Table of Contents

The Issue in Brief

March/April 2019

Systolic Blood Pressure and Cognitive Decline in Older Adults With Hypertension

Jacobijn Gussekloo , and colleagues

Background Studies of hypertension tend to exclude patients with complex health problems and lack generalizability. This study set out to determine if, for older patients being treated for hypertension, both with and without complex health problems, systolic blood pressure is linked to one-year changes in cognitive/daily functioning or quality of life.

What This Study Found In people aged 75 years and older who are being treated for hypertension, systolic blood pressure less than 130 mm Hg is associated with additional cognitive decline, particularly in individuals with complex health problems. Researchers in the Netherlands analyzed data for 1,266 participants in the Integrated Systematic Care for Older Persons study. Patients were stratified by systolic blood pressure in the year before baseline, and change was evaluated from baseline to one-year follow-up in outcome measures evaluating cognitive function (the Mini-Mental State Examination), activities of daily living, and quality of life. For participants being treated for hypertension, there was a clear trend across categories of systolic blood pressure: with lower systolic blood pressure, cognitive declined worsened at one-year follow-up. For participants being treated for hypertension and with systolic blood pressure less than 130 mm Hg, cognitive decline in one year averaged 0.90 points on the Mini-Mental State Examination compared to 0.14 points for those with systolic blood pressure greater than 150 mm Hg, a 0.76-point less decline. The results were similar for participants with complex health problems (n=674). Compared to the reference group (systolic blood pressure less than 130 mm Hg), participants showed less cognitive decline after one year by 0.99 points on the Mini-Mental State Examination when systolic blood pressure was 130-150 mm Hg and by 1.39 points when systolic blood pressure was greater than 150 mm Hg. Daily functioning and quality of life were the same across the strata of systolic blood pressure and antihypertensive treatment.

Implications

• The authors call for more studies to determine if there is a causal relationship between systolic blood pressure and cognitive decline and to understand the mechanism of the association observed. Until the results of new trials are available, they state, clinicians must decide on the appropriate treatment for hypertension in older patients.

Loneliness in Primary Care Patients: A Prevalence Study

Rebecca A. Mullen , and colleagues

Background Loneliness has important health consequences. However, little is known about loneliness in primary care patient populations. This study describes the prevalence of loneliness in patients presenting for primary care and its association with demographic factors, health care utilization, and health-related quality of life.

What This Study Found Twenty percent of adult patients making routine primary care visits report being lonely, and the prevalence is higher in younger patients. A survey of 1,235 primary care patients in Colorado and Virginia found that 246 (20 percent) reported lack of companionship, feeling left out, and feelings of isolation from others. The prevalence of loneliness decreased with age, with 33 percent (18/58) of respondents less than 25 years old reporting loneliness compared to 11 percent (34/307) of those over 65 years old. Loneliness was significantly associated with relationship status and employment status. Respondents who were divorced, separated, widowed or never married, as well as those who were unemployed or disabled, had a significantly higher prevalence of loneliness than other respondents. People in poor health were more likely to report loneliness, and a high level of loneliness was positively associated with three measures of health care utilization: number of visits to the primary care office, number of hospitalizations, and number of emergency room or urgent care visits.

Implications

• These findings contribute to the growing body of evidence that loneliness is widespread and associated with poor health.
• The authors call on primary care clinicians to prioritize social connections as they consider the risks and needs of lonely patients.

Trends in Providing Out-of-Office, Urgent After-Hours, and On-Call Care in British Columbia

Lindsay Hedden , and colleagues

Background Providing care outside of office hours and in alternative (non-office) locations (such as facilities for urgent after-hours care or long-term care), helps increase access and comprehensiveness of primary care. This study examines trends in and determinants of the provision of these services in a cohort of primary care physicians in British Columbia, Canada.

What This Study Found During a six-year period, there was a significant decline in the provision of primary care services outside of regular office hours and at alternative locations. An analysis of physician-level payments for all primary care physicians practicing in British Columbia between 2006 and 2012 (n=6,531 physicians) found that the proportion of physicians providing care in non-office locations and after hours declined significantly in rural, urban, and metropolitan practice locations. Declines ranged from five percent for long-term care visits to 22 percent for after-hours care. Female physicians and those in the oldest age category had lower odds of providing care at alternative locations or in urgent after-hours care. Rural physicians had significantly higher odds of providing care in alternative locations and after hours compared to those practicing in metropolitan areas. The authors note that these declines occurred in the context of significant financial incentives intended to promote full-service family practice.

Implications

• This trend in provision of services points to increasing challenges in primary care accessibility, both within Canada and elsewhere, according to the authors.

Antibiotic Prescribing for Acute Respiratory Tract Infections 12 Months After Communication and CRP Training: A Randomized Trial

Paul Little , and colleagues

Background Training clinicians in communication skills to explore patients' concerns has been shown reduce antibiotic prescribing for lower respiratory tract infections. In addition, point-of-care testing for C-reactive protein can have diagnostic utility in cases of respiratory tract infection. A study of internet-based physician training for communication skills, including use of an interactive patient booklet, and testing for C-reactive protein previously found that, at 3 months, both interventions reduced antibiotic prescribing. This report examines the effect of the interventions after 12 months.

