to meet the growing national emphasis on documentation of social determinants of health in EHRs, a wide range of factors and substantial gaps in knowledge must be addressed.
Xueyan Wang , and colleagues
Background Children's intake of beverages high in free (i.e., added) fructose have been tied to an increased incidence of asthma. This study investigates possible associations between allergic sensitization and consumption of drinks high in free fructose by children and adolescents.
What This Study Found This study offers preliminary evidence of a possible link between beverages that are high in free (added) fructose and allergic symptoms or allergic sensitization in children and adolescents. Analyses of 860 children and 1,142 adolescents in the 2005-2006 National Health and Nutrition Examination Survey do not yield entirely consistent findings, but lend some support to an association between allergy and high intake of beverages with excess free fructose. After controlling for potential confounders, children who consumed non-diet fruit drinks at least five times per week had 2.5 times greater odds of allergic sensitization than children who consumed such beverages one to three times per month. The association was stronger among adolescents; those who consumed beverages with excess free fructose one to four times per week or at least five times per week were five times more likely to have allergic symptoms than those who seldom drank such beverages. Adolescents consuming apple juice at least five times per week were twice as likely to have allergic sensitization than those who seldom consumed such beverages.
Implications
- These findings provide some evidence for the hypothesis that there may be a link between intake of beverages high in free fructose and allergic symptoms or allergic sensitization in children and adolescents. Longitudinal studies are needed to confirm the causality and to clarify underlying mechanisms
Emergency Department Use and Enrollment in a Medical Home Providing After-Hours Care
Tara Kiran , and colleagues
Background Compared to other high-income countries, Canada and the US have among the highest rates of emergency department use and the lowest rates of primary care physicians reporting arrangements for after-hours care. This study evaluates whether enrollment in a medical home mandated to provide after-hours care in Ontario, Canada is associated with reduced emergency department use.
What This Study Found Enrollment in a medical home mandated to provide after-hours care is associated with a small increase in emergency department visit rates. This large-scale study of all adults in Ontario enrolled in medical homes between April 1, 2005 and March 31, 2012 (n = 2,945,087) found that in the years before enrollment in a medical home, the emergency department visit rate increased by 0.8 percent per year. After medical home transition, the rate increased by 1.5 percent per year. Enrollment in a medical home was also associated with a decrease in the overall primary care visit rate but a small increase in continuity of care. The authors hypothesize that the decline in the primary care visit rate associated with medical home enrollment may help explain the counter-intuitive increase in emergency department visits. Canada's health care reforms were implemented in the context of a relatively fixed primary care workforce, and increased after-hours primary care may have been offset by a decrease in regular office hours. Another possible explanation is that introducing mandatory after-hours provision with medical homes fueled greater demand for health care.
Implications
- This study highlights the importance of prospectively evaluating reform efforts that aim to improve access to primary care after hours, the authors state.
Predicting an Unfavorable Course of Dizziness in Older Patients
Hanneke Stam , and colleagues
Background Dizziness, which strongly affects daily functioning in older adults, can refer to several different sensations. Defining the type of dizziness might help the physician better understand the cause of a patient"s dizziness. The aim of this study is to develop and externally validate a prediction model for an unfavorable course of dizziness in older people in primary care, with dizziness-related impairment as starting point.
What This Study Found A new tool can help primary care physicians identify older patients at risk of an unfavorable course of dizziness (i.e., six months of substantial dizziness-related impairment). The risk score, based on a validated prediction model, consists of four easily obtained predictors of dizziness: age, history of arrhythmia, score on the Dizziness Handicap Inventory (screening version), and looking up as a trigger for dizziness.
Implications
- The authors suggest that the tool can activate primary care physicians to target potential contributing factors for high risk of an unfavorable course of dizziness, even when the cause of dizziness is unknown.
Top 20 POEMs of the Past 20 Years: A Survey of Practice-Changing Research for Family Physicians
Mark H. Ebell , and colleagues
Background POEMs (Patient Oriented Evidence that Matters) are studies that address a relevant clinical question, demonstrate improved patient-oriented outcomes, and have the potential to change practice. This report identifies POEMs in each of the last 20 years that were highest ranked by the originators of POEMs for having recommended a major and persistent change in practice.
What This Study Found POEMs have recommended novel effective interventions (e.g., beta-blockers in heart failure and a longer interval between Pap smears for most women), abandoning ineffective practices (e.g., routinely recommending hormone replacement therapy for postmenopausal women), and abandoning potentially harmful practices (e.g., intensive blood sugar control for patients with type 2 diabetes mellitus and aggressive therapy for low-grade prostate cancer).
