Index by author
The Issue in Brief
Ann Fam Med 17: 290.
The Issue in Brief
A Nationwide Flash-Mob Study for Suspected Acute Coronary Syndrome
Jochen W.L. Cals , and colleagues
Background The dual aim of this study was to evaluate the Marburg Heart Score, a clinical decision rule, and/or develop an adapted clinical decision rule for family practitioners to safely rule out acute coronary syndrome in patients referred to secondary care for suspected ACS; and also to evaluate the feasibility of using a "flash mob" method, an innovative new study design, for large scale research in family medicine.
What This Study Found This study finds that, in emergency care, acute coronary syndrome cannot be safely ruled out using the Marburg Heart Score or the family physicians' clinical assessment. In a period of only 2 weeks, researchers at Maastricht University collected data on 258 ACS-suspected patients by mobilizing 1 in 5 family physicians throughout the Netherlands to participate in the study. This mobilization was done by enlisting ambassadors among the FP community in the Netherlands who then spread the word through traditional professional and social networks. The study found that among 243 patients receiving a final diagnosis, 45 (18.5%) were diagnosed with acute coronary syndrome. Sensitivity for the FP rating was 86.7% and sensitivity for the MHS was 94.4%.
Implications
- While large, prospective studies can be time consuming and costly, this innovative flash mob method of research, named after the large-scale public collaborations/gatherings driven by social media, allowed for the fast investigation of one simple question on a large scale in a short timeframe.
Family Physicians' Experiences of Physical Examination
Martina Ann Kelly , and colleagues
Background The increased availability of reliable diagnostic technologies has stimulated debate about the utility of physical examination in contemporary clinical practice. To reappraise its utility, this study explored family physicians' experiences.
What This Study Found As Affordable Care technology has gained ground in medicine and critics have called into question the diagnostic accuracy of physical examinations, what place does the practice of the physical exam have in today's clinic? In depth, qualitative interviews with 16 family physicians in Canada revealed a common view that physical examinations help promote a healthy patient-physician relationship and constitute an integral part of being a good doctor. Guided by principles of phenomenology, which considers how human beings experience a certain phenomenon--in this case, the physical examination itself--the research found that in addition to diagnostic information gained in physical examinations, the empathic benefits of "laying on hands" served as an important reminder of the physician's role as healer.
Implications
- At a time when contemporary clinical practice is grappling with the influx of emerging diagnostic technology, the physical exam is seen by many doctors as a grounding and centering element of the time-honored art of family medicine.
Hajira Dambha-Miller , and colleagues
Background It is hypothesized that better patient experiences of practitioner empathy could lead to better health outcomes.
What This Study Found A United Kingdom study designed to examine the association between primary care practitioner empathy and incidence of cardiovascular disease and all-cause mortality among type 2 diabetes patients found that those patients experiencing greater empathy in the year following their diagnosis saw beneficial long-term clinical outcomes. Using the consultation and relational empathy (CARE) questionnaire, which measures patients' experience of care with a focus on empathy, a numerical score for 628 participants from 49 general practices in East Anglia, UK, was computed 12 months after diagnosis. Those patients reporting better experiences of empathy had a lower risk (40-50%) of all-cause mortality over the subsequent 10 years compared with those reporting low practitioner empathy.
Implications
- While medicine moves increasingly towards precision, target-driven health care and technology-based assessment models, these findings suggest that interpersonal, empathic care may be an important determinant in the risk of mortality.
Michael L. Parchman , and colleagues
Background Six key elements to opioid medication management redesign in primary care have been previously identified. This study examines the effect of implementing these "Six Building Blocks" on opioid prescribing practices.
What This Study Found In rural practice, a system redesign resulted in declines in the proportion of patients on high dose opioids and the number of patients receiving opioids. The Six Building Blocks, a team-based redesign of opioid medication management within smaller practice settings addressing policy changes, patient agreements, patient tracking, in-clinic support, and success metrics, was implemented in 20 clinic locations across eastern Washington and central Idaho. Among patients aged 21 years and over, there was a 2.2% decline in patients receiving high dose opioids over a period of 15 months, compared to a 1.3% decline in the control group. Similarly, a 14% decline was observed in the total number of patients receiving opioids in the intervention clinics compared to a 4.8% control group decline.
