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July/August 2019 Annals of Family Medicine tip sheet

July 10, 2019

Diabetes Patients Experiencing Empathy From Primary Care Practitioners Have Lower Risk of Mortality

A United Kingdom study designed to examine the association between primary care practitioner empathy and incidence of cardiovascular disease and all-cause mortality among type 2 diabetes patients found that those patients experiencing greater empathy in the year following their diagnosis saw beneficial long-term clinical outcomes. Using the consultation and relational empathy (CARE) questionnaire, which measures patients' experience of care with a focus on empathy, a numerical score for 628 participants from 49 general practices in East Anglia, UK, was computed 12 months after diagnosis. Those patients reporting better experiences of empathy had a lower risk (40-50%) of all-cause mortality over the subsequent 10 years compared with those reporting low practitioner empathy. While medicine moves increasingly towards precision, target-driven health care and technology-based assessment models, these findings suggest that interpersonal, empathic care may be an important determinant in the risk of mortality.

Association Between Primary Care Practitioner Empathy and Risk of Cardiovascular Events and All-Cause Mortality Among Patients With Type 2 Diabetes: A Population-Based Prospective Cohort Study
Hajira Dambha-Miller, MRCGP, PhD et al
University of Cambridge, United Kingdom
http://www.annfammed.org/content/17/4/311


Metformin Could Lower Risk of Dementia in African Americans With Type 2 Diabetes

A large observational cohort study examining male veterans aged over 50 years with type 2 diabetes found that metformin use was associated with a significantly lower risk of dementia in African American patients. The study included data from 73,500 patients who received care through the Veteran's Health Administration from 2000-2015 and were diabetes- and dementia-free at baseline and who subsequently developed type 2 diabetes and began treatment with either metformin or sulfonylurea. Cox proportional hazards models, using propensity scores and inverse probability treatment to balance confounding factors, were computed to measure the association of both drugs and incident dementia across race and age groups. For African American patients aged 50-64 years, the hazard ratio for developing dementia was 0.60 (CI, 0.45-0.81), and for African American patients aged 65-74 years, the hazard ratio was 0.71 (CI, 0.53-0.94). The study showed modest to no association between metformin and lower risk for dementia in white patients 65-74 and no association in other age groups. The present results may point to a novel approach for reducing dementia risk in African Americans with type 2 diabetes mellitus.

Association Between Metformin Initiation and Incident Dementia Among African American and White Veterans Health Administration Patients
Jeffrey F. Scherrer, PhD, et al
Saint Louis University, St. Louis, Missouri
http://www.annfammed.org/content/17/4/352


Redesign of Opioid Medication Management Shows Impact in Rural Clinics

In rural practice, a system redesign resulted in declines in the proportion of patients on high dose opioids and the number of patients receiving opioids. The "Six Building Blocks," a team-based redesign of opioid medication management within smaller practice settings addressing policy changes, patient agreements, patient tracking, in-clinic support, and success metrics, was implemented in 20 clinic locations across eastern Washington and central Idaho. Among patients aged 21 years and over, there was a 2.2% decline in patients receiving high dose opioids over a period of 15 months, compared to a 1.3% decline in the control group. Similarly, a 14% decline was observed in the total number of patients receiving opioids in the intervention clinics compared to a 4.8% control group decline. The results indicate that efforts to redesign care by primary care teams, guided by the Six Building Blocks framework, can improve opioid prescribing practices and possibly reduce dependency.

Team-Based Clinic Redesign of Opioid Medication Management in Primary Care: Effect on Opioid Prescribing
Michael L. Parchman, MD, MPH, et al
Kaiser Permanente Washington Health Research Institute, Seattle
http://www.annfammed.org/content/17/4/319


Many Still Uninsured After Affordable Care Act Implementation

In community health centers in Medicaid expansion states, among established patients who were uninsured prior to the Affordable Care Act, many remained uninsured after implementation of the Obama-era law. Using electronic health record data across 11 Medicaid expansion states, an Oregon Health & Science University study tracking uninsured patients before and after the implementation of the ACA found that 21% of those patients remained continuously uninsured, 15% gained Medicaid, 12% gained other insurance, and 51% did not visit their Community Health Center post ACA implementation. The 21% who remained uninsured were largely Hispanic and spoke Spanish as their primary language, indicating both a language and potential legal barrier to enrollment in the ACA. These uninsured patients continued to have frequent healthcare visits and the majority had at least one health condition that would require continuous care. The results of this study point to a need for additional funding to support the needs of Community Health Centers serving the uninsured.

