Table of Contents

The Issue in Brief

July/August 2018

Influence of a New Diabetes Diagnosis on the Health Behaviors of a Patient's Partner

Julie A. Schmittdiel, and colleagues

Background Spouses and partners of people with diabetes may have an increased risk of developing the disease themselves due to shared dietary habits, exercise patterns, and other health behaviors. Little is known about whether educating diabetes patients in healthy behaviors can lead to behavior change in other members of the household. This study explores whether partners of people with newly-diagnosed diabetes increase their health seeking and monitoring behaviors following their spouse's diagnosis.

What This Study Found Partners of people with newly diagnosed diabetes are more likely to change their health behaviors than partners of people without the disease. Among more than 180,000 couples in the Kaiser Permanente Northern California health plan from 2007-2011, partners of patients with newly diagnosed diabetes had higher rates of participation in weight management classes, use of medications to stop smoking, glucose screening, clinically meaningful weight loss, lipid screening, influenza vaccination, and blood pressure screening compared to partners of people without diabetes. Even when clinicians did not focus on family members' lifestyle, partners of people with newly diagnosed diabetes exhibited small but significantly higher levels of behavioral change than their counterparts in other households.

Implications

• A diabetes diagnosis may be a teachable moment for family members and an opportunity to reduce their risk of developing diabetes.
• The authors call for a new focus on health risk interventions not just for individuals but for families and social networks.

Association Between Alcohol Consumption and Nocturnal Leg Cramps in Patients Over 60 Years Old: A Case-Control Study

Chloé Delacour, and colleagues

Background Nocturnal leg cramps have a negative effect on patients' quality of sleep and quality of life. This study evaluates the association between nocturnal leg cramps and consumption of alcohol in older general practice patients.

What This Study Found Among patients over 60 years old, there is a strong association between consumption of alcoholic beverages and nocturnal leg cramps. In a case control study in France, 140 general practice patients with and without leg cramps were administered a food frequency questionnaire. Researchers found an association between global consumption of alcoholic beverages and nocturnal leg cramps. No relationship was found between amount of alcohol consumed and odds of leg cramps.

Implications

• The authors call for additional research to evaluate the existence of a causal link and to determine the pathophysiology of leg cramps and alcohol's impact on them.

Community College Pathways to Medical School and Family Medicine Residency Training

Efrain Talamantes, and colleagues

Background With both a growing demand for primary care physicians and declining medical student interest in the field, this study examines a possible pathway to meeting the United States' primary care workforce needs.

What This Study Found The study of US medical school graduates from 2010 to 2012 finds that graduates who attended community college as pre-medical students are more likely to train in family medicine than those who attended other institutions. Specifically, among 43,382 medical school graduates, 3,787 (9 percent) trained in family medicine and, of those, 1,298 (34 percent) attended community college. According to logistic regression analysis models, community college attendees were more likely to train in family medicine compared to all other specialties. In addition, sensitivity analysis revealed that community college attendance was not significantly associated with training in internal medicine, pediatrics, and combined internal medicine/pediatrics. Within the family medicine residency workforce, 51 percent of Latinos, 35 percent of Asians, 33 percent of whites, and 32 percent of African Americans/blacks, as well as 42 percent of first generation college students, attended community college.

Implications

• Nurturing early interest in family medicine during high school and community college may be one strategy to increase the supply and diversity of the United States' primary care physician workforce, the authors explain. They call for longitudinal research that follows high school, community college, and four-year university students to better understand the experiences and programs that influence their career decisions.

Finance and Time Use Implications of Team Documentation for Primary Care: A Microsimulation

Sanjay Basu, and colleagues

Background Team documentation (i.e., the use of scribes) has the potential to improve primary care clinician satisfaction and efficiency, yet little has been known about the financial and time use implications.

