Index by author
The Issue in Brief
The Issue in Brief
Martijn J.L. Verhulst, and colleagues
Background Individuals with diabetes are at greater risk of developing oral health issues, like gum disease, yet care for these linked health issues are usually disconnected, split between primary care and dental care. A research team from the University of Amsterdam developed an intervention that provided primary care–based oral health information and dental referrals for patients with diabetes.
What This Study Found In a cluster randomized controlled trial, 764 patients from 24 primary care practices received either the oral health support or standard primary care. Participants were asked to rate their oral health quality of life, as well as their general health and any oral health complaints, at the start and end of the study. Analysis showed that individuals who received the primary care–based oral health support intervention had a significant increase in their self-reported oral health quality of life when compared with the control group.
Implications
- The authors conclude that, “patients with type 2 diabetes who attend primary diabetes care can benefit from extra attention to oral health.” They add, “It also further reflects the concept of oral health and general health being connected.”
Clinical Quality Measure Exchange Is Not Easy
Robert L. Phillips, Jr, and colleagues
Background Family physicians provide nearly 20% of all clinical outpatient visits, translating to 200 million visits in the U.S. annually, according to the Centers for Disease Control and Prevention. Frontline clinicians continue to report failures of certified electronic health records (EHRs) to meet federal certification requirements and electronic reporting needs.
What This Study Found Researchers created the Trial of Aggregate Data Exchange for Maintenance of certification
and Raising Quality, a randomized controlled trial, to assess whether quality measure
reporting could be made a byproduct of clinical care and quality improvement. They
recruited family physicians from four health systems. A total of 256 family physicians
participated. Of 19 measures negotiated for use, five were used by all systems. The
researchers identified 15 types of errors, including breaks in data delivery; changes
in measures; and nonsensical measure results. Only one system had no identified errors.
The study concluded that the secure transfer of standardized, physician-level quality
measures from the four health systems, despite their having mature processes in place,
proved difficult. There were many errors that required human intervention and manual
repair, which precluded full automation.
Implications
- The study reconfirms that despite widespread health information technology adoption and federally meaningful use policies, health care remains far from reaching its goals of making clinical quality reporting a reliable byproduct of care.
Takashi Chinen, and colleagues
Background It’s widely understood that people taking a common class of antibiotics like ciprofloxacin and levofloxacin run the risk of tendonitis and tendon ruptures. However, a new analysis sheds light on newer, third-generation fluoroquinolones and suggests they may have a lower risk of Achilles tendon rupture.
What This Study Found Researchers from Jichi Medical University in Tochigi, Japan, used health care administrative data to identify 504 patient cases of Achilles tendon ruptures with co-occurrence of antibiotics. They found that third-generation fluoroquinolones were not associated with an increase in Achilles tendon rupture. First and second generation fluoroquinolones like ciprofloxacin and ofloxacin were at elevated risk of tendon rupture, which was consistent with previous evidence.
Implications
- Third-generation fluoroquinolone use was not associated with an increased risk of Achilles tendon rupture. These antibiotics may be a safer option for patients in whom this risk is elevated, such as athletes.
Drivers of Scope of Practice in Family Medicine: A Conceptual Model
Amy Russell, and colleagues
Background Although new family medicine graduates intend to provide a broader scope of practice than their senior counterparts, individual family physicians’ scope of practice has been decreasing, with fewer family physicians providing basic primary care services, such pediatric and prenatal care.
What This Study Found Russell et al conducted a study to explore family medicine graduates’ attitudes and perspectives on modifiable and non-modifiable factors that influenced their scope of practice and career choices. The authors conducted five focus group discussions with 32 family physicians and explored their attitudes and perspectives on their desired and actual scope of practice. Using a conceptual framework to understand the influences on practice scope, the authors found that personal factors played a role on desired scope while workplace, environmental and population factors influenced actual practice scope. Stressors that occurred in these four categories often caused family physicians to narrow their scope of practice. Understanding personal, environmental, workplace and population factors that influence practice scope can inform specific interventions that create desirable jobs for family physicians and improve their ability to meet changing population needs. Supportive factors of a broader-scope practice include training and access to additional medical education after training; access to mentors; strong organizational leadership; and team-based care.
Randi G. Sokol, and colleagues
Background Between 11% to 40% of adults in the U.S. experience chronic pain, and primary care physicians may feel ill-equipped to effectively and safely care for patients with chronic pain, addiction or both.
What This Study Found Researchers from Tufts University conducted a study to evaluate the effectiveness of an interdisciplinary consultation service that supports primary care physicians (PCPs) who care for patients experiencing chronic pain and addiction. The goal was to identify new and effective strategies that clinics can use to support PCPs.