Implications
- The results indicate that efforts to redesign care by primary care teams, guided by the Six Building Blocks framework, can improve opioid prescribing practices and possibly reduce dependency.
A Structured Approach to Detecting and Treating Depression in Primacy Care: VitalSign6 Project
Madhukar H. Trivedi , and colleagues
Background Major Depressive Disorder affects 5-10% of adults in the United States every year. This report describes outcomes of an ongoing quality-improvement project in a large US metropolitan area to improve recognition, treatment, and outcomes of depressed patients in sixteen primary care clinics.
What This Study Found A questionnaire-based management algorithm for major depressive disorder in primary care is feasible to implement, though attrition from treatment is high. Among 25,000 patients in primary care clinics in a large metropolitan area, 4,325 (17%) screened positive for depression with 2,426 having a clinician-diagnosed depressive disorder. Of the 2,160 patients who had 18 weeks of follow-up care, 65% were treated with medication. Remission, defined as a PHQ-9 score of less than 5, was more common in patients who experienced 3 or more follow-up visits. Of those who returned for 3 or more visits, 41.7% achieved remission. However, more than one-half of those diagnosed did not return for any follow-up care.
Implications
- The findings of this study suggest that patients suffering from depression can be successfully treated using measurement-based care within the primary care setting, and stronger emphasis on patient education and other approaches to reduce attrition may be needed for patients who fail to return for follow-up care.
Nathalie Huguet , and colleagues
Background The Affordable Care Act improved access to health insurance, yet millions remain uninsured. While many of those uninsured patients receive care from community health centers (CHCs), little is known about their health conditions and utilization. We assessed ambulatory care utilization and diagnosed health conditions among a cohort of CHC patients uninsured pre-ACA and followed them post-ACA.
What This Study Found In community health centers in Medicaid expansion states, among established patients who were uninsured prior to the Affordable Care Act, many remained uninsured after implementation of the Obama-era law. Using electronic health record data across 11 Medicaid expansion states, an Oregon Health & Science University study tracking uninsured patients before and after the implementation of the ACA found that 21% of those patients remained continuously uninsured, 15% gained Medicaid, 12% gained other insurance, and 51% did not visit their Community Health Center post ACA implementation. The 21% who remained uninsured were largely Hispanic and spoke Spanish as their primary language, indicating both a language and potential legal barrier to enrollment in the ACA. These uninsured patients continued to have frequent healthcare visits and the majority had at least one health condition that would require continuous care.
Implications
- The results of this study point to a need for additional funding to support the needs of Community Health Centers serving the uninsured.
Family Physician Perceptions of Their Role in Managing the Opioid Crisis
Laura Desveaux , and colleagues
Background This study examines the perspectives of family physicians on opioid prescribing and management of chronic pain to better understand the barriers to safer prescribing in primary care as well as the differences in perspectives that may drive variations in practice.
What This Study Found Family physicians prescribe the greatest volume of opioids (22.9%) and number of prescriptions (31.2%) to individuals with chronic noncancer pain, making them targets for quality improvements in safer prescribing practices. Interviews with 22 family physicians in Ontario, Canada, from June to July 2017 identified key themes driving the overprescription of opioids in managing chronic pain: the contrast between doctors' training and current expectations; navigating patient and system expectations; and the duration and quality of therapeutic relationships. Physicians with 5 or fewer years' professional experience emphasized the need to create trusting relationships with their patients as well as the difficulties arising in conversations about chronic pain, including surveillance and urine screening. Physicians with longstanding, stable practices of around 15 years or more, described stronger, more trusting therapeutic relationships that lessened the need for strict enforcement measures. Both groups complained of a lack of resources to support effective pain management.