What This Study Found Although training physicians in communication skills and in testing for C-reactive protein has short-term effectiveness in reducing antibiotic prescriptions, this analysis finds that only communication training remains effective over time. In this six-country study, 246 general practices received internet-based training in patient-centered communication, including use of an interactive patient booklet, and point-of-care testing for C-reactive protein. Participants were cluster randomized to one of four groups: usual care (n=61), training for C-reactive protein point-of-care testing (n=62), training in communication skills and use of patient booklet (n=61), or combined interventions (n=62). At 12 months, antibiotic prescribing was reduced in usual care (from 58 percent at three months to 51 percent at 12 months), but increased in the C-reactive protein testing group (from 35 percent to 43 percent). When compared to three-month data, reductions in prescribing for communication training were maintained at 40 percent (465/1,166). Despite being freely provided, C-reactive protein testing was rarely used, and patient booklets were used only sparingly.

Implications

• The authors suggest that, in routine primary care practice, training clinicians to use CRP testing is likely to yield short-term benefits. Training in enhanced communication skills provides the most useful long-lasting effects.

Identifying Adverse Drug Events in Older Community-Dwelling Patients

Caitriona Cahir , and colleagues

Background Patient reporting of suspected adverse drug events could increase knowledge about the safety of medication and provide important information to healthcare professionals. This study evaluates a patient-reported instrument for identifying adverse drug events in older adults with multiple medical conditions in the community setting.

What This Study Found Older adults often do not recognize a medical symptom as an adverse effect of their medication. In the study, patients 70 years of age or older were asked if they had experienced a list of 74 symptoms in the previous six months and if, (1) they believed the symptom was related to their medication; (2) the symptom had bothered them; (3) they had discussed it with their family physician, and (4) they required hospital care due to the symptom. Self-reported symptoms were independently reviewed by two clinicians who determined the likelihood that the symptom was an adverse drug event. Family physician medical records were also reviewed for any report of an adverse drug event. Among 859 participating patients, 674 (78 percent) were classified as having at least one adverse drug event during the study period. Antithrombotic drugs (intended to reduce the formation of blood clots) were most frequently associated with adverse drug events, with 86 percent of patients prescribed aspirin and warfarin reporting bruising, bleeding, and indigestion. Patients were most bothered by muscle pain and weakness (75 percent), dizziness or lightheadedness (61 percent), and unsteadiness on their feet (52 percent) but did not associate these symptoms with their medication. Patients were less bothered by more prevalent adverse drug events; only 21 percent were bothered by minor hemorrhages from antithrombotic therapy. On average, patients reported 39 percent of adverse drug events to their family physician. Patients who did not do so felt the symptoms were the result of old age and did not want to bother their doctors.

Implications

• The authors call for health information technology and patient outreach programs to manage and track medication symptoms and help patients monitor their medications.

Visit Planning Using a Waiting Room Health IT Tool: The Aligning Patients and Providers Randomized Controlled Trial

Richard W. Grant , and colleagues

Background There is limited time during primary care visits. This study tests the hypothesis that an information technology tool in the waiting room could help patients identify and express their top visit priorities, which would lead to better visit interactions and improved quality of care.

What This Study Found An information technology tool in waiting rooms of primary care practices helped patients prepare questions and express their concerns to their doctors, but did not reduce gaps in clinical care. The "Visit Planner" tool, which was placed in eight primary care practices, was designed to help adult patients identify priorities for their visit and effectively express them to their clinician. Eligible patients had at least one clinical care gap (eg, not meeting diabetes goals). Of 359 patients in the intervention group, 59 percent (n=198) reported that they "definitely" prepared questions for their doctor, compared to 45 percent (n=160) of control patients. A high percentage of intervention group patients also reported "definitely" expressing their top concerns at the beginning of the doctor visit (91 percent vs 83 percent of control group patients). Patients in both arms of the study reported high levels of satisfaction with their care. Overall, half of study patients (394/747, 53 percent) had all baseline care gaps closed by the end of the 6-month follow-up period. The prevalence of clinical care gaps was reduced by a similar amount in both groups.

Implications

• The Visit Planner successfully guided patients to begin primary care visits by communicating their top care priorities, an important gap in visit interactions. Improving this crucial first step of prioritization, the authors state, can be a building block for the next generation of tools that address communication barriers related to care planning with the ultimate goal of improving clinical care outcomes.

Primary Care Clinician Adherence to Specialist Advice in Electronic Consultation

Clare Liddy , and colleagues

Background Electronic consultation (eConsult) services can improve access to specialist advice, however, little is known about whether and how often primary care clinicians adhere to the advice they receive. This study evaluates how primary care clinicians use recommendations conveyed by specialists in an eConsult service and how eConsult affects clinical management of patients in primary care.

