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May/June 2019 Annals of Family Medicine tip sheet

May 14, 2019

More Than a Half-Million Parents With Opioid Use Disorder Live With Children

An estimated 623,000 parents with opioid use disorder in the United States are living with children under the age of 18, and fewer than one-third of the parents have received substance use treatment. An additional four million parents have other substance use disorders, with even lower treatment rates. Researchers from the Urban Institute analyzed data from the 2015 to 2017 National Survey of Drug Use and Health, a nationally representative cross-sectional survey. They found that the rate of opioid use disorder among parents living with a child under 18 years of age was 0.9%, or an estimated 623,000 parents. Of these, 42% had one or more other substance use disorders in addition to opioid use disorder. Among parents living in households with children, 6%, or an estimated 4.2 million parents, had substance use disorders that did not include opioids. More than one in five parents with opioid use disorder had suicidal thoughts and behavior and nearly 25% had serious mental illness, a higher rate of mental health problems than parents with other substance use disorders. Twenty-eight percent of parents with opioid use disorder received drug or alcohol treatment at a specialty facility or other doctor's office, compared to 6% of those with other substance use disorders. Primary care practices can play a critical role in addressing substance use disorder issues among parents, the authors state, including screening and diagnosing substance use disorders, motivating behavior change, and facilitating initiation of treatment.

Opioid and Substance Use Disorder and Receipt of Treatment Among Parents Living With Children in the United States, 2015-2017
Lisa Clemans-Cope, PhD, et al
Urban Institute, Washington, DC
http://www.annfammed.org/content/17/3/200


Does Health Care Help Us Live Longer?

A widely cited statistic suggests that health care services account for only a small percentage of the variation in American life expectancy. However, the methodology supporting the finding has been challenged. To explore the robustness of the finding, a new report examined four methods that rely on different outcome measures, analytic techniques, and data sets, to consider the percentage of premature deaths or poor health outcomes attributable to various factors including health care. Estimates from the four methods suggest that health care accounts for between 5% and 15% of the variation in premature death. In contrast, behavioral and social factors account for a much higher percentage of variation in premature mortality, ranging from 16% to 65%. According to the authors, this analysis affirms previous findings that health care is only one component of a larger set of influences on health outcomes. They suggest that a more diversified portfolio of national investments would generate a higher health yield. For example, spending on non-medical social services for each dollar spent on medical care averages about two dollars in wealthy countries that report data to the Organization for Economic Cooperation and Development compared to 55 cents in the United States. According to the authors, the recently enacted Chronic Care Act allowing Medicare Advantage plans to cover interventions beyond traditionally defined health care is a step in the right direction. Extending similar coverage to pregnant women and children enrolled in Medicaid may generate even higher yields, they state.

Contributions of Health Care to Longevity: A Review of 4 Estimation Methods
Robert M. Kaplan, PhD and Arnold Milstein, MD, MPH.
Stanford University School of Medicine
Stanford, California
http://www.annfammed.org/content/17/3/267


Health is About More Than Health Care

In an accompanying editorial, Steven H. Woolf, MD, MPH, states that, "The reason why nations that spend less on health care can experience better health is obvious: health is about more than health care." Woolf identifies five interrelated domains that shape our health: health care, health behaviors, the physical and social environment, socioeconomic status, and public policy. Socioeconomic status may be the greatest influence on health, Woolf states. "In a knowledge economy like the United States, education--and the income and wealth it provides--opens the doors to opportunity and health, enabling people to afford medical care, nutritious foods, and homes in healthy neighborhoods. Public policy influences all of these domains: national, state, and local leaders in public and private sectors influence access to good schools, jobs, and economic opportunity. Policy choices also shape social divides; they either correct or perpetuate inequities among marginalized populations...and neglected neighborhoods." Woolf calls on clinicians to pay attention to the socioeconomic status of patients and tailor care plans accordingly, advocate for policies that address social needs in their communities, and join organizations that work to address social determinants of health. He notes the vital role of universal health insurance coverage, access to primary care, and innovations to improve quality. "Spending lavishly on health care will not solve the US health disadvantage," he states.

