November/December 2020 Annals of Family Medicine tip sheet

November 10, 2020

Treating Opioid Addiction in Primary Care Benefits Both Patients and Cash-Strapped Medical Practices

Buprenorphine-based treatment for opioid addiction is in short supply in many areas of the United States. And while many physicians want to offer it, clinics are unsure how to offer buprenorphine therapy in a financially sustainable way. A team of researchers at Harvard Medical School conducted financial cost and revenue analysis for four different approaches to delivering buprenorphine-based treatment in primary care practices. The approaches differed based on who in the clinic delivered the majority of face-to-face care, the presence of nurse care managers, and whether care was delivered in traditional one-on-one or group settings.

Microsimulation modelling found that all four approaches to care produced positive net revenue after the first year, and net revenues were consistently highest for rural practices. Physician-led treatment and shared medical visits, both of which relied on nurse care managers, consistently produced the greatest net revenue gains. Additionally, net revenues were positive for all primary care practices that had at least nine patients in buprenorphine treatment per provider at any given time and no-show rates less than 34 percent. The findings suggest that in the current fee-for-service-dominated environment, offering office-based therapy for opioid addiction with buprenorphine can be a financially sustainable choice for cash-strapped primary care practices, despite hurdles.

Financing Buprenorphine Treatment in Primary Care: A Microsimulation Model
Sanjay Basu, MD, PhD, et al
Harvard Medical School, Center for Primary Care, Boston, Massachusetts

The EAR-PC Study Findings Encourages Screening for Hearing Loss in Older Adults

Hearing loss is the second most common disability in the United States and comes with it a higher risk for being diagnosed with significant health conditions, such as hypertension, diabetes, dementia and depression, as well as higher health care cost and use. The Early Auditory Referral-Primary Care (EAR-PC) study was designed to address the lack of data about hearing loss screening. Implemented in real-world, community-based clinics, it evaluated the effect of a tailored electronic clinical alert appearing at all visits of patients 55 and older, to encourage clinicians to ask, "Do you have difficulty with your hearing?" The study's lead author is Philip Zazove, M.D., who is hearing impaired. He and his team of researchers evaluated a screening paradigm for identifying patients 55 years and older at risk of hearing loss from 10 family medicine clinics in two health systems for formal hearing evaluation and treatment. An electronic prompt alerted clinicians to screen for hearing loss during visits. About 25 percent of the patients had signs of hearing loss with the primary care screener (Hearing Handicap Inventory for the Elderly). Referral rates to audiology specialists increased from baseline rates of 3.2 percent to 14.4 percent at one health system and 0.7 percent to 4.7 percent at the other. Considering the high prevalence of hearing loss and the impact on quality of life, increasing referral rates for audiology testing may improve health outcomes.

Effective Hearing Loss Screening in Primary Care: The Early Auditory Referral-Primary Care Study
Philip Zazove, MD, MM, et al
University of Michigan, School of Medicine, Ann Arbor, Michigan

Six Ways Primary Care "Medical Homes" Are Lowering Health Care Spending

New analysis of 394 U.S. primary care practices identifies the aspects of care delivery that are associated with lower health care spending and lower utilization of emergency care and hospital admissions. Researchers from the Urban Institute and RTI International analyzed health care cost data from a large group of Medicare patients and their primary care practices. Each practice previously took part in a 2011-2014 Centers for Medicare and Medicaid Services initiative to establish advanced primary care "medical homes," with improved and centralized care coordination.

What worked to reduce overall health care cost and utilization? At the top of the list: primary care practices that used patient clinical data to identify and remind patients due for preventive services saved, on average, about $70 per patient per month, lowered acute care hospital spending, and reduced hospitalizations and emergency department visits in their patient population.. Additionally, using their patient clinical records to initiate pre-visit planning, clinician reminders, targeted patient outreach, and population health monitoring were also linked to lower total Medicare spending. In short, practices that were able to leverage their patient data registry to anticipate need and target effective preventive services saved money.

Additional activities that were associated with fewer emergency department visits, reduced acute care spending and/or reduced hospital admissions include: offering targeted consultations for patients with chronic conditions to set health goals; following patients during hospital stays and supporting other specialists in patient care; establishing a protocol for sharing information in medical referrals; and adopting systematic approaches to quality improvement. Surprisingly, expanding access to care, such as expanded night and weekend hours, was not associated with lowered health care spending, utilization of emergency departments, nor reduced hospital readmissions.