What This Study Found In a retrospective chart audit of 291 eConsults, primary care clinicians adhered to specialist advice in 82 percent of cases. Questions asked of specialists most often related to diagnosis (63 percent). Other questions addressed management (27 percent), drug treatment (10 percent), and procedure (1 percent). The eConsult's results were communicated to patients in 79 percent of cases, most often by face-to-face meeting (38 percent), phone call (32 percent), or through a patient portal (9 percent). Communication occurred in a median of 5 days. The most consulted specialties were dermatology (32 percent), orthopedics (8 percent), and neurology (7 percent).

Implications

• In light of the high primary care clinician adherence to specialist recommendations and primary care clinician-to-patient communication, the authors suggest that eConsult delivers good quality care and improves patient management.

Geographic Characteristics of Loneliness in Primary Care

Sebastian Tong , and colleagues

Background There is growing evidence of the effects of loneliness on aspects of health, but little is known about whether loneliness is associated with where we live. This study set out to determine the associations between community factors and loneliness.

What This Study Found Living in zip codes with higher unemployment, poor access to health care, lower income, and poor transportation are associated with higher mean loneliness scores. The findings were based on responses to the Three-Item Loneliness Scale screening tool. Of 1,235 survey respondents, 20 percent were identified as lonely. Higher mean loneliness scores were associated with a number of neighborhood characteristics: greater poverty, higher social deprivation, higher proportions of unemployment, more one-person households, more female residents, more black residents, higher mean travel time to work, higher percentage of households with no vehicle, a higher percentage of residents without health insurance, and a higher percentage of residents with no usual source of medical care.

Implications

• Given the associations between loneliness and other community-level factors, screening for loneliness may be a proxy for other social needs, the authors suggest.
• The authors call on primary care practices to take a leading role in developing and testing interventions for loneliness and to consider loneliness as an important social concern for their patients.

The Practice Gap: National Estimates of Screening and Counseling for Alcohol, Tobacco, and Obesity

Paul R. Shafer , and colleagues

Background Tobacco use, lack of physical activity and poor diet, and alcohol consumption are leading causes of death in the United States and the US Preventive Services Task Force has developed recommendations aimed at reducing their prevalence. This study estimates screening and counseling rates using a nationally representative sample of adults.

What This Study Found Based on a survey of 2,186 adults, researchers estimated appropriate screening and counseling rates for tobacco use, obesity, and alcohol misuse. They found that receipt of recommended levels of services ranged from nearly two-thirds (64 percent for obesity and 62 percent for tobacco use) to less than half (41 percent for alcohol misuse).

Implications

• The authors note that while there is significant room for improving screening and counseling rates, primary care practices will likely need additional resources to effectively do so. For example, counseling can be provided within primary care or referred from primary care, and strategies are available.
• Because solutions may vary, the authors call for approaches that take into account the local environment in order to balance the many competing demands of primary care.

Accuracy of Signs and Symptoms for the Diagnosis of Acute Rhinosinusitis and Acute Bacterial Rhinosinusitis

Mark H. Ebell , and colleagues

Background Although acute rhinosinusitis (sinus inflammation) is the most common reason for outpatient prescription of antibiotics, only about one-third of patients with sinus symptoms have a confirmed bacterial pathogen that is amenable to antibiotics. Helping physicians more accurately identify patients with acute bacterial rhinosinusitis could reduce inappropriate antibiotic use and its harms. This study analyzes existing research to evaluate the accuracy of signs and symptoms of acute rhinosinusitis.

What This Study Found Based on an analysis of existing research, three symptoms can help clinicians identify patients with the bacterial rhinosinusitis. These symptoms include clinical impression (the clinician's preliminary or working diagnosis), pain in the teeth, and bad breath. Acute rhinosinusitis, which may be viral or bacterial, is significantly less likely in patients without nasal discharge, without a complaint of purulent nasal discharge (yellow to green mucus), and in those with normal transillumination (light can be transmitted through the sinuses and is not blocked by secretions). Clinical decision rules for the diagnosis of both acute and acute bacterial rhinosinusitis have not yet been prospectively validated.

Sharing My Diagnosis: How Much is Too Much?

Heather A. Thompson Buum

Background For a primary care physician diagnosed with breast cancer, becoming a patient profoundly influenced her practice style and patient interactions. She wondered, "Is it ever appropriate to disclose my situation, my diagnosis, any details about my cancer journey to my patients?"

What This Study Found As a member of the medical profession, in which privacy is highly valued, she recognized the need for boundaries and objectivity. As a patient, however, she learned the importance of personal connection and support. "I have no easy answers," she states, "but I do see potential benefits to helping patients cope with the nature of an illness, a new diagnosis, potentially frightening or confusing treatment plans--that's what I spent years of my life training to do, and continue to do, every day. I just never thought I would accomplish any of it in quite this way."