Table of Contents

The Issue in Brief

Chronic Opioid Prescribing in Primary Care: Factors and Perspectives

Sebastian Tong , and colleagues

Background Primary care clinicians write almost half of all opioid prescriptions in the United States but little is known about the characteristics of these clinicians and their patients who receive opioids. This study describes patient and clinician characteristics and clinicians' perspectives of chronic opioid prescribing in primary care

What This Study Found Chronic opioid prescribing in primary care varies significantly by patient and clinician characteristics. This analysis of 2016 electronic health record data included 21 primary care practices, 271 clinicians, and 84,929 patients. Eleven percent of patients seen received an opioid prescription, while 1% received chronic opioid prescriptions. Oxycodone-acetaminophen was the most commonly prescribed opioid, followed by oxycodone. In urban underserved clinics, 10% of prescriptions written were for opioids, compared to 3% of prescriptions in suburban clinics. Being female, being of black race, and having risks for opioid-related harms, such as mental health diagnoses, substance use disorder and concurrent benzodiazepine use, were associated with being prescribed chronic opioids. Patients with higher comorbidities were more likely to receive chronic opioid prescriptions and at higher doses. In interviews, clinicians described the use of opioids to manage chronic pain as appropriate for patients with extensive medical comorbidities or patients for whom non-opioid pain medications were contraindicated. However, most were reluctant to begin patients on opioids for chronic pain. Many felt frustrated by lack of time to appropriately manage patients� chronic pain and lack of control over patients' access to other sources of opioids.

Implications

• The authors call for research to explore trends in opioid prescribing, compare the differences in opioid prescribing in various settings, and test interventions to help primary care clinicians overcome barriers in weaning patients with high risks of opioid-related harms.

Opioid and Substance Use Disorder and Receipt of Treatment Among Parents Living With Children in the United States, 2015-2017

Lisa Clemans-Cope , and colleagues

Background Previous research shows that about one in five people with opioid use disorder receive treatment, but little is known about the prevalence of the disorder or treatment for it among parents who live with children.

What This Study Found An estimated 623,000 parents with opioid use disorder in the United States are living with children under the age of 18, and fewer than one-third of the parents have received substance use treatment. An additional four million parents have other substance use disorders, with even lower treatment rates. Researchers from the Urban Institute analyzed data from the 2015 to 2017 National Survey of Drug Use and Health, a nationally representative cross-sectional survey. They found that the rate of opioid use disorder among parents living with a child under 18 years of age was 0.9%, or an estimated 623,000 parents. Of these, 42% had one or more other substance use disorders in addition to opioid use disorder. Among parents living in households with children, 6%, or an estimated 4.2 million parents, had substance use disorders that did not include opioids. More than one in five parents with opioid use disorder had suicidal thoughts and behavior and nearly 25% had serious mental illness, a higher rate of mental health problems than parents with other substance use disorders. Twenty-eight percent of parents with opioid use disorder received drug or alcohol treatment at a specialty facility or other doctor's office, compared to 6% of those with other substance use disorders.

Implications

• Primary care practices can play a critical role in addressing substance use disorder issues among parents, the authors state, including screening and diagnosing substance use disorders, motivating behavior change, and facilitating initiation of treatment.

Comparing Buprenorphine-Prescribing Physicians Across Nonmetropolitan and Metropolitan Areas in the United States

Lewei (Allison) Lin , and colleagues

Background As the United States undertakes intense efforts to increase the number of prescribers of buprenorphine for opioid use disorder, it is critical to understand who currently provides such treatment and how.

What This Study Found In nonmetropolitan areas, buprenorphine is almost twice as likely to be provided by a primary care physician, compared to large metropolitan areas where specialists in addiction or psychiatry provide a majority of treatment. In a survey of a national random sample of buprenorphine physician prescribers (N = 1,174), 11% (N = 132) practiced in nonmetropolitan/rural areas, 33% (N = 382) practiced in small metropolitan areas, and 56% (N = 660) were located in large metropolitan areas. Buprenorphine prescribers in nonmetropolitan areas were much more likely to be primary care physicians, accept Medicaid, and less likely to work in an individual practice. Overall, buprenorphine prescribers across the rural/urban continuum were similar in many of their treatment practices, including frequency of visits and dosing.

Implications

• The authors recommend further research to understand variation in treatment practices and quality and how treatment relates to patient perceptions and outcomes.

A New Comprehensive Measure of High-Value Aspects of Primary Care

Rebecca S. Etz , and colleagues

Background There are a number of measures to assess aspects of primary care, but a new measure breaks new ground by combining experiences of patients, clinicians, and payers and allowing the most informed reporter--the patient--to assess vital primary care functions that are often missed.

What This Study Found Researchers asked crowdsourced samples of 412 patients, 525 primary care clinicians, and 85 health care payers to describe what provides value in primary care, then asked 70 primary care and health services experts for additional insights. A multidisciplinary team analyzed these qualitative data to develop a set of patient-reported items. The resulting Person-Centered Primary Care Measure concisely represents the broad scope of primary care, with 11 domains each represented by a single item: accessibility, comprehensiveness, continuity, integration, coordination, relationship, advocacy, family context, community context, health promotion, and goal-oriented care. While existing measures evaluate the experience of care delivery based only on clinical processes and outcomes, the new measure focuses on care aspects that contribute to patient perceptions of the integrating, prioritizing, and personalizing functions of primary care.

Implications

• The ability to assess primary care as a whole and through the lens of the patient makes the Person-Centered Primary Care Measure both unique and meaningful, the authors state.