Patient-Centered Medical Home Activities Associated With Low Medicare Spending and Utilization
Rachel A. Burton, MPP, et al
The Urban Institute, Washington, D.C.

Improving Affordable Care and Quality of Life for Seniors

Nitin Budhwar, MD, a geriatrician, and Soraya Gollop, PhD, a medical ethicist, find the U.S. medical system at a crucial juncture where we should aim to both reduce per capita health care costs, but also provide health care to facilitate the best possible quality of life. Their editorial highlights two studies in this issue, Burton et al. and Zazove et al., that present strategies for progressing toward these goals while improving the quality of life for seniors. While underlining the value of both studies, Drs. Budhwar and Gollop remind us how much work remains to be done: "The issue here is not that primary care clinics fail to implement best practices, but rather that policy has not made it rational for primary care clinics to implement these proven practices."

Editorial: Can You Hear Me Now? Refining the PCMH Model and an Overlooked Disability Affecting Seniors Nitin Budhwar, MD, FAAFP and Soraya Gollop, PhD
University of New Mexico, Albuquerque

Older Americans Who Are Black, Hispanic, or Medicaid-Eligible Are More Likely to Experience Preventable Hospitalizations

When complications due to diabetes, asthma, urinary tract infections, high blood pressure and other common conditions lead patients to visit the ER, researchers and health care quality administrators may label these visits as "potentially preventable hospitalizations." That is, with good outpatient care, these visits could have been potentially avoided. Potentially preventable hospitalizations are costly and can negatively impact the health and well-being of individuals, particularly if they are older. Researchers examined national trends in PPH to see differences across racial and socioeconomic subpopulations, as well as county-level differences, using 2010-2014 Medicare claims data. Overall, PPH rates consistently declined across all subpopulations. However, they found that Black and Hispanic Americans had higher PPH rates compared to Whites. Additionally, those who also had Medicaid insurance had higher rates than those with only Medicare coverage.

This examination of county-level potentially preventable hospitalization trends can inform health and social policies to support groups identified to be at-risk of PPH. The primary care system needs to be accessible and affordable, particularly for populations who are at higher risk of PPH. Policies with financial incentives to increase the number of primary care physicians, especially in rural and low-income areas, can potentially improve health care access and reduce PPH among vulnerable populations.

Potentially Preventable Hospitalizations Among Older Adults: 2010-2014
Elham Mahmoudi, PhD, et al
University of Michigan, School of Medicine, Ann Arbor, Michigan

Pre-embargo article link--TEMPORARY, link expires 11/9/2020, 5 p.m. EST
Post-embargo published article link--Will become active after 11/9/2020, 5 p.m. ESTPrimary Care Teams Test New Tool to Prescribe Referrals for Community Health and Social Services

Family physicians provide the majority of health care for underserved rural and urban populations in the U.S. and treat a more diverse population of patients than any other medical specialty. They have an important role to play in helping to mitigate health inequities by connecting patients to community-based wellness and self-care resources such as food and nutrition supports, weight management and smoking cessation to support them in preventing and managing cardiovascular disease.

CommunityRx-H3 is a practice-level, customizable community resource referral system that uses evidence-based algorithms to auto-generate a list of community resources to address such needs. This study evaluated the implementation of CommunityRx-H3 through the perspective of primary care practice facilitators.

This study found that practice facilitators can play a key role in implementing quality improvement initiatives like CommunityRx-H3. However, it also underscores the importance of support from an engaged practice leadership to address such barriers as: limited time, lack of staff, staff apathy, material resources (e.g., printers and paper) and lack of integration between a community resource referral system and the practice's EMR system.

Implementation of Community-Based Resource Referrals for Cardiovascular Disease Self-Management
Emily Abramsohn, MPH, et al
The University of Chicago, Chicago, Illinois

Under-Insured Transgender Americans Turn to Riskier, Non-Licensed Sources for Gender-Affirming Hormones

Transgender people who lack access to insurance coverage for gender-affirming hormone therapy are more likely to use hormones from sources other than a licensed prescriber, compared to those with insurance coverage. Analysis of the most recent United States Transgender Survey shows that about 9 percent of transgender adults - which comes to about 170,000 transgender adults in the U.S. today - access hormones from non-licensed sources like friends or online. The study found an association between the use of non-prescribed hormones and lack of health insurance or denial of insurance coverage for gender-affirming medical care. Survey respondents also identified insurance coverage as a prevailing barrier; it was ranked as a top issue affecting transgender people in the United States, ranked second only to direct violence.