Necessary But Not Sufficient: Why Health Care Alone Cannot Improve Population Health and Reduce Health Inequities
Steven H. Woolf, MD, MPH
Virginia Commonwealth University, Richmond, Virginia
http://www.annfammed.org/content/17/3/196


Inappropriate Prescribing Can Lead to Adverse Outcomes

In older adults, inappropriate prescribing in primary care is associated with a wide range of adverse outcomes, but not mortality. An analysis of existing studies looked at potentially inappropriate prescribing--the prescribing or underprescribing of medications in older persons that could cause significant harm. The analysis found that, although potentially inappropriate prescribing did not affect mortality, it was significantly associated with emergency room visits, adverse drug events, functional decline, health-related quality of life, and hospitalizations. According to the authors, the findings highlight the need to address potentially inappropriate prescribing in primary care. They call for further research into effective interventions, and they call on researchers to consider the potential implications of how potentially inappropriate prescribing is operationalized in their work.

Potentially Inappropriate Prescribing Among Older Persons: A Meta-Analysis of Observational Studies
Tau Ming Liew, MBBS, MRCPsych, MCI, et al
Institute of Mental Health, Singapore
http://www.annfammed.org/content/17/3/257


Learning More About Opioid Prescribing in Primary Care

Chronic opioid prescribing in primary care varies significantly by patient and clinician characteristics, according to a new study. Researchers at Virginia Commonwealth University analyzed 2016 electronic health record data from 21 primary care practices with 271 clinicians. Of 84,929 patients seen, 11% received an opioid prescription, while 1% received chronic opioid prescriptions. Oxycodone-acetaminophen was the most commonly prescribed opioid, followed by oxycodone. In urban underserved clinics, 10% of prescriptions written were for opioids, compared to 3% of prescriptions in suburban clinics. Being female, being of black race, and having risks for opioid-related harms, such as mental health diagnoses, substance use disorder and concurrent benzodiazepine use, were associated with being prescribed chronic opioids. Patients with higher comorbidities were more likely to receive chronic opioid prescriptions and at higher doses. In interviews, clinicians described the use of opioids to manage chronic pain as appropriate for patients with extensive medical comorbidities or those for whom non-opioid pain medications were contraindicated. However, most were reluctant to begin patients on opioids for chronic pain. Many felt frustrated by lack of time to appropriately manage patients' chronic pain and lack of control over patients' access to other sources of opioids. The authors call for research to explore trends in opioids prescribing, compare the differences in opioid prescribing in various settings, and test interventions to help primary care clinicians overcome barriers in weaning patients with high risks of opioid-related harms.

Chronic Opioid Prescribing in Primary Care: Factors and Perspectives
Sebastian T. Tong, MD, MPH, et al
Virginia Commonwealth University, Richmond, Virginia
http://www.annfammed.org/content/17/3/200


Serious Adverse Outcomes From Respiratory Tract Infection are Rare but Predictable

In routine primary care practice, serious adverse outcomes occur in only 1% of adult patients with lower respiratory tract infection, but such outcomes may be predicted with moderate accuracy. In a prospective cohort study of 28,846 adult patients with lower respiratory tract infections, researchers recorded patient characteristics and clinical findings, and identified adverse events (i.e., late onset pneumonia, hospital admission, or death) during a 30-day period following the patient visit. Serious adverse outcomes occurred in only 325 out of 28,846 patient visits. Three categories of factors independently predicted adverse outcomes from lower respiratory tract infection: severity of patient symptoms, patient vulnerability to serious illness, and the physiological impact of symptoms. These factors can be used to predict adverse outcomes by conversion to an eight-point score. Since patients with respiratory tract infection get little if any benefit from antibiotics, the authors state, the score may help clinicians target prescribing based on predicted risk and identify a small group of high risk patients who may benefit from closer monitoring.