Predictors of Adverse Outcomes in Uncomplicated Lower Respiratory Tract Infections

Michael Moore , and colleagues

Background Although antibiotics provide little benefit for acute uncomplicated respiratory tract infections, patients and clinicians are often concerned about more severe or prolonged illness and complications. To help decision making in such cases, this study investigates the clinical features that predict future serious adverse outcomes of respiratory tract infections.

What This Study Found In routine primary care practice, serious adverse outcomes occur in only 1% of adult patients with lower respiratory tract infection, but such outcomes may be predicted with moderate accuracy. In this study of 28,846 adult patients with lower respiratory tract infections, researchers recorded patient characteristics and clinical findings and identified adverse events (i.e., late onset pneumonia, hospital admission, or death) during a 30-day period following the patient visit. Serious adverse outcomes occurred in 325 of 28,846 patient visits. Three categories of factors independently predicted adverse outcomes from lower respiratory tract infection: severity of patient symptoms, patient vulnerability to serious illness, and the physiological impact of symptoms. These factors can be used to predict adverse outcomes by conversion to an eight-point score.

Implications

• An 8-item clinical prediction score for respiratory tract infections may help clinicians target prescribing based on predicted risk and identify a small group of high risk patients who may benefit from closer monitoring.

Reducing Primary Care Attendance Intentions for Pediatric Respiratory Tract Infections

Annegret Schneider , and colleagues

Background Respiratory tract infections are a common reason that children visit a primary care clinician, yet such visits are costly, time-consuming and can lead to unnecessary antibiotic prescribing. This study examines whether providing mothers with actionable information can reduce their intentions to visit primary care for their children's respiratory tract infections.

What This Study Found An online intervention with real-time information on locally circulating viruses may reduce mothers� intentions to visit their primary care doctor. A representative sample of mothers in the United Kingdom (N = 806) was randomized to receive the online intervention, including locally enhanced influenza statistics, symptom information, and home-care advice, either before (intervention group) or after (control group) responding to a hypothetical respiratory tract infection illness scenario. Participants in the intervention group had lower intentions to visit the doctor than those in the control group when adjusted for demographic and clinical characteristics. Intervention material was generally well received, with information on symptoms and when to visit the primary care doctor rated as more important than information on locally circulating viruses.

Implications

• If the intervention were rolled out widely, the authors surmise that it would have impact, given the high rates at which parents of children with respiratory tract infections visit primary care clinicians..
• The authors call for research to evaluate intervention effects on observed behavioral outcomes in real-world settings and examine long-term effects and cost-effectiveness

Shifting Implementation Science Theory to Empower Primary Care Practices

Jenna Howard , and colleagues

Background Primary care dissemination and implementation science has focused on strategies to help practices implement evidence-based care to achieve quality metrics and meet policy requirements. For many practices, this "outside in" approach has had unintended consequences including disempowerment, limited success, and burnout from burden, disruption and moral distress.

What This Study Found Three cases reveal that it is possible for some primary care practices to shift the direction of change by seizing ownership of their care and prioritizing the craft of family medicine. In all three cases, practice founders were unable to match their practice to their values because of conventional financing systems and commercial electronic health records. Each developed a business model that circumvented the limitations of fee-for-documentation and pay-for-performance. Clinical care and business models differed between the practices, but all three succeeded in shifting the source and directional emphasis of change from outside-in to inside-out. The authors explain that, based on these examples, they are re-imagining the science of dissemination and implementation, from helping practices comply with externally-sourced evidence and recommendations to empowering practices to discover and enact their own wisdom in a challenging environment.

Implications

• Shifting the direction of practice change from "outside in" to "inside out" could open a new frontier in the science of dissemination and implementation and inform better health policy, the authors state.

Potentially Inappropriate Prescribing Among Older Persons: A Meta-Analysis of Observational Studies

Tau Ming Liew , and colleagues

Background Potentially inappropriate prescribing (the prescribing or under-prescribing of medications) is a common yet preventable medical error. This study examines whether such prescribing produces adverse outcomes in older primary care patients.

What This Study Found In older adults, inappropriate prescribing in primary care is associated with a wide range of adverse outcomes, but not mortality. An analysis of existing studies looked at potentially inappropriate prescribing in older persons that could cause significant harm. The analysis found that, although potentially inappropriate prescribing did not affect mortality, it was significantly associated with emergency room visits, adverse drug events, functional decline, health-related quality of life, and hospitalizations.

Implications

• According to the authors, the findings highlight the need to address potentially inappropriate prescribing in primary care. They call for further research into effective interventions, and they call on researchers to consider the potential implications of how potentially inappropriate prescribing is operationalized in their work.

Contributions of Health Care to Longevity: A Review of 4 Estimation Methods

Robert M. Kaplan , and colleagues

Background A widely cited statistic suggests that health care services account for only a small percentage of the variation in American life expectancy. However, the methodology supporting the finding has been challenged. To explore the robustness of the finding, a new report examines four methods that rely on different outcome measures, analytic techniques, and data sets to consider the percentage of premature deaths or poor health outcomes that can be attributed to health care and other factors.

What This Study Found Health care services account for only a small percentage of the variation in American life expectancy, according to the report. Estimates from four methods suggest that health care accounts for between 5% and 15% of the variation in premature death. In contrast, behavioral and social factors account for a much higher percentage of variation in premature mortality, ranging from 16% to 65%. This analysis affirms previous findings that health care is only one component of a larger set of influences on health outcomes.

Implications

• The authors suggest that a more diversified portfolio of national investments would generate a higher health yield. For example, spending on non-medical social services for each dollar spent on medical care averages about two dollars in wealthy countries that report data to the Organization for Economic Cooperation and Development compared to 55 cents in the United States.