The authors note that hormones accessed from an unlicensed source may pose health and safety risks, as medications may be unmonitored for content, quality, formulation and dosing. Additionally, use of non-prescription hormones likely entails decreased monitoring of hormone levels and less opportunity for mitigating risks or other forms of harm reduction and preventive care.

Insurance Coverage and Use of Hormones Among Transgender Respondents to a National Survey
Daphna Stroumsa, MD, MPH, et al
University of Michigan, Ann Arbor, Michigan

New Analysis Finds Lung Cancer Screening Reduces Rates of Lung Cancer-Specific Death

Low-dose CT screening methods may prevent one death per 250 at-risk adults screened, according to a meta-analysis of eight randomized controlled clinical trials of lung cancer screening. Researchers at the University of Georgia analyzed the health outcomes of 90,275 patients, comparing those who were screened versus those who received usual medical care or chest x-rays. Their analysis found a clinically and statistically significant 0.4 percent reduction in lung cancer-caused death long term, which translates into one preventable death per 250 at-risk adults screened. The authors recognize the important potential harm of overdiagnosis in cancer screening programs, and there was some evidence of overdiagnosis due to increased incidence in the screened group. However, based on the reduction in all-cause mortality being in the same direction and magnitude as lung cancer mortality, the authors interpret that the associated harms "do not appear to increase other causes of mortality," and the results of the study align with the U.S. Preventive Services Task Force recommendations for CT-based lung cancer screenings for adults age 55 to 80 who have a history of regular smoking.

Cancer-Specific Mortality, All-Cause Mortality, and Overdiagnosis in Lung Cancer Screening Trials: A Meta-Analysis
Mark H. Ebell MD, MS, et al
University of Georgia, College of Public Health, Athens, Georgia

My Mother's Brave Choice of Medical Aid in Dying

Epidemiologist Margaret Handley, PhD, MPH, presents a narrative about her mother's decision to use the End of Life Act to request aid-in-dying drugs after being diagnosed with atypical lymphoma. The End of Life Act became law in California in 2015 and has been in effect since 2016. The law allows an adult diagnosed with a terminal disease, who meets certain qualifications, to request aid-in-dying drugs from their attending physician.

Handley's mother went through three painful months of surgery, radiation and a single horrific round of chemotherapy near the end of her life. While her mother was recovering in the hospital after chemo, three doctors left an important impression: the palliative care doctor, who established a deep connection which helped Handley's mother see the trajectory of her life, the doctor from the end of life options group who gave her information without expectation, and the oncologist who helped her understand her choices in context.

Handley writes that what was vital for her mom's decision to feel right for her and to bring her comfort was the oncologist's engagement with her. "The clarity the oncologist gave her through his honesty and explanation was essential to her peace of mind in her decision making, and as a result she gained her life back. She was able to 'die well,' feeling content in her resolve because she could see that she had the option to live, but it was one she could reject... " Handley writes.

In a corresponding editorial, palliative care doctor Lou Lukas, MD, worries about altering rules the medical establishment has put in place about participating in a patient's hastened death. She also has concerns that if the choice of a quick, controlled death is made too easy for patients, that we as a society may forsake what she calls "vital lessons" that come at the end of life--namely the opportunity to practice compassionate presence and the acquisition of deep wisdom and courage when the ego "lets go" of the fear of death. Lukas cites emerging research that patients with terminal cancer have been helped by brief supportive counseling and one monitored session of high-dose psilocybin, the active ingredient in magic mushrooms. The classic psychedelic drug, however, is inaccessible to doctors to prescribe to their patients. Lukas finds it ironic that while there is movement to allow physicians to prescribe legally available medications specifically intended to end a patient's life, they have no legal access to a drug that could restore a patient's ability to live comfortably through a terminal diagnosis.

