Table of Contents
The Issue in Brief
Patients' Expectations of Screening and Preventive Treatments
Ben Hudson , and colleagues
Background An informed decision about whether to accept screening and preventive care requires balancing the potential benefits and harms of the intervention. This study assesses participants' estimates of the benefit, as well as the minimum acceptable benefit, of screening for breast and bowel cancer and of medication to prevent hip fracture and cardiovascular disease.
What This Study Found Many patients appear willing to undergo preventive care on the basis of overly optimistic expectations of the benefits of preventive interventions and screening. Data from 354 patient questionnaires found that participants overestimated the degree of benefit of all interventions. A lower level of education was associated with higher estimates of minimum acceptable benefit for all interventions. Increasing age was associated with higher levels of minimum acceptable benefit for all interventions other than hip fracture prevention.
Implications
- The authors conclude that, when counseling patients, physicians should consider these misperceptions, which may impair informed decision making about the use of such interventions.
- Clinicians should also consider using decision aids when discussing preventive care, especially with older patients and those with a lower level of education, as the aids may reduce patients' tendency to overestimate intervention benefits.
Projecting US Primary Care Physician Workforce Needs: 2010-2025
Winston R. Liaw , and colleagues
Background In the United States, the Affordable Care Act (ACA) will expand insurance coverage to an additional 34 million people. This study projects the number of primary care physicians that will be needed to address expected increases in use, including increases due to insurance expansion.
What This Study Found Researchers project the United States will need 52,000 additional primary care physicians by 2025 - a 25% increase in the current workforce - to address the expected increases in demand due to population growth, aging, and insurance expansion. Population growth will be the single greatest driver of increased primary care utilization, requiring approximately 33,000 additional primary care physicians by 2025, while 10,000 additional physicians will be needed to accommodate population aging. Insurance expansion will require approximately 8,000 additional primary care physicians, a 3% increase in the current workforce.
Implications
- Given the current maldistribution of physicians, increased productivity will not always be sufficient to meet the increased demand for primary care. As a result, the authors suggest, policy options that increase the size of the primary care workforce without addressing distribution will be less successful.
Incidental Chest Radiographic Findings in Adult Patients With Acute Cough
Saskia van Vugt , and colleagues
Background Imaging can sometimes produce unexpected or incidental findings that have consequences for patients and lead to further investigations. This study examines the type and prevalence of incidental chest radiography findings in primary care patients with acute cough.
What This Study Found Clinically relevant incidental findings on chest radiographs in primary care adult patients with acute cough are uncommon. Researchers in the Netherlands analyzed 2,823 chest radiographs from patients consulting for acute cough in 16 different European primary care networks and found that although incidental findings were reported on 19 percent of patients, only 3% of those patients had clinically relevant incidental findings, including lung nodules and shadows. Notably, the frequency of the reporting of incidental findings varied dramatically between the different primary care networks, ranging from 0% to 3%.
Implications
- These findings can inform decisions about the appropriate threshold for ordering chest radiographs in primary care and guide clinicians in informing patients about the possibility of incidental findings.
Eleanor Bimla Schwarz , and colleagues
Background A "contraceptive vital sign" (routine intake assessment of women's pregnancy intentions and contraceptive use) could help spur preconception counseling and safe prescribing of teratogenic medications (drugs known to cause congenital malformations). This study evaluates the feasibility and efficacy of using a contraceptive vital sign in primary care.
What This Study Found A contraceptive vital sign improves documentation of pregnancy intentions and contraception in a manner that is acceptable to patients but has little effect on the rate of family planning counseling and prescribing of potentially teratogenic medications. Specifically, the study of more than 2,304 women found documentation of contraception increased from 23% to 57% in the intervention group but remained 28% in the control group. For visits involving a teratogenic prescription, documentation increased from 14% to 48% in the intervention group and decreased from 29% to 26% in the control group. Provision of new family planning services increased only minimally, however, including among visits with potentially teratogenic prescriptions. When women with documented nonuse of contraception were prescribed potential teratogens, family planning services were provided to only 7%.