Following Uninsured Patients Through Medicaid Expansion: Ambulatory Care Use and Diagnosed Conditions
Nathalie Huguet, PhD, et al
Oregon Health & Science University, Portland
http://www.annfammed.org/content/17/4/336


"Flash Mob" Study Puts Clinical Decision Rules for ACS to the Test

A novel "flash mob" study finds that, in emergency care, acute coronary syndrome cannot be safely ruled out using the Marburg Heart Score or the family physicians' clinical assessment. In a period of only two weeks, researchers at Maastricht University collected data on 258 ACS-suspected patients by mobilizing one in five family physicians throughout the Netherlands to participate in the study. This mobilization was done by enlisting ambassadors among the FP community in the Netherlands who then spread the word through traditional professional and social networks. The study found that among 243 patients receiving a final diagnosis, 45 (18.5%) were diagnosed with acute coronary syndrome. Sensitivity for the FP rating was 86.7% and sensitivity for the MHS was 94.4%. While large, prospective studies can be time consuming and costly, this innovative "flash mob" method of research, named after the large-scale public collaborations/gatherings driven by social media, allowed for the fast investigation of one simple question on a large scale in a short timeframe.

A Nationwide Flash-Mob Study for Suspected Acute Coronary Syndrome
Jochen W.L. Cals, MD, PhD, et al
Maastricht University, The Netherlands
http://www.annfammed.org/content/17/4/296


The Next Generation of Connectivity in Family Medicine Research

In an accompanying editorial, Mohammed (Ahmed) Rashid, MD, MPH, and Larry A. Green, MD, point out that in a more connected world, the innovative flash mob method "prompts consideration of a potentially important benefit of conducting clinical research in a connected world: time." The potential for cost savings and benefits for clinicians and patients alike are great, but more research needs to be done to establish best practices for such things as spreading awareness on social media and whether to introduce on a large institutional scale or smaller word-of mouth scale. Rashid and Green also voice concern over whether this approach is sustainable and viable across the field of family medicine, writing, "It will be important to consider how networks can be maintained and energized in the longer term, including how the process and bureaucracy can be best simplified, and whether or not there will be any kind of incentives for physicians or health care organizations to take part." Likening the innovativeness of this approach to practice-based research networks, they note that the Cals paper expands on innovative approaches to studying problems in a primary care setting.

The Next Generation of Connectivity in Family Medicine Research
Mohammed A. Rashid, MD, MPH
University College, London, United Kingdom
Larry A. Green, MD
University of Colorado Denver, Aurora
http://www.annfammed.org/content/17/4/291


Caught in the Middle: Family Physicians Discuss Their Role in the Opioid Crisis

Family physicians prescribe the greatest volume of opioids (22.9%) and number of prescriptions (31.2%) to individuals with chronic noncancer pain, making them targets for quality improvements in safer prescribing practices. Interviews with 22 family physicians in Ontario, Canada, from June to July 2017, identified key themes driving the over prescription of opioids in managing chronic pain: the contrast between doctors' training and current expectations; navigating patient and system expectations; and the duration and quality of therapeutic relationships. Physicians with five or fewer years' professional experience emphasized the need to create trusting relationships with their patients as well as the difficulties arising in conversations about chronic pain, including surveillance and urine screening. Physicians with longstanding, stable practices of around 15 years or more, described stronger, more trusting therapeutic relationships that lessened the need for strict enforcement measures. Both groups complained of a lack of resources to support effective pain management. A combination of outside pressures and system expectations around the issue of opioid prescriptions places family physicians at the center of an emotionally-charged debate, and at a heightened risk of burnout.

Family Physician Perceptions of Their Role in Managing the Opioid Crisis
Laura Desveaux, PT, PhD, et al
Women's College Hospital / University of Toronto, Canada
http://www.annfammed.org/content/17/4/345


A Structured Approach to Detecting and Treating Depression in Primary Care

A questionnaire-based management algorithm for major depressive disorder in primary care is feasible to implement, though attrition from treatment is high. Among 25,000 patients in primary care clinics in a large metropolitan area, 4,325 (17%) screened positive for depression with 2,426 having a clinician-diagnosed depressive disorder. Of the 2,160 patients who had 18 weeks of follow-up care, 65% were treated with medication. Remission, defined as a PHQ-9 score of less than five, was more common in patients who experienced three or more follow-up visits. Of those who returned for three or more visits, 41.7% achieved remission. However, more than one-half of those diagnosed did not return for any follow-up care. The findings of this study suggest that patients suffering from depression can be successfully treated using measurement-based care within the primary care setting, and stronger emphasis on patient education and other approaches to reduce attrition may be needed for patients who fail to return for follow-up care.

A Structured Approach to Detecting and Treating Depression in Primary Care
Madhukar Trivedi, MD, et al
University of Texas Southwestern Medical Center, Dallas
http://www.annfammed.org/content/17/4/326


Are Physical Examinations Really Necessary?