Predictors of Adverse Outcomes in Uncomplicated Lower Respiratory Tract Infections
Michael Moore, BM, BS, MRCP, et al.
University of Southampton, Southampton, United Kingdom
http://www.annfammed.org/content/17/3/231


Online Intervention Reduces Mothers' Intentions to Visit Doctor for Respiratory Tract Infection

Visits to the doctor for a respiratory tract infection can lead to unnecessary antibiotic prescribing, but an online intervention with real-time information on locally circulating viruses may reduce mothers' intentions to visit their primary care doctor. A representative sample of mothers in the United Kingdom (N=806) was randomized to receive the online intervention, including locally enhanced influenza statistics, symptom information, and home-care advice, either before (intervention group) or after (control group) responding to a hypothetical respiratory tract infection illness scenario. Participants in the intervention group had lower intentions to visit the doctor than those in the control group when adjusted for demographic and clinical characteristics. Intervention material was generally well received, with information on symptoms and when to visit the primary care doctor rated as more important than information on locally circulating viruses. If the intervention were rolled out widely, the authors surmise that it would have impact, given the high rates at which parents of children with respiratory tract infections visit primary care clinicians. The authors call for research to evaluate intervention effects on observed behavioral outcomes in real-world settings and examine long-term effects and cost-effectiveness.

Reducing Primary Care Attendance Intentions for Pediatric Respiratory Tract Infections
Annegret Schneider, PhD, et al
University College London, London, United Kingdom


In Rural Areas, Buprenorphine is Provided by Primary Care Clinicians

As the United States undertakes intense efforts to increase the number of prescribers of buprenorphine for opioid use disorder, it is critical to understand who currently provides such treatment and how. A new study finds that in nonmetropolitan areas, buprenorphine is almost twice as likely to be provided by a primary care physician, compared to large metropolitan areas where specialists in addiction or psychiatry provide a majority of treatment. In a survey of a national random sample of buprenorphine physician prescribers (N=1,174), 11% (N=132) practiced in nonmetropolitan/rural areas, 33% (N=382) practiced in small metropolitan areas, and 56% (N=660) were located in large metropolitan areas. Buprenorphine prescribers in nonmetropolitan areas were much more likely to be primary care physicians, accept Medicaid, and less likely to work in an individual practice. Overall, buprenorphine prescribers across the rural/urban continuum were similar in many of their treatment practices, including frequency of visits and dosing. The authors recommend further research to understand variation in treatment practices and quality and how treatment relates to patient perceptions and outcomes.

Comparing Buprenorphine-Prescribing Physicians across Nonmetropolitan and Metropolitan Areas in the United States
Lewei (Allison) Lin, MD, MS, et al
University of Michigan, Ann Arbor, Michigan
http://www.annfammed.org/content/17/3/212


New Theory of Dissemination and Implementation Shifts Source and Direction of Practice Change

Primary care dissemination and implementation science has focused on evaluating strategies to help practices implement evidence-based care to achieve quality metrics and meet policy requirements. For many practices, this "outside in" approach has had unintended consequences including disempowerment, limited success, and burnout from burden, disruption and moral distress. Three cases reveal that it is possible for some primary care practices to shift the direction of change by seizing ownership of their care and prioritizing the craft of family medicine. In all three cases, practice founders were unable to match their practice to their values because of conventional financing systems and commercial electronic health records. Each developed a business model that circumvented the limitations of fee-for-documentation and pay-for-performance. Clinical care and business models differed between the practices, but all three succeeded in shifting the source and directional emphasis of change from outside-in to inside-out. The authors explain that, based on these examples, they are re-imagining the science of dissemination and implementation, from helping practices comply with externally-sourced evidence and recommendations to empowering practices to discover and enact their own wisdom in a challenging environment. Based on an inside-out approach, they posit a number of questions for future research: What would it look like to start interventions from the inside-out, helping practices reflect on their vision and craft? What if researchers helped practices learn to develop congruent sensing tools and measures, innovative business models, and innovative interactions with the external environment including managing up if owned by a health system How can researchers better engage practices and patients in developing new evidence? Such questions, spurred by the examples of three pioneer practices, could open a new frontier in the science of dissemination and implementation and inform better health policy, the authors state.