Implications
- These POEMs illustrate the breadth of practice change in primary care and the need for family physicians to have a systematic approach to keeping up with the medical literature.
Opioid-Prescribing Continuity and Risky Opioid Prescriptions
Sara E. Hallvik , and colleagues
Background In an effort to reduce risks associated with taking opioids, clinical guidelines often emphasize continuity between patients and opioid prescribers. This study aims to better understand the association between opioid prescribing continuity, risky prescribing patterns, and overdose risk.
What This Study Found An ongoing relationship between patients with long-term opioid use and the doctors who prescribe the medication is associated with fewer risky opioid prescriptions and fewer opioid-related hospitalizations. This retrospective cohort study analyzed data from Oregon"s Prescription Drug Monitoring Program, Vital Statistics, and hospital discharge registry for more than 78,000 patients with long-term opioid use. Patients with higher continuity with the physician prescribing opioids received fewer risky prescriptions (based on multiple prescriber metrics) compared to patients in the lowest continuity quartile, and were less likely to be hospitalized for opioid-related causes. However, on average, patients with long-term opioid use had significantly lower continuity scores than patients with long-term use of a stimulant or benzodiazepine, suggesting that efforts are still needed to improve opioid prescribing continuity.
Implications
- This study, which adds to the limited literature on prescriber continuity and opioids, suggests that continuity with the prescribing physician is an important factor associated with reducing opioid harms.
Buprenorphine Provision by Early Career Family Physicians
Sebastian T. Tong , and colleagues
Background Buprenorphine can be used to treat opioid use disorder, but many family physicians feel unprepared to provide such care. This study describes preparedness to provide and current provision of buprenorphine treatment by early career family physicians.
What This Study Found Few early career family physicians report being adequately trained to provide buprenorphine treatment for opioid use disorder and even fewer provide it in their practices. Analyses of data from 1,979 family physicians who completed residency in 2013 found that 10 percent (n = 198) felt adequately trained during residency to provide buprenorphine, and seven percent (n = 138) reported providing buprenorphine treatment in their current practice. Of those currently providing buprenorphine, 46 percent (n = 63) reported they were prepared in residency to do so. However, more than two-thirds of those residency-trained to provide buprenorphine are not doing so in practice, suggesting logistical barriers to providing buprenorphine after graduation.
Implications
- According to the authors, promoting residency training in buprenorphine treatment and overcoming barriers to its provision in practice could increase access to addiction services.
Employment Interventions in Health Settings: A Systematic Review and Synthesis
Andrew D. Pinto , and colleagues
Background Employment status is a key social determinant of health. This analysis sets out to identify existing studies of employment interventions in health settings and common characteristics of successful interventions.
What This Study Found When health care organizations try to help patients find employment, they do so through innovative, complex interventions. Researchers in Toronto conducted a systematic review of 88 existing studies of interventions in a variety of health settings (e.g., primary care practices, hospitals, emergency departments, community health centers, and health centers in prisons) to help unemployed patients gain employment. Most articles (89 percent) focused on people with mental illness. The majority of studies (74 percent) succeeded in helping patients gain employment. Characteristics of successful interventions included, (1) a collaborative multidisciplinary team with regular communication, (2) a comprehensive package of services, (3) individualized components, (4) a holistic view of health and social needs, and (5) prospective engagement with employers.
Implications
- The authors suggest that primary care practices can begin addressing employment issues by raising awareness of employment as an important social determinant of health, training staff (e.g., social workers, community health workers and system navigators) to provide employment support, and building relationships with employment services.
- Research to evaluate the long-term impact of employment interventions across different health care settings and with diverse patients is also needed, the authors state.
Professional Loneliness and the Loss of the Doctors' Dining Room
John J. Frey III
Background Amongst the many ongoing discussions of physician burnout and dysphoria, the loss of professional connections and relationships among physicians -- being a part of a professional community -- is rarely mentioned as a source of professional unhappiness. In this essay, family physician John Frey reflects on how, as an intern in the 1960s, the hospital dining room for doctors was his source of political and medical acculturation and socialization.
What This Study Found The demise of doctors' dining rooms in subsequent years, Frey suggests, reflects the professional isolation that characterizes primary care practice today, with fewer opportunities to interact with colleagues, particularly those outside the physician's practice setting. For most medical professionals, he observes, lunch has become a solitary pursuit in front of a computer screen, rather than a shared collegial experience. Frey calls for more social interaction during medical training and more emphasis on being part of a community of professionals: "Not valuing time with other physicians or making informal conversations possible leads to a soulless efficiency and professional isolation that drains physicians of our ability to help ourselves, help each other and help patients," he writes.