What This Study Found Compared to fee-for-service payment, capitation-based systems may require less external financing to support team documentation. The study used a microsimulation model of practice costs, revenues, and time use data from 643 primary care practices. Researchers estimated critical threshold values for time saved from routine visits that would need to be redirected to new visits to avoid net revenue losses, comparing documentation conducted by scribes to advanced team-based care in which medical assistants perform history, documentation, counseling, and order entry. They found that, to prevent net revenue losses under fee-for-service, physicians would need to save 3.5 minutes per encounter using scribes and 7.4 minutes per encounter using medical assistants. The redirected time was expected to add 317 additional visit slots per year under the scribe strategy and 720 visit slots using the medical assistant approach. In comparison, to prevent losses under capitated payment, the scribe approach would require physicians to empanel at least 127 more patients and 279 additional visit slots per year, while the medical assistant strategy would require 227 more patients and 499 visit slots per year. In the fee-for-service environment, the authors explain, team documentation would have to focus on providing efficiency to redirect time for additional visits to pay for itself. By contrast, a capitated practice would need to empanel new patients to pay for the team documentation costs, and typical additional visits for these new patients would be lower in cost.

Implications

• The study findings, the authors suggest, can assist in estimating both start-up and longer-term benchmarks for time use for practices considering either the use of scribes or advanced team-based care and can inform ongoing discussions about how payment reform could affect the potential for team-based care.

Booklet for Childhood Fever in Out-of-Hours Primary Care: A Cluster-Randomized Controlled Trial

Eefje G. P. M. de Bont, and colleagues

Background Fever is a common reason for a child to be taken to a doctor, particularly during evening hours. Since antibiotic prescribing is strongly influenced by patients' expectations, researchers developed and studied the effectiveness of an interactive booklet on managing fever for parents using after-hours care.

What This Study Found Antibiotic prescribing rates are not affected (to a statistically significant degree) when physicians have access to a parent-focused booklet on childhood fever but do decrease if the booklet is used. As part of a two-armed cluster-randomized trial at 20 out-of-hours general practice centers in The Netherlands, family physicians in the intervention group had access to a booklet on children's fever. The booklet, designed to be used in discussion with parents, provided advice on when to consult a family physician, self-management strategies, and the duration of common childhood infections. The study included 25,355 children. Antibiotic prescribing was not significantly different in the intervention and control groups, however, after adjusting for compliance (use of the booklet), there was a significant reduction in antibiotic prescribing in children managed by a family physician using the booklet (n=3407) compared to children in the control group. Children in the intervention group were also less likely to receive a prescription for any medication, including non-antibiotic medication.

Implications

• Although the reduction in antibiotic prescribing in this implementation study was modest, the authors suggest that it provides evidence of the likely "real world" benefits and efficacy of the intervention and its relevance to efforts to reduce antimicrobial resistance.

Predicting Incident Multimorbidity

Jose M. Valderas, and colleagues

Background If multimorbidity (multiple medical conditions in an individual) is to be prevented, it is important to identify the characteristics that contribute to it.

What This Study Found Results of a 10-year study find that, for adults age 50 and older, risks of developing multimorbidity are positively associated with age and are higher for those with low socioeconomic status, obesity, low level of physical activity, or an external locus of control (believing that life events are outside of their control). No significant associations were observed for sex, educational attainment, or social detachment.

Implications

• The authors suggest that future work to reduce the incidence of multimorbidity should promote healthy lifestyles while targeting an internal locus of control in order to empower patients to achieve and maintain behavior change with the potential for synergistic effects.

The Evaluation of Physicians' Communication Skills From Multiple Perspectives

Jenni Burt, and colleagues

Background Previous research into communication between patients and physicians has focused on series of appointments. This study compares physicians', patients', and trained clinical raters' assessments of communication in individual appointments in order to examine where discrepancies arise and to learn more about doctors' insights into patients' perceptions of care.

What This Study Found Family physicians have a different view of what constitutes good communication compared to patients and trained clinical raters. Forty-five family physicians and 503 patients independently completed a questionnaire assessing physician communication quality immediately after their visits. Patient visits were video recorded and 55 were selected for assessment by trained clinical raters. Physicians' ratings of themselves were, on average, lower than patients' ratings (mean physician score 75; mean patient score 94). Sixty-three percent (319) of patients assigned physicians the maximum score of 100, while the mean trained rater score was 57. There was little correlation between communication scores of physicians and patients and between physicians and trained raters, and a moderate and statistically significant association between patients and trained raters.

Implications

• The authors suggest that the generally high scores assigned by patients could reflect a reluctance to report poor experiences and highlights the need for external peer assessment of communication skills in order to identify areas in which support and training are needed.

Mental Health Messages in Prominent Mental Health Apps

Lisa Parker, and colleagues

Background There are tens of thousands of commercially available mental health applications (apps). Given the enthusiasm for mental health apps demonstrated by governments, health services and the public, this study analyzes the content and kinds of messages in mental health apps.

