Table of Contents
The Issue in Brief
Vincent A. van Vugt , and colleagues
Background Dizziness is a common problem among older patients in primary care but is complex for clinicians to measure and diagnose. The diagnostic process is particularly challenging in older patients with dizziness, because the cause of their dizziness is usually multifactorial. Determining the cause of dizziness might help in choosing an appropriate treatment. The research team originally conducted a 2006 prospective cohort study with 417 older adults with dizziness (mean age 79 years) in primary care. At that time, participants received a full diagnostic evaluation by a physician and were classified into four dizziness subtypes: presyncope, vertigo or disequilibrium. The participants were further classified by causes of dizziness, with cardiovascular disease and peripheral vestibular disease being the most common causes. The objective of the current study was to follow participants ten years later to investigate the long-term prognosis of older patients with dizziness in primary care and their mortality and impairment outcomes.
What This Study Found In this 10 year follow up study, 169 (40.5%) of the participants from the previous study had died. Many of the patients still alive at follow-up reported experiencing substantial dizziness-related impairment (47.7%). There was no significant difference in substantial impairment between different subtypes or primary causes of dizziness. Those classified in the vertigo subtype had significantly lower mortality rates than the other subtypes after 10 years. Patients with dizziness caused by peripheral vestibular disease had a lower mortality rate than that of patients with cardiovascular disease.
Implications
- These results provide new insights in the prognosis of older patients with dizziness in primary care. The large percentage of older patients that report experiences of long-term substantial dizziness-related impairment indicates that current treatment strategies in primary care may be suboptimal.
Effect of an Interactive Website to Engage Patients in Advance Care Planning in Outpatient Settings
Michelle Howard , and colleagues
Background Advance care planning conversations do not always happen routinely between patients and health care clinicians in primary care or cancer care settings because of system constraints. Online programs may help to engage patients in advance care planning in outpatient settings. A team of Canadian researchers tested PREPARE, a one-hour online program that guides patients through the process of advance care planning. The program was developed by clinicians at the University of California San Francisco and the Veterans Affairs Medical Center, San Francisco, to increase engagement in advance care planning. The goal of the study was to implement the tool in primary care and cancer care outpatient settings in real-world practice to evaluate its impact on advance care planning engagement among older adults in the study.
What This Study Found One hundred thirty-six participants from across multiple outpatient clinic sites in Canada completed the self-paced program and a before-and-after survey. Researchers found they were better equipped to handle advance care planning after completing the online program, with improvements in their knowledge, decision making, confidence and readiness for the planning process. Additionally, participants took modest action to begin advance care planning.
Implications
- The results suggest that self-directed advance care planning tools like PREPARE could support advance care planning initiatives in outpatient health care settings and among the public.
Predicting Opioid Use Following Discharge After Cesarean Delivery
Karsten Bartels , and colleagues
Background Women who take less opioid pain medication in the 24-hour period before being discharged from the hospital after a cesarean delivery also use less opioid medication during the four weeks following discharge. Doctors prescribe opioids to most C-section patients, though the total milligram morphine equivalents they prescribe vary widely, which can unintentionally result in overprescribing pain medication. While persistent opioid use after C-section is rare, overprescribing creates a pool of uncontrolled opioids in the community, which poses a potential risk for non-medical use.
What This Study Found A team of researchers at the University of Colorado who conducted a prospective cohort study of 203 C-section patients found that those reporting low opioid intake after discharge took on average 44% less opioids in the 24-hours prior to discharge compared with those reporting higher usage. Researchers also learned that most of the patients in the study did not properly dispose of leftover opioids.
Implications
- Quantifying the amount of opioids taken during the last day of hospitalization may help better inform prescribing practices for the continuation of pain medication during recovery. The researchers recommend further study to evaluate the impact of implementing such measures on prescribing practices, pain, and functional outcomes.