From that interdisciplinary consultation service, the researchers collected and thematically
analyzed 66 referral questions and 14 interviews with PCPs to better understand the
types of support physicians would find most beneficial.
PCPs’ expressed needs included needing expertise in addiction, safe prescribing of
opioids, non-opioid treatment options, communication strategies for difficult conversations,
a comprehensive review of the case, and a biopsychosocial approach to management.
Some additional needs were identified after interviews, including confirmation of
their medical decision-making process, emotional validation, feeling more control,
having an outside entity take the burden off the PCP for management decisions, boundary
setting, and reframing the visit to focus on the patient’s function, values, and goals.
Implications
- An interdisciplinary consultation service can effectively support primary care physicians
who care for patients battling pain and addiction. The authors offer potential strategies
that health systems can use to support PCPs in caring for patients living with chronic
pain and addiction.
Anna Ishani Perera, and colleagues
Background Inappropriate antibiotic prescribing for upper respiratory tract infections contributes to antibiotic resistance, making some bacterial infections difficult to treat. This often leads to higher medical costs, prolonged hospital stays and increased mortality. Still, many physicians report prescribing antibiotics at their patients’ request. To address patients’ expectations for antibiotic prescribing for URTIs, researchers conducted an experiment in which study participants were assigned brief educational videos to watch on a tablet immediately prior to their appointment.
What This Study Found The authors randomized patients into three groups – one that viewed a presentation about the futility of antibiotic treatment of URTIs; a second group that viewed a presentation about the adverse effects associated with antibiotics; and a third control group that learned about the benefits of healthy diet/exercise.The researchers then measured the effects of the presentations on patients’ beliefs that antibiotics are helpful for URTIs; their expectations to be prescribed an antibiotic; and whether they were actually prescribed antibiotics for their URTIs. Participants who viewed either the futility or adverse effects presentations had greater reductions in their expectations of receiving antibiotics compared to the group that viewed the video about the benefits of healthy/diet and exercise. However, there was no significant difference between the three groups when it came to doctors actually prescribing antibiotics to patients.
Implications
- A brief, tablet-based waiting room intervention significantly changes participants’
expectations on receiving antibiotics for URTIs, but that future efforts to improve
antibiotic prescribing need to involve both patients and their doctors.
Deborah J. Cohen, and colleagues
Background In order to make meaningful gains in cardiovascular disease care, primary care medical practices should adopt a set of care improvements specific to their practice size and type. High blood pressure and smoking are among the biggest risk factors associated with cardiovascular disease. Primary care physicians help patients manage high blood pressure and provide smoking cessation interventions. Researchers collected qualitative data from a subset of participating EvidenceNOW primary care practices to answer the following research question: In the context of an initiative focused on improving cardiovascular disease preventive care, what factors and operational changes were linked to improvements in smoking and blood pressure outcomes?
What This Study Found Researchers found that there is no one central playbook for all types of practices,
but they did identify combinations of practice characteristics, amount of practice
facilitation, and operational changes linked with improved cardiovascular disease
care. Smaller, solo and clinician-owned practices that changed routine aspects of
their process, such as training medical assistants to perform accurate blood pressure
readings; allowing staff to take repeated blood pressure measures and note second
readings in electronic medical records; and equipping clinicians with the tools to
perform smoking screening and cessation referrals, were able to make substantial improvements.
In addition, working with a practice facilitator helped. Smaller practices that participated
in a moderate amount of facilitation were able to make these improvements. However,
for larger hospital or health system–owned practices and Federally Qualified Health
Centers more facilitation was necessary.
Implications
- Researchers conclude: “making operational changes alone—in certain clinical settings—was insufficient to achieve meaningful improvements.” In practices that are part of larger, more complex systems, external facilitation along with prioritization of operational changes may be critical to successful quality improvement.
Emily C. White VanGompel, and colleagues
Background Most patients with depression are treated in primary care, and the majority of those
patients prefer psychotherapy over treatment that includes medication (i.e., pharmacotherapy).
Primary care physicians, however, don’t usually provide psychotherapy and are inclined
to prescribe antidepressants to patients with depression in their care.
Although studies have shown the effectiveness of psychotherapy in primary care patients,
researchers haven’t extensively examined the outcomes in which psychotherapy for primary
care patients is compared with pharmacotherapy, combined treatment, and other clinical
scenarios.
What This Study Found Researchers at the Vrije University Amsterdam examined the effects of the two major
approaches to treating depression: psychotherapy and pharmacotherapy, as well as combined
treatment and care-as-usual. The study integrated the results of 58 randomized controlled
trials with a total of 9,301 patients. Results concluded that both psychotherapy and
pharmacotherapy were significantly more effective than care-as-usual or waitlist control.