What This Study Found Mental health apps convey two dominant messages: that virtually everyone has some type of mental health problem and that individuals can easily manage those problems by using an app. An interpretive analysis of 61 popular mental health apps in the United States, United Kingdom, Canada, and Australia found that apps predominantly addressed anxiety, panic, and stress (56 percent) and/or mood disorders (26 percent). Apps presented mental health problems as psychological symptoms, a risk state, or lack of achievement in life. They tended to medicalize normal mental states, with a focus on abnormal responses to mild triggers rather than external stressors. Apps encouraged frequent use and promoted personal responsibility for improvement. Therapeutic strategies included relaxation, cognitive guidance, and self-monitoring. While mental health problems were framed as present in everyone, in promotional materials "everyone" was predominantly represented as employed, white, and in a family.

Implications

• In light of the tremendous popularity of mental health apps, the authors suggest that doctors emphasize to patients that self-help is just one aspect of a supportive mental health approach.

Perceptions of Primary Care Notes by Patients With Mental Health Diagnoses

Joann G. Elmore, and colleagues

Background A significant proportion of mental health care is delivered in the primary care setting, where medical records, including clinical notes, are increasingly available to patients via secure online portals. However, there are lingering concerns about sharing clinic notes with patients with mental health diagnoses. This study compares perceptions of patients with and without a mental health diagnosis regarding access to primary care clinic notes.

What This Study Found Primary care patients with mental health diagnoses are as enthusiastic about the utility of viewing their doctors' notes as other patients. A survey of 2,534 patients (400 with mental health diagnoses and 2,134 without) who had read at least one online doctor's note found that patients saw similar benefits in access to the notes, regardless of mental health status. Ninety-two percent of patients in both groups reported that access to doctors' notes would help them feel in control of their health care and help them understand their health and medical conditions. High percentages of both groups also reported they would take better care of themselves, be more prepared for doctor visits, and would more likely take medications as prescribed as a result of access to doctors' notes.

Implications

• In spite of lingering concerns about whether patients with mental illness should have access to their online medical records, the authors suggest that providing such access to all patients might contribute to greater adherence and trust and could potentially help destigmatize mental illness.
• The authors call for a fuller understanding of risks and benefits of online note access in patients with mental health conditions and interventions to mitigate potential adverse effects of this new tool.

Warm Handoffs and Attendance at Initial Integrated Behavioral Health Appointments

Christine A. Pace, and colleagues

Background In programs that integrate behavioral health services into primary care, "warm handoffs," in which primary care clinicians introduce patients to behavioral health professionals, are commonly used. This study set out to determine if warm handoffs are associated with improved attendance at subsequent behavioral health appointments.

What This Study Found Warm handoffs are not associated with improved attendance at behavioral health intake appointments. It has been theorized that warm handoffs could build patients' trust in behavioral health clinicians and reduce patients' stigma about behavioral health care, potentially translating to improved attendance at behavioral health appointments. Instead, researchers found that the most significant predictor of attendance at an initial intake was time from referral until appointment, consistent with other studies in specialty mental health and other clinical settings.

Implications

• The authors call for a prospective study comparing different types of warm handoffs to standard referrals to determine if warm handoffs improve attendance at initial intake appointments and which features are most beneficial. Such a study could also evaluate whether certain patient groups benefit more than others from warm handoffs, and if this type of referral can help address disparities in attendance across demographic groups and diagnoses.
• In the interim, they suggest that making wait times for appointments as brief as possible is likely to improve attendance at integrated behavioral health intake appointments.

Physicians' Views of Self-Monitoring of Blood Glucose in Patients With Type 2 Diabetes Not on Insulin

Sonia A. Havele, and colleagues

Background Although evidence shows that routine self-monitoring of blood glucose in patients with non-insulin treated type 2 diabetes increases costs with few health benefits, some physicians continue to recommend it. This study examines to what extent and why physicians recommend self-monitoring of blood glucose.