Implications
- A combination of outside pressures and system expectations around the issue of opioid prescriptions places family physicians at the center of an emotionally-charged debate, and at a heightened risk of burnout.
Jeffrey F. Scherrer , and colleagues
Background African American patients are more likely than white patients to experience cognitive decline following type 2 diabetes mellitus. While metformin use has been associated with a lower risk of dementia compared with sulfonylurea, evidence for whether this association differs by race is sparse.
What This Study Found A large observational cohort study examining male veterans aged over 50 years with type 2 diabetes found that metformin use was associated with a significantly lower risk of dementia in African American patients. The study included data from 73,500 patients who received care through the Veteran's Health Administration from 2000-2015 and were diabetes- and dementia-free at baseline and who subsequently developed type 2 diabetes and began treatment with either metformin or sulfonylurea. Cox proportional hazards models, using propensity scores and inverse probability treatment to balance confounding factors, were computed to measure the association of both drugs and incident dementia across race and age groups. For African American patients aged 50-64 years, the hazard ratio for developing dementia was 0.60 (CI, 0.45-0.81), and for African American patients aged 65-74 years, the hazard ratio was 0.71 (CI, 0.53-0.94). The study showed modest to no association between metformin and lower risk for dementia in white patients 65-74 and no association in other age groups.
Implications
- The present results may point to a novel approach for reducing dementia risk in African American patients with type 2 diabetes mellitus.
Primary Care Appointments for Medicaid Beneficiaries With Advanced Practitioners
Molly Candon , and colleagues
Background Under the Affordable Care Act (ACA), the US uninsured rate fell from 13.3% in 2013 to 8.8% in 2017. Because the supply of primary care physicians remained relatively stable, it has been theorized that advanced practitioners are increasingly being relied on to treat Medicaid patients. This study considers that possibility using a secret shopper study that measures the share of primary care appointments scheduled with advanced practitioners before, during, and after the ACA.
What This Study Found The advent of the Affordable Care Act has led to millions of new patients seeking primary care. Because the number of primary care physicians has remained stable, access to care has been a concern. This "secret shopper" study performed between 2012 and 2016 showed that the proportion of primary care appointments scheduled for Medicaid patients with nonphysician advanced practitioners, like nurse practitioners and physician assistants, increased from 7.7% to 12.9% across a sample of 3,742 randomly selected primary care practices in 10 states. This roughly corresponds with the decrease in the rate of uninsured Americans and with the increase in Medicaid recipients since the Affordable Care Act began. The number of appointments scheduled with nonphysician advanced practitioners was higher at federally qualified health centers than other non-FQHC clinics.
Implications
- As the population ages and chronic conditions increase, demand for primary care may strain the supply of primary care physicians. Medicaid beneficiaries are at particular risk of poor access due to lower reimbursement rates and less physician participation in Medicaid. These findings indicate that primary care practices are already accommodating these patients by increasing the share of appointments scheduled with APs.
Powering-Up Primary Care Teams: Advanced Team Care With In-Room Support
Thomas Bodenheimer , and colleagues
Background Primary care teams are underpowered because they do not maximally redistribute team functions, causing physicians to perform time-consuming clerical work. This commentary describes "advanced team care with in-room support" as a way to power-up primary care teams.
What This Study Found In this special report, the authors argue that the current primary care team paradigm is underpowered, in that most of the administrative responsibility still falls mainly on the physician. Jobs not requiring a medical education, such as entering data into electronic health records, should not be handled by physicians and advanced practitioners. The authors propose a model where a physician with 2 or 3 highly trained care team coordinators (CTCs) share patient responsibilities, with the CTCs organizing the visit, completing documentation, and coordinating follow-up care, and the physician handling components of the visit that require more complex decision making. There is evidence that this model improves patient care, reduces physician burnout, and is financially sustainable.
Implications
- The authors identify a number of themes, or mindsets, such as the idea that technology can replace people, that are barriers to implementation of these models in family medicine.