Table of Contents
The Issue in Brief
Lay Health Coaching to Increase Appropriate Inhaler Use in COPD: A Randomized Controlled Trial
Rachel Willard-Grace , and colleagues
Background Over 14 million U.S. adults have chronic obstructive pulmonary disease, and many face barriers to using inhaled medications regularly and effectively. Although inhaled medications can improve daily life and long-term outcomes, only 25 to 43% of people with COPD use them regularly. In addition, inhalers can be complex to use--requiring users to master a series of six to eight steps that differ across devices. Physicians and health teams have not yet found a solution to bring COPD medication adherence to the level of other chronic diseases.
What This Study Found In a multi-site randomized controlled trial from the University of California, San Francisco, non-licensed, trained health coaches offered COPD patients one-on-one support in person and by phone, with contact at least every three weeks for nine months. Participants were primarily low-income, African American and Latino men in an urban area. Those who received health coaching showed significant improvement in adherence to controller inhalers and improved inhaler technique, with 40% of health-coached patients versus 11% of a control group able to demonstrate effective use of their inhalers after the intervention.
Implications
- The study's lay health coaching approach is grounded in shared decision making principles, which aligns with recent calls to incorporate collaborative care to address and improve adherence to inhaled medication for COPD. Researchers conclude that improved inhaler technique and adherence are one of multiple factors contributing to long-term COPD outcomes, but their research has confirmed one technique--use of lay health coaches--that may help patients get optimal benefit from their COPD medications.
Monika M. Safford , and colleagues
Background Rural communities in the Southeastern United States have the highest prevalence of diabetes in the nation. They face considerable barriers to successful diabetes self-management, and up to 75% of adults with diabetes report chronic pain, and may also have depression, anxiety, and physical or emotional disabilities. Cognitive behavioral therapy (CBT) is an effective nonpharmacologic intervention for chronic pain, but it hasn't been well studied in diabetes and chronic pain. Evidence for the effectiveness of peer coach-delivered CBT-based programs for diabetes and chronic pain is also limited.
What This Study Found Trained community members in rural Alabama delivered a diabetes self-management program that incorporated cognitive behavioral approaches to overcoming pain as a barrier to physical activity. Peer trainers were African American women who had personal experiences with diabetes and were lifelong community members. Similarly, participants were mostly low-income African American women recruited through community connections and assigned to the intervention by town block randomization. Adults who completed the 10-week program showed significant improvements in functional status, pain, and quality of life, when compared to a peer-led general health advice control group. At the end of the program, adults in the cognitive behavioral therapy-based program were more likely to report having no pain or finding alternative exercises when pain prevented them from walking.
Implications
- These results demonstrate that peers trained to deliver CBT-based interventions can improve health outcomes in areas where access is limited.
- A peer-delivered program for managing diabetes and chronic pain was shown to be beneficial for rural adults in communities that might otherwise lack access to physician-led services.
Takuya Aoki , and colleagues
Background In Japan, primary care services are generally delivered in both outpatient departments within hospitals and in community-based offices, that are often privately-owned and operate independently of hospitals. Little is known on the differences in patient experience between hospital-based and community-based office primary care practices in Japan.
What This Study Found A comparison of the strengths and challenges of primary care between hospital-based practices and community-based office practices was observed in a cross-sectional study in Japan. Six small and medium-sized hospitals and 19 community-based office practices participated in the study of 1,725 patients. Patient experience was measured using a Japanese version of the Primary Care Assessment Tool, which was comprised of first contact, longitudinality, coordination, comprehensiveness (services provided), and community orientation.
Implications
- Understanding the strengths of each practice type with respect to patient experience may inform future efforts to improve the patient experience overall.
Caregiver and Clinician Perspectives on Missed Well-Child Visits
Elizabeth R. Wolf , and colleagues
Background Despite the benefits of well-child care visits (WCV), up to half of WCVs are missed. Little is known about why children miss these visits.