What This Study Found Physicians continue to recommend routine self-monitoring of blood glucose for patients with non-insulin treated type 2 diabetes, in spite of its lack of effectiveness, because they believe it drives the lifestyle change needed to improve glycemic control. In a qualitative study of 17 primary care physicians, proponents stated that self-monitoring works best at initial diagnosis, facilitating education and self-management, a view that may be encouraged by the American Diabetes Association's support of self-monitoring based on expert opinion. In contrast, opponents are concerned about lack of efficacy in lowering HbA1c, often citing peer-reviewed evidence to support their views, and believe office-based education encourages patient activation. Health care systems have been shown to view self-monitoring of blood glucose as cost-saving and relatively harmless, yet previous research shows that it can be painful, inconvenient, and depressing for patients.

Implications

• The authors suggest that targeting physician beliefs about the effectiveness of self-monitoring of blood glucose for patients with non-insulin treated type 2 diabetes, along with policy-based interventions, could reduce the practice.

Solving the Diagnostic Challenge: A Patient-Centered Approach

Norbert Donner-Banzhoff

Background According to family physician Norbert Donner-Banzhoff, building an effective relationship with a patient and making a diagnosis are not separate skills. Rather, diagnosing a patient efficiently and effectively is a process best shared by patient and physician.

What This Study Found Donner-Banzhoff introduces the concept of inductive foraging, which begins with inviting patients to describe the problem that brings them to the doctor. "If they are allowed to do this without interference," he writes, "they will lead their clinician to symptoms and problems as they perceive them," often mentioning additional symptoms, associations, and potential explanations or concerns. This is particularly important in primary care, because the problem space, i.e., the universe of potential diagnoses, is vast and the probability of specific diagnoses is small. After the patient has helped define the problem space, physicians can gain additional information by direct questions, however Donner-Banzhoff cautions against testing hypotheses too early, because important information might be missed. This process depends on the quality of the clinician-patient relationship and requires sufficient time and encouragement for the patient to mention all concerns. The result, he states, is a synergistic and ultimately time-saving process of shared enquiry.

Continuity and Access in the Era of Part-Time Practice

Thomas Bodenheimer, and colleagues

Background As an increasing number of physicians opt for part-time practice--in some cases a response to stress and burnout--three physicians propose strategies to ensure that continuity and access remain part of the foundation of primary care.

What This Study Found Strategies include the following: design part-time work schedules to maximize physician availability to patients (e.g., more half days rather than fewer full days); require part-time physicians to respond to important electronic messages from patients and practice staff daily; ensure that staff can reach physicians with important patient questions on non-clinical days; establish job-sharing, in which a full patient panel is shared by two part-time physicians or a part-time physician and nurse practitioner/physician assistant; educate patients about how to maximize continuity of care; and retain physicians by allowing benefits for working fewer clinical hours. In addition to focusing on continuity and access, the authors note, it is vital that part-time physicians remain attentive to patients' desire for a trusting therapeutic relationship.

Implications

• Although part-time practice can affect access and continuity, physicians in part-time practice are often less burned out than those in full-time practice, which may translate into higher quality of care and greater patient satisfaction.

They Didn't Believe Her Pain: My Education in Interpersonal Violence

Amelia Goodfellow, and colleagues

What This Study Found As a first-year medical student, Amelia Goodfellow was discouraged to find that her classmates quickly dismissed the pain of patients who had experienced interpersonal violence (IPV). Over the years, she gained an understanding of the biology of the physical and mental pain of interpersonal violence as well as insights into ways to support patients in their recovery, including reducing barriers to screening patients for violence. Now, as a medical resident, she considers how she and other physicians can best treat patients who have experienced violence. "I hope that sensitive inquiry into history of IPV and referral to treatment will become more commonly taught and practiced skills in medical training. But first, as a beginning, I hope we can simply agree to believe our patients' pain."

On Blindness and Blind Spots

Ruth Kannai, and colleagues

What This Study Found According to family physician Ruth Kannai, "Sometimes the only way into a patient's world is through the window they offer. It is important to follow that lead." In an essay in the Annals of Family Medicine, Dr. Kannai reflects on her efforts to treat a long-time patient who developed a severe conversion disorder (a neurologic symptom that cannot be explained by medical evaluation) causing the patient occasional blindness. Through her ongoing efforts, which sometimes failed, and the patient's own realization that she needed to attend to the connection between her body and her "inner self," the episodes of blindness significantly decreased. Reflecting on blindness as a metaphor, the author acknowledges her own blind spots in trying to understand and help the patient. Yet, "despite that blindness, which may be my own, my role as her physician is to care for her completely, to enable her to trust me, by trusting her, and trusting in the process of our relationship."