Shifting Implementation Science Theory to Empower Primary Care Practices
William L. Miller, MD, MA, et al
Lehigh Valley Health Network, Allentown, Pennsylvania
http://www.annfammed.org/content/17/3/250


New Tool Measures Primary Care as a Whole

There are a number of measures to assess aspects of primary care, but a new measure breaks new ground by combining experiences of patients, clinicians, and payers and allowing the most informed reporter--the patient--to assess vital primary care functions that are often missed. Researchers asked crowd-sourced samples of 412 patients, 525 primary care clinicians and 85 health care payers to describe what provides value in primary care, then asked 70 primary care and health services experts for additional insights. A multidisciplinary team analyzed these qualitative data to develop a set of patient-reported items. The resulting Person-Centered Primary Care Measure concisely represents the broad scope of primary care, with 11 domains each represented by a single item: accessibility, comprehensiveness, continuity, integration, coordination, relationship, advocacy, family context, community context, health promotion, and goal-oriented care. While existing measures evaluate the experience of care delivery based only on clinical processes and outcomes, the new measure focuses on care aspects that contribute to patient perceptions of the integrating, prioritizing, and personalizing functions of primary care. This ability to assess primary care as a whole and through the lens of the patient makes the Person-Centered Primary Care Measure both unique and meaningful, the authors state. They anticipate that the new measure, which reduces measurement burden, will complement existing measures and can be used in research and quality improvement to understand the mechanisms by which primary care affects outcomes for patients, health care systems and populations.

A New Comprehensive Measure of High-Value Aspects of Primary Care
Rebecca S. Etz, PhD, et al
Virginia Commonwealth University, Richmond, Virginia
http://www.annfammed.org/content/17/3/221


Innovations in Primary Care

Innovations in Primary Care are brief one-page articles that describe novel innovations from health care's front lines. In this issue:
  • A 60-Second Survey to Identify Patients' Unmet Social Needs - A brief, easy-to-use survey of social needs can help practices prioritize and target community partnerships of value to their patients. http://www.annfammed.org/content/17/3/274.full
  • Screening for Depression in Pregnancy--There's an App for That! - Integrating an innovative smartphone app into OB practice can improve screening for depression during pregnancy or postpartum. http://www.annfammed.org/content/17/3/275.full
  • Humanwide: A Comprehensive Data Base for Precision Health in Primary Care - A primary care demonstration project offers patients genetic screening, wearable sensors, health assessment, and wellness coaching. http://www.annfammed.org/content/17/3/273.full
-end-
Annals of Family Medicine is a peer-reviewed, indexed research journal that provides a cross-disciplinary forum for new, evidence-based information affecting the primary care disciplines. Launched in May 2003, Annals is sponsored by seven family medical organizations, including the American Academy of Family Physicians, the American Board of Family Medicine, the Society of Teachers of Family Medicine, the Association of Departments of Family Medicine, the Association of Family Medicine Residency Directors, the North American Primary Care Research Group, and The College of Family Physicians of Canada. Annals is published six times each year and contains original research from the clinical, biomedical, social and health services areas, as well as contributions on methodology and theory, selected reviews, essays and editorials. Complete editorial content and interactive discussion groups for each published article can be accessed free of charge on the journal's website, http://www.AnnFamMed.org.

Media Contact: Janelle Davis
Annals of Family Medicine
(800) 274-2237, Ext. 6253
JDavis@aafp.org

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