What This Study Found A team of researchers and pediatricians at Virginia Commonwealth University, University of Washington, and the University of Vermont sought to understand the challenges that prevent families from attending their child's scheduled appointment. They interviewed English and Spanish-speaking caregivers of children who had missed WCVs as well as family and pediatric physicians from a large safety-net health system in Richmond, Virginia. Caregivers and physicians alike identified social and structural factors as key barriers to attendance, including transportation, difficulty taking time off from work, childcare, and underlying financial stressors. Clinicians also thought that caregivers may prioritize attending WCVs in which vaccinations are typically given. Clinicians expressed concern that immigration and language differences may be barriers to attendance. Spanish-speaking caregivers thought that availability of language services made them more interested in attending WCVs.
Implications
- The researchers conclude, "Our findings suggest there is a need to further explore the potential relationship between well-child visit attendance and social determinants of health..." Future research emphasis could be placed on understanding and helping the children missing the greatest number of visits."
Patients Assess an eConsult Model's Acceptability at 5 US Academic Medical Centers
Sara L. Ackerman , and colleagues
Background Electronic consultation (eConsult), involving asynchronous primary care clinician-to-specialist consultation, is being adopted at a growing number of health systems. A new study shifts focus from clinician to patient perspectives on the idea of eConsult and patient preferences for involvement in eConsult decision making.
What This Study Found A study across five academic medical centers examined the reaction of patients to the use of electronic consultation for primary care for provider-to-specialist consultation. This focus group study of adult primary care patients was conducted to better understand patients' opinions, as most previous studies focused on clinical and financial impacts and clinician responsibility. Fifty-two participants across five focus groups were introduced to the eConsult model and were asked to discuss potential benefits and drawbacks, as well as acceptability of a hypothetical copay and preferences for involvement in future eConsult decision making and communication. Participants reacted favorably to the eConsult concept; quicker access to specialty care and convenience were cited as key benefits, with approval rates particularly high among those having a trusted primary care clinician. Some patients wanted to be involved in the eConsult decision making and communication. They also expressed a decreased enthusiasm about eConsults if they had a copay. Participants were also concerned about potential misuse of the system and about the exclusion of the patient's illness narrative in the eConsult exchange.
Implications
- The authors argue that the success of eConsult models hinges not only on the engagement and buy-in of primary care clinicians and specialists, but on patient-clinician relationships.
- Furthermore, they recommend that eConsult program implementation projects build in patient outreach strategies and include patients' perspectives in clinician education efforts. The authors note that talking with patients at an early phase of the eConsult implementation process enabled them to share findings with implementation teams as they developed clinician and patient outreach strategies.
- They also recommend that future research assess eConsult experiences and decision-making preferences of more diverse patients, including those with limited digital literacy and without a regular primary care clinician.
Scott R. Garrison , and colleagues
Background Without supporting evidence, clinicians commonly recommend that warfarin be taken in the evening.
What This Study Found A new study shows evidence that morning versus evening dosing has insignificant bearing on how long the drug provides the most benefit for preventing adverse health events. Two hundred and seventeen adults who regularly used warfarin in the evenings were randomized to the trial, with about half switching to morning medication use for seven months. Researchers measured the effectiveness of the drug by tracking the proportion of time that patients spent outside of the range for maximum effectiveness of the drug. Therapeutic changes did not significantly differ for patients who switched to morning administration.
Implications
- The clinical research team concluded that the time of day a patient takes the medicine has no effect on the stability of warfarin�s anticoagulant effect. Patients should take warfarin whenever regular compliance would be easiest.
Sonal J. Patil , and colleagues
Background Conventional clinic blood pressure measurements are frequently inaccurate, and physicians and patients are often reluctant to intensify hypertension treatment when convinced of falsely elevated readings in clinic. At the same time, clinic readings are routinely used for hypertension diagnosis, management, and physician performance measures. Additionally, there is evidence that BP measured at home, repeatedly, and then averaged provides more accuracy than clinic readings alone.