Implications
- Because most potentially teratogenic medications are prescribed by primary care clinicians, ongoing efforts are needed to ensure these patients receive preconception counseling and family planning services.
- The authors note that although the intervention was designed to limit primary care physicians' liability when a potential teratogen was prescribed, it may have inadvertently increased liability when contraceptive nonuse was explicitly documented alongside a potential teratogenic prescription.
Airway Obstruction and Bronchodilator Responsiveness in Adults With Acute Cough
Lidewij Broekhuizen , and colleagues
Background Cough is one of the most common conditions for which people seek health care. This study looks at adult patients with acute cough in primary care to determine the prevalence of abnormal lung function results that could suggest the risk of chronic obstructive pulmonary disease (COPD) or asthma.
What This Study Found In a 12-country study, approximately one-fifth of adult patients without an established diagnosis of asthma or COPD consulting their family physician for acute cough showed subsequent airway obstruction or bronchodilator responsiveness, both of which are suggestive of undiagnosed asthma or COPD. Analyzing data on 3,105 adult patients consulting for acute cough in primary care practices in 12 European countries, researchers found 240 patients (12%) showed bronchodilator responsiveness and 193 patients (10%) had obstructive spirometry according to the Global Initiative for Chronic Obstructive Lung Disease grading system.
Implications
- Because both asthma and COPD benefit from appropriate and timely interventions, including pharmacological and lifestyle modifications such as quitting smoking, clinicians should be aware and responsive to potential underdiagnosis.
- The authors note that detection of asthma and COPD may help reduce unnecessary use of antibiotics in patients with acute cough.
Low Primary Cesarean Rate and High VBAC Rate With Good Outcomes in an Amish Birthing Center
Lee T. Dresang , and colleagues
Background Women's risk of mortality is decreased by vaginal birth after cesarean (VBAC) compared with repeat cesarean delivery, yet the cesarean rate in the US has risen dramatically. A Wisconsin birthing center serving Amish women provides an opportunity to look at the effects of local culture and practices that support vaginal birth and trial of labor after cesarean (TOLAC). This study describes childbirth and perinatal outcomes over 17 years in LaFarge, Wisconsin.
What This Study Found Analyzing data on 927 deliveries in this nonhospital setting, the authors found a cesarean rate of 3.8% (compared with 33% in the United States in 2009), a TOLAC rate of 100%, and a VBAC rate of 95% (compared with 8% in the United States in 2006). There were no cases of uterine rupture or maternal death, and the neonatal mortality rate of 5.4 of 1,000 was comparable to that of Wisconsin (4.6 of 1,000 in 2008) and the United States (4.5 of 1,000).
Implications
- These findings show that, in the right circumstances and practice environment, cesarean rates can be decreased and VBAC rates increased in a safe and evidence-based manner.
- The authors suggest that these results support a low-tech approach to delivery.
Jeffrey A. Johnson , and colleagues
Background Vaccines can help prevent influenza and pneumococcal disease, but vaccination rates are low. In this study, researchers review existing evidence to determine the effectiveness of different quality improvement interventions aimed at increasing vaccination rates.
What This Study Found The analysis of 106 studies involving more than 470,000 patients suggests that the best chance for improving vaccination rates may be achieved by (1) shifting vaccine administration from physicians to other members of the primary care team with clear responsibilities for chronic and preventive care and (2) activating patients through personal contact.
Implications
- The impact of these interventions is modest. The authors call on policy makers to temper their expectations of such interventions.
Ferdinand Schreuder , and colleagues
Background Many non-Western immigrants suffer musculoskeletal pain that is hard to treat. This study examines the effect of high-dose vitamin D on nonspecific persistent musculoskeletal complaints in vitamin-D-deficient non-Western immigrants.