However, they found no significant difference between psychotherapy and pharmacotherapy
as stand-alone treatments. Combined treatment, particularly in studies that included
cognitive behavioral therapy, was better than either pharmacotherapy or psychotherapy
alone.
Implications
- Treatment in primary care should be organized to accommodate any of these treatments
in response to patients’ preferences and values.
Shared Medical Appointments and Prediabetes: The Power of the Group
Aphrodite Papadakis, and colleagues
Background Shared medical appointments are typically delivered in a medical clinic by physicians and other health care providers. Within the context of this study, shared medical appointments consisted of patients consulting with their doctors one-on-one and then joining a group of similar patients to set goals and review lab results with the same family physician and a diabetes educator.
What This Study Found Researchers from the Cleveland Clinic and Takeda Pharmaceutical Company conducted
a study to evaluate the effectiveness of shared medical appointments for people with
pre-diabetes compared with a group of patients receiving usual care. Researchers also
assessed the impact of attending a shared medical appointment versus care-as-usual
on chronic conditions such as high blood sugar, cholesterol and blood pressure.
Over 24 months, patients who took part in shared medical appointments lost more weight
than those who received usual care. By the conclusion of the study period, patients
who attended shared medical appointments showed better outcomes in managing the aforementioned
chronic conditions than those patients who received usual care.
Implications
- shared medical appointments may provide an effective model of treatment for patients with pre-diabetes. As the diabetes epidemic continues, the authors call for more research using shared medical appointments to manage prediabetes in health care systems.
Pim Cuijpers, and colleagues
Background Surgical cesarean births can expose new mothers to a range of health complications, including infection, blood clots and hemorrhage. As part of Healthy People 2020 and other maternal health objectives, the state of California exerted pressure to reduce cesarean deliveries, and statewide organizations established quality initiatives in partnership with those goals.
What This Study Found In this study, researchers from Stanford University and the University of Chicago
examined unit culture and provider mix differences on hospital and delivery units
to identify characteristics of units that successfully reduced their cesarean delivery
rates. The mixed-methods study surveyed and interviewed labor and delivery teams from
37 California hospitals that were participating sites in the California Maternal Quality
Care Collaborative’s Supporting Vaginal Birth initiative.
Respondents at successful hospitals included more family physicians and midwives,
and physicians who had been in practice for less time. The study identified a number
of unit culture factors that also predicted success.
Implications
- “Family medicine, a discipline that strongly identifies itself as valuing patient-centered care and shared decision-making, may be in a unique position to contribute positively to this aspect of culture change on labor and delivery units.”
It's Not You, It's Me: Learning to Navigate the Patient-Physician Relationship
Melissa B. Hill
Background Melissa B. Hill, BS, a medical student at Icahn School of Medicine at Mount Sinai, writes a first-person narrative about her relationship with a pregnant patient with whom she connected while participating in a medical school program supporting expectant mothers with limited support systems during their pregnancies.
What This Study Found Hill writes that, though she learned in her preclinical “doctoring” courses how to build quick connections with patients, her training didn’t teach her how to manage meaningful, emotionally complex connections she might form with patients during longitudinal rotations. She notes how she invested an “enormous amount of time and invested a great deal emotionally” following and supporting the pregnant patient but lacked guidelines on how to end the partnership, causing her to feel like she was abandoning a good friend. As Hill reflects on the end of this particular relationship, she writes that she learned to appreciate the power of the longitudinal physician-patient relationship and that taking care of patients also requires that she take care of herself.
A Thoughtful Rebirth of Health Care: Lessons From the Pandemic
Elena Rosenbaum
Background In this essay, Elena Rosenbaum, MD writes that the COVID-19 pandemic has forced many physicians to approach patient care in completely different ways. She believes this is a critical time to refocus and ensure that health care is person-centered, encompasses all modifiable health determinants, and helps individuals achieve health rather than primarily manage disease. This is especially important now that COVID-19 has emphasized the flaws of the current health care system and the health inequities that exist in this country.
What This Study Found Changing the U.S. health care system is daunting, but Rosenbaum is optimistic that the challenges we have faced during the pandemic will help bring about meaningful reform. She writes about the need for a multi-pronged approach that eliminates fee-for-service payment and advocates for universal health care or alternative payment models that allow physicians to address lifestyle, behavior and social determinants of health with their patients. Rosenbaum also recognizes the benefits of telemedicine, which has given doctors a window into patients’ worlds and helped them stay connected to their most vulnerable patients. With the shift in how health care is administered, she believes now is the time for doctors to proactively reduce health disparities by examining and addressing systemic racism in medical care and collaborating with community members, public health experts and governments to break down health silos and bring about meaningful systemic change for our patients.