What This Study Found A pilot study from the University of Missouri concluded that a physician's decision not to intensify hypertension treatment is often a contextually appropriate choice. In two-thirds of cases where physicians did not change treatment for patients with hypertension, patients' blood pressure returned to normal in follow-up readings taken at home. This pre- and post-study tracked 90 patients with hypertension to understand the role that follow-up home blood pressure measures could play in understanding cases of "therapeutic inertia." Sixty-six percent of patients who had a blood pressure reading of 140/90 or higher when they were in the clinic and whose doctors did not change their treatment, had average readings under 140/90 when patients took their blood pressure at home. Additionally, when surveyed after the home blood pressure reading intervention, participants shared that home blood pressure monitoring enhanced their understanding of blood pressure control. Eighty-three percent of participants agreed that they would consider buying a home blood pressure monitor if it was covered by insurance.
Implications
- According to the authors, there are implications for health care quality metrics. Doctors' success rates in controlling hypertension are based solely on clinic blood pressure rates. The authors extrapolated the home blood pressure metrics to show that when home metrics replaced clinical ones, the department�s hypertension control success rates rose from 58% to 86%. They conclude, "Most validated home blood pressure should be accepted and preferred for physician hypertension performance measures."
Cancer Screening Among Women Prescribed Opioids: A National Study
Alicia Agnoli , and colleagues
Background Concerns have been raised that in the primary care setting, treating chronic pain and managing opioid prescriptions may be associated with negative preventive care outcomes. Managing patient pain and prescription opioids takes considerable time, and these competing demands may strain and impair the delivery of evidence-based preventive health needs, such as recommended cancer screenings.
What This Study Found Researchers at the University of California, Davis analyzed data from a nationally representative sample of 53,982 women in the United States. Findings revealed that women who are prescribed opioids were more likely to receive breast, cervical, and colorectal cancer screenings for the simple fact that they are frequent users of the health care system. They had a median number of doctor visits that was five times higher than their non-prescribed counterparts. When this factor was controlled for, analysis showed no association between prescription opioid use and cancer screening. Authors conclude that U.S. women who take prescription opioids are no less likely to receive key cancer screenings when compared to women who are not prescribed opioids.
Implications
- This study is one of the first to examine access to key preventive health services for opioid versus non-opioid users. Authors suggest that "the key driver of whether women receive recommended cancer screening is simply how often they see the doctor."
Differences in Diabetes Care With and Without Certification as a Medical Home
Leif I. Solberg , and colleagues
Background There are still many unanswered questions on what makes a patient-centered medical home (PCMH) distinct from non-certified practices in primary care. Researchers pose the question: How do practice systems and outcomes in a PCMH-recognized practice different from those in others without that designation? And further, are PCMH practice system requirements associated with better diabetes outcomes?
What This Study Found Researchers compared 258 certified medical home primary care practices in Minnesota to 136 non-certified practices, to see if certification had any bearing on performance measures related to the quality of diabetes care. Certified practices were found to have slightly more medical home practice systems than uncertified practices. Additionally, certified practices had somewhat better performance outcomes on quality measures related to diabetes care. Uncertified practices, comprising 39 percent of the surveyed practices, were noted to be more rural but had similar patient populations.
Implications
- Practices certified as medical homes have more systems and improved performance for diabetes care, but the differences are modest.
- According to the authors, the data collected suggests that practices that chose to be certified may have done so in part because they already had more systems and were performing better on outcome measures.
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A Blueprint for Planning and Implementing a Transgender Health Program
, and colleagues
Background Many transgender people seek medical interventions to affirm their gender identity, but few primary care programs provide gender-affirming hormone therapy, surgical referrals, or wrap-around services to an increasingly visible transgender population.
What This Study Found Leading educators and clinical experts on transgender health care from Harvard, Fenway Health, and The Fenway Institute provide a concise and practical guide to developing transgender health programs within existing primary care practices. Programs may be as streamlined as having one or two clinicians who provide hormone therapy within a welcoming primary care practice. The guide provides tips on how to access low-cost clinical training and how to generate organizational buy-in for the development of new services. The plan can be adapted across primary care practices of varying sizes and resources.
Implications
- This is the first peer-reviewed publication that provides a guide to implementing a transgender health program in primary care settings. Such programs provide a much-needed service for this underserved but increasingly visible population that experiences significant health inequities.