As technology has gained ground in medicine and critics have called into question the diagnostic accuracy of physical examinations, what place does the practice of the physical exam have in today's clinic? In depth, qualitative interviews with 16 family physicians in Canada revealed a common view that physical examinations help promote a healthy patient-physician relationship and constitute an integral part of being a good doctor. Guided by principles of phenomenology, which considers how human beings experience a certain phenomenon--in this case, the physical examination itself--the research found that in addition to diagnostic information gained in physical examinations, the empathic benefits of "laying on hands" served as an important reminder of the physician's role as healer. At a time when contemporary clinical practice is grappling with the influx of emerging diagnostic technology, the physical exam is seen by many doctors as a grounding and centering element of the time-honored art of family medicine.

Family Physicians' Experiences of Physical Examination
Martina Kelly, MA, MBBCh, FRCGP, CCFP, et al
University of Calgary, Alberta, Canada
http://www.annfammed.org/content/17/4/304


Nonphysician Advanced Practitioners Absorbing More New Patient Requests Post Affordable Care Act

The advent of the Affordable Care Act has led to millions of new patients seeking primary care. Because the number of primary care physicians has remained stable, access to care has been a concern. This "secret shopper" study performed between 2012 and 2016 showed that the proportion of primary care appointments scheduled for Medicaid patients with nonphysician advanced practitioners, like nurse practitioners and physician assistants, increased from 7.7% to 12.9% across a sample of 3,742 randomly selected primary care practices in 10 states. This roughly corresponds with the decrease in the rate of uninsured Americans and with the increase in Medicaid recipients since the Affordable Care Act began. The number of appointments scheduled with nonphysician advanced practitioners was higher at federally qualified health centers than other non-FQHC clinics. The findings suggest that practices may be relying on nonphysician health professionals to accommodate new Medicaid beneficiaries.

Primary Care Appointments for Medicaid Beneficiaries With Advanced Practitioners
Molly Candon, PhD, et al
University of Pennsylvania, Philadelphia
http://www.annfammed.org/content/17/4/363


A New Approach to Primary Care: Advanced Team Care With In-Room Support

In this special report, the authors argue that the current primary care team paradigm is underpowered, in that most of the administrative responsibility still falls mainly on the physician. Jobs not requiring a medical education, such as entering data into electronic health records, should not be handled by physicians and advanced practitioners. The authors propose a model where a physician with two or three highly trained "care team coordinators" share patient responsibilities, with the CTCs organizing the visit, completing documentation, and coordinating follow-up care, and the physician handling components of the visit that require more complex decision making. There is evidence that this model improves patient care, reduces physician burnout, and is financially sustainable. The authors identify a number of themes, or mindsets, such as the idea that technology can replace people, that are barriers to implementation of these models in family medicine.

Powering-Up Primary Care Teams: Advanced Team Care With In-Room Support
Thomas Bodenheimer, MD, MPH
University of California, San Francisco
Christine A. Sinsky, MD
American Medical Association, Chicago
http://www.annfammed.org/content/17/4/367


How Primary Care Physicians Can Make Astana Work

The Astana Declaration, adopted by the World Health Organization in October 2018, acknowledges the importance of primary health care to achieve better health outcomes globally. But how, the authors ask, can physicians make this declaration work? Family physicians, the authors argue, can serve an important role in improving primary health care if they are better integrated "horizontally," translating their localized knowledge of health trends to wider populations and communities. Conversely, data on wider populations needs to be better translated to specific communities to "help primary health care address social determinants of health as part of individual care." Besides ongoing advocacy for comprehensive primary care, and strengthening of professionalism through teaching and practice development, the Astana declaration should be amended to include: "engagement with policy makers and public health to detail the professional contribution of primary care in the broader context of primary health care to secure person centered, population oriented integrated care."

The essential role of Primary care professionals in achieving Health for all - how to make "Astana" work.
Prof. Chris van Weel
Prof. Maria van den Muijsenbergh
Radboud University Medical Center, Nijmegen, Netherlands
http://www.annfammed.org/content/17/4/293


Innovations in Primary Care

Innovations in Primary Care are brief 1-page articles that describe novel innovations from health care's front lines. In this issue:
  • Utilizing PHATE: A Population Health-Mapping Tool to Identify Areas of Food Insecurity - An easy-to-use population health tool enables clinicians to better identify geographic regions with high concentrations of patients who screen positive for food insecurity.
    http://www.annfammed.org/content/17/4/372.full
  • EMR Happy Hour: New Approach to Electronic Medical Record Continuous Learning - Monthly online meetings between clinical faculty and other EMR users encourages sharing challenges and proposing solutions while improving provider self-efficacy, a tool in reducing burnout.
    http://www.annfammed.org/content/17/4/373.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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