General Practitioners in US Medical Practice Compared With Family Physicians
William R. Phillips , and colleagues
Background Among the mix of primary care clinicians in the US are general practitioners who provide primary care services, but whose role has evolved over the past 50 years. Historically, most generalist physicians were called general practitioners (GPs) and entered practice with 1 to 2 years of hospital-based training that was not designed to prepare physicians for community-based primary care practice. The specialty of family medicine was built on this foundation, addressing problems of insufficient access to primary care, fragmentation of care, and increasing costs. In 1969, the American Medical Association (AMA) Council on Medical Education and the independent American Board of Medical Specialties approved the American Board of Family Practice (now Family Medicine ABFM) to set standards for residency training, examination, and ongoing certification. ABFM certification requires completion of 3 years of residency training and passing of the examination. There is no certification in general practice recognized by the American Board of Medical Specialties. Those outside the medical profession, including researchers and policy makers, tend to treat GPs and FPs as a single undifferentiated group, thereby risking misclassification bias in their work and threatening the validity of their findings.
What This Study Found In this study, which was supported, in part, by the American Board of Family Medicine Foundation, family medicine researchers from the University of Washington, University of Wisconsin, University of Kentucky, and the ABFM analyzed national data on physicians in direct patient care, linking records from the AMA to ABFM board certification status, as well as to data from the Centers for Medicare and Medicaid Services and the US Department of Health and Human Services. In their analysis of all 102,604 MD and DO physicians in the United States, the authors of this study describe the personal, professional, and practice characteristics of self-identified general practitioners (GPs) as compared with American Board of Family Medicine certified family physicians (FPs). They found significant differences between the two groups. GPs are more likely to be older (average age 64.6 years for GPs compared with 49.4 for FPs), male (77% of GPs vs. 58% of FPs), DOs (28% vs. 10%), and graduates of non-US medical schools (41% vs. 23%). Few GPs have family medicine residency training (9%); less than half have any residency training directly relevant to primary care (48%). GPs and board-certified FPs practice in similar geographic locations, but GPs are less likely to participate in Medicare (53% vs. 76%) or work in hospitals (13% vs. 22%). GPs are slightly more likely to provide nursing home services (13% vs. 11%) and to make home visits (3% vs. 1%). The American Board of Family Medicine is among the Annals of Family Medicine's seven sponsoring organizations.
Implications
- General practitioners in the United States are a varied group that differ significantly from board-certified family practitioners. The authors recommend that GPs and FPs be considered separate groups for research, workforce, and policy purposes.
Anticoagulants' Safety and Effectiveness in General Practice: A Nationwide Prospective Cohort Study
Paul Frappe , and colleagues
Background Oral anticoagulant medications, like warfarin--a vitamin K antagonist, have well-proven effectiveness for those atrial fibrillation and venous thromboembolic disease indications but the drugs are associated with increased bleeding risk. The aim of this study was to compare safety and effectiveness between patients treated with vitamin K antagonists (VKAs) and patients treated with direct oral anticoagulants (DOACs) in a general practice setting.
What This Study Found Researchers tracked 1,882 adult primary care patients treated with either VKA or DOAC in their usual primary care. Their doctors recorded incidences of significant bleeding events, blood clots and death over the course of one year. Researchers then compared health outcomes for the two drug groups using a matched propensity score model. The two groups had similar rates of serious adverse events, like blood clots and major bleeding, however the VKA group had a lower incidence of minor and non-major clinically significant bleeding. However, the study also showed two times higher incidence of death in the VKA group.
Implications
- The two times higher incidence of death among patients taking VKAs aligns with prior analysis from health insurance data. The authors call for further research to explain the excess mortality with VKA.