What This Study Found High-dose vitamin D supplementation may have a positive effect on persistent musculoskeletal pain among vitamin D-deficient patients. A study of 84 non-Western immigrants in Western Europe, a population prone to vitamin D deficiency and musculoskeletal problems, revealed a small positive effect on pain 6 weeks after supplementation with 150,000 IU of Vitamin D3 on vitamin D-deficient patients. Specifically, patients randomized to receive vitamin D supplementation were significantly more likely than those in a control group to report pain relief 6 weeks after treatment (35% vs 20%). The former were also more likely to report an improved ability to walk stairs (21%t vs 8%). In a nonsignificant trend, patients receiving vitamin D over 12 weeks were more likely to have an improvement than patients receiving it over 6 weeks.
Implications
- The authors call for future investigation involving greater numbers of participants with longer follow-up and higher doses.
Treatment of Ingrown Toenail With Proximolateral Matrix Partial Excision and Matrix Phenolization
Nezih Karaca , and colleagues
Background Ingrown toenails are a common problem that may recur after treatment. This study evaluates the efficacy of proximolateral chemical matricectomy with phenol ablations for the treatment of ingrown toenails and prevention of recurrences.
What This Study Found In a series of 348 proximolateral partial matricetomies and phenol ablations in 225 patients with stage 2 or 3 ingrown toenail, there was only one recurrence during the 24-month follow-up period, no severe complications, and excellent cosmetic results.
Implications
- The authors assert that this surgical technique, which is more invasive than simple partial nail avulsion and easier to perform than wide wedge excision, is the most important determinant of the study's success rate.
A Model for the Electronic Support of Practice-Based Research Networks
Kevin A. Peterson , and colleagues
Background This study describes a new model of electronic infrastructure to support clinical research in primary care practice-based researach networks (PBRNs) in order to foster growth and expand the reach of PBRN research. This paper describes a novel architecture and model of supporting PBRN research through information technology that builds upon approaches employed in existing clinical trials management systems, but it adapts these approaches and solutions to the unique features of PBRN research
What This Study Found The model includes an information architecture that provides for essential interactions, activities, data flows, and structural elements to support PBRN translational research activities. The model enables information exchange between investigators and clusters of independent practices supported by networked administrative coordinators for research purposes. It is designed to be used in recruitment for clinical trials, collection of aggregated anonymous data, and retrieval of identifiable data from subjects across hundreds of practices.
Implications
- The proposed model provides an important foundation for the development of software supporting PBRN research activities.
Reconciling Primary Care and Specialist Perspectives on Prostate Cancer Screening
Richard M. Hoffman , and colleagues
Background This essay examines whether primary care clinicians should adopt guidelines developed by specialists. Different perspectives between primary care clinicians and specialists can create conflict when specialists propose screening guidelines. The case of prostate cancer screening in younger men illustrates this issue.
What This Study Found The authors argue that there is no direct evidence that starting PSA screening at age 40 years, as recently recommended by two specialty organizations, instead of the previously recommended age of 50 years has any impact on prostate cancer-specific mortality. Although well-meaning, the authors assert, the specialty guidelines distract primary care physicians from providing services with proven benefit and value for patients. The US Preventive Services Task Force currently recommends delivering 35 adult preventive services, for which it finds high certainty of moderate or high net benefit - services that investigators estimate require 7.4 hours a day to deliver. Given the limited time in a typically rushed primary care visit, the authors conclude there is insufficient evidence that the benefits of starting PSA screening at age 40 years justifiy the additional counseling time.
Implications
- The authors call on primary care professional societies to vet specialty guidelines using evidence-based processes to determine which belong in primary care, thus enabling physicians to focus on providing patients services with proven effectiveness and value.
- The authors also call for primary care physicians and experts in evidence synthesis to participate on guideline review panels to ensure guidelines are based on systematic review of evidence and not solely on expert opinion.