, and colleagues
Background Most Muslims who have diabetes engage in intermittent fasting during Ramadan, yet there are concerns regarding how to safely manage diabetes while fasting. A study of fasting adults with type 2 diabetes found that those who managed their condition in collaboration with their health care provider using an empowerment-based approach, saw greater improvements in glycemic control. Health researchers from the University of California, Irvine and the National University of Singapore developed a collaborative diabetes management tool tailored for fasting Muslims and their doctors called FAST, or "Fasting Algorithm for Singaporeans with Type 2 Diabetes." The FAST tool sought to empower diabetic patients who fast with Ramadan-specific educational materials, dosing modification information for patients and their doctors, and encouragement of active self-monitoring of blood glucose before, during and after fasting.
What This Study Found The FAST tool was evaluated for safety and effectiveness in a prospective, multi-center, randomized controlled trial with 111 fasting adults with type two diabetes in Singapore. Additionally, the FAST protocol did not increase the risk of hypoglycemic events. On average, those in the FAST intervention group showed four times the reduction in hemoglobin A1c compared to the control group (-0.4% vs -0.1%, 95% CI: -0.605 to - 0.001, p = 0.049), in measures taken before and after the fasting period. There were no major hypoglycemic events in either group, and no increase in minor hypoglycemic events in the FAST group.
Implications
- The researchers conclude that the use of empowerment-based, tailored tools for diabetes management like FAST can help observant Muslims with diabetes fast safely. According to the lead author, "This is one of the first tools that brings together Ramadan education, guidance for healthcare providers and elements of patient empowerment, which can be incorporated into standard practice guidelines and resulting in a global paradigm shift for diabetes management among Muslims who fast during Ramadan."
Assessing Risks of Polypharmacy Involving Medications With Anticholinergic Properties
Frances S. Mair , and colleagues
Background Many common prescription medications for urinary problems and muscle spasms, as well over-the-counter medications for cold, cough and allergies, share an anticholinergic property. The use of multiple medications in this class can lead to negative cumulative effects referred to as anticholinergic burden. ACB is known to increase the risk for future adverse events like falls, dementia, heart attack, stroke, and death. Guidelines recommend against using anticholinergic medications for geriatric patients, but little is known about their effect on middle-aged patients. A variety of assessment scales are available for doctors and researchers to calculate a patient's risk of ACB. A study of more than 500,000 middle-aged adults, aged 37 to 73 years in the United Kingdom, compared 10 of those scales to assess their accuracy in predicting risk for future adverse events.
What This Study Found Researchers found that all 10 ACB scales identified individuals at higher risk for heart attack, stroke and death, after adjusting for sociodemographic and baseline health factors. Each scale also had significant predictive accuracy for falls and dementia. While the study showed consistent association between ACB and adverse outcomes, regardless of which scale was used, the populations identified as being at risk varied considerably depending on which scale was used. Less than one in four people detected to be at risk by one scale were also detected by the other three most frequently used scales.
Implications
- This variation across scales has implications for clinical practice and research interventions to target anticholinergic burden.
Maternity Care and Buprenorphine Prescribing in New Family Physicians
Josh St. Louis , and colleagues
Background Data focused on opioid-use disorder (OUD) among pregnant women shows that opioid-related overdoses constitute a major contribution to pregnancy-related mortality despite the existence of effective treatment options. The Federal Drug Administration has approved the use of both methadone and buprenorphine for management of OUD during pregnancy. While methadone is obtained by visiting a federally certified outpatient treatment center daily to receive a dose, pregnant women can get buprenorphine in primary care. Physicians, nurse practitioners (NPs), and physician assistants (PAs) can prescribe buprenorphine for treatment of OUD to patients in their care, including pregnant women, after completing a brief training course (8 hours for physicians and 24 hours for NPs and PAs). Medication-assisted treatment has been shown to decrease mortality from OUD as well as to decrease overdose, acquisition of HIV and hepatitis C, and relapse, in comparison with abstinence-based treatment. Yet only 10.6% of patients with OUD are receiving treatment, and women with OUD still experience high rates of overdose and mortality, particularly in the postpartum period.
What This Study Found The research team behind this study sought to characterize the recently trained family medicine workforce that may be providing buprenorphine to pregnant patients. Using data from the 2016, 2017 and 2018 National Family Medicine Graduate Survey, administered annually by the American Board of Family Medicine, they asked clinicians who graduated from family medicine residency programs within the past three years whether "maternity care" or "buprenorphine treatment" were part of their practice and whether they were currently delivering babies. Of the 5,103 respondents in their sample, 153 both deliver babies and prescribe buprenorphine. A further 108 respondents provide maternity care and prescribe buprenorphine but do not perform deliveries. The researchers note that it is not clear whether the surveyed physicians are necessarily providing pregnancy care and prescribing buprenorphine to the same patients. Of 614 total family medicine residencies represented in the survey, only 15 of them, mostly in urban areas on the East and West Coasts, trained 25% of the respondents who provide this care. Early-career family physicians who both provide maternity care and prescribe buprenorphine primarily completed their training in a small number of residency programs. As data about the risks of maternal mortality from substance use disorder emerges, it will be important to increase training opportunities in family medicine residencies to meet the needs of pregnant women with substance use disorder.
Implications
- The workforce of family physicians providing coordinated care for pregnant women with OUD in the United States appears to be small, concentrated in urban areas, and is overwhelmingly comprised of family physicians who trained in a small number of residency programs.
- Innovative solutions for improving access to this particularly vulnerable patient population should focus on incentivizing integration of buprenorphine training into more family medicine and OB/GYN residency programs, especially those found in rural areas of the United States.
Carol Sinnott , and colleagues
Background Operational failures in health care are system-level errors in the supply of information, equipment, and materials to health care personnel. By degrading individual and organizational performance, operational failures complicate the delivery of high-quality care, with multiple adverse consequences for patient safety and experience, efficiency, and worker satisfaction. In this systematic review, the authors synthesize the existing research literature on operational failures in primary care.
What This Study Found The included studies show a gap between what physicians perceived they should be doing and what they were doing, which was strongly linked to operational failures--including those relating to technology, information, and coordination--over which physicians often had limited control. Operational failures actively configured physicians� work by requiring significant compensatory labor to deliver the goals of care. This labor was typically unaccounted for in scheduling or reward systems and had adverse consequences for physician and patient experience.
Implications
- Primary care physicians' efforts to compensate for suboptimal work systems are often concealed, risking an incomplete picture of the work they do and problems they routinely face. Future research must identify which operational failures are highest impact and tractable to improvement.
What I Wish My Doctor Really Knew: The Voices of Patients With Obesity
Christie Befort , and colleagues
Background "Obese--what a cruel word," opens an essay written by a coalition of patients involved in a weight reduction medical trial. The essay channels the collective voice of a group of patients who were organized to advise the study.
What This Study Found The authors share the doubt, dread and anxiety they experience at doctors appointments--fearing judgement, prejudice and insensitivity--and in conversations with doctors around weight management and their health. They identify key limitations in how obesity is addressed in primary care visits and describe the components of more effective treatment plans. Finally, the patient advisory panel describes the competencies they would like to see from medical professionals: "If we had to summarize what we want providers to know...it is this: we want you to know how to look at us, to see each of us as a person."
Caring for Rohingya Refugees With Diphtheria and Measles: On the Ethics of Humanity
Ramin Asgary
Background In 2017, Rohingya refugees fleeing Myanmar arrived in Bangladesh, where Ramin Asgary, MD, an MSF medical advisor and professor of global health, was helping to establish medical services. The refugee camps were ravaged by a dual outbreak of measles and diphtheria--two diseases that, under less complex circumstances, were easily preventable with inexpensive vaccines.
What This Study Found A Doctors Without Borders/Medecins Sans Frontieres field doctor reveals the personal toll it takes to establish medical services during a humanitarian health crisis. In his essay, Asgary invites readers to join him on his medical rounds as he treats patients in makeshift medical tents. Intimately, he reveals the thought process of a humanitarian physician responding to an environment of perpetual desperation.