The "Foresty Way": My Mother's Brave Choice of Medical Aid in Dying
Margaret A. Handley, PhD, MPH
University of California, San Francisco; Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California

Editorial: Nonlinear Dynamics and Navigating the End of Life

Lou Lukas, MD
Veterans Administration; University of Nebraska Medical Center, Omaha

Essay Calls for Physician Mindfulness When Caring for Patients With Dementia

In medical school, Rebecca MacDonell-Yilmaz delayed her neurology rotation as a way to avoid acknowledging her mother's developing symptoms of dementia. As her mother's cognitive and functional abilities declined further, Dr. MacDonell-Yilmaz had no option but to confront this reality. While her training in palliative care gave her effective clinical tools for assessing dementia, her own experience taught her how important it is for physicians and other health professionals to be mindful of the deeply personal side of caring for a loved one with dementia. She recognizes that while personal markers of decline such as her mother's inability to follow the plot of a television program, "cannot indicate eligibility for a clinical trial or hospice services and will vary between families, they offer vivid illustrations of who patients were prior to their illness, how drastically their cognitive or functional status has changed, and how this evolution impacts both patient and family."

Counting Backward by Seven
Rebecca E. MacDonell-Yilmaz, MD, MPH
Brown University, The Warren Alpert School of Medicine; Hasbro Children's Hospital, Providence, Rhode Island

Standing in the Breach with Patients and their Families

Timothy P. Daaleman, DO, MPH, shares in an essay about his value as a doctor beyond the performance data he accesses on a daily basis, which quantifies the number of patients who received his services and his response time in answering their questions, among other services he renders. Dr. Daaleman explores the philosophic question of value and the difference between intrinsic and extrinsic value. Data has extrinsic value, he writes, but what about his doctoring has intrinsic value, that makes him unique in the clinical setting? Though it took him time and self-insight, Dr. Daaleman realized that as a doctor, he literally "stands in the breach" with patients and their families during a medical crisis that brings about challenging emotions for each person involved, whether they are the patients themselves or family members. "I can see now that determining the value of what I do is not important," Dr. Daaleman writes. "What is of greater importance is my identity as a physician, and the humdrum work which places me in the midst of the height and depth and width of the human condition." In other words, his weekly performance reviews blinded him to his lived experience. This realization has led him to make it a daily practice of reflecting on his day with gratitude; an attention to his own emotions; the recognition of any minor or major "gifts" he has received, such as a co-worker asking him how his day is going or delivering the news to a patient that all evidence of his or her cancer is gone; and a request for grace to move forward the next day.

What Is My Value as a Doctor?
Timothy P. Daaleman, DO, MPH
University of North Carolina at Chapel Hill

I Found Myself Hating the Words "Metastatic Breast Cancer": How a Nursing Professor Shared Her Own Cancer Story

After a 40-year career as a nurse, professor, and Dean of the Fay W. Whitney School of Nursing at the University of Wyoming, Mary E. Burman shares a personal account of her diagnosis of metastatic breast cancer. In the essay, she follows the information trail of her own terminal illness diagnosis. Starting from a pain in her chest that signaled conversations with her primary care clinician, to CT scan information shared between clinicians that led to a diagnosis delivered first digitally--through her patient portal--and in-person at her nurse practitioner's office. Post-diagnosis, she wrestles with how to disclose her diagnosis of metastatic breast cancer to friends, family and her professional community. In sharing her personal experience, Burman challenges readers to focus attention and primary care practice improvements on three pivotal relationships in one's cancer journey: the patient and primary care clinician and sharing bad news; the patient and their support community and the stress of sharing a diagnosis; and the online patient portal linking individuals to the health care environment.

How Giving and Receiving Information Has Shaped My Cancer Journey
Mary E. Burman, PhD, BSN, RN
University of Wyoming, Fay W. Whitney School of Nursing, Laramie, Wyoming

Representation of Female Authors in Family Medicine Academic Journals is Trending Upward

After decades of underrepresentation in medicine, women are now entering many specialties in the United States, including family medicine, at higher rates than men. Despite the rising proportion of female physicians in family medicine, they continue to be underrepresented in the highest levels of professional attainment, particularly in academic settings. This study from the Robert Graham Center examines female authorship of research published in three leading U.S. family medicine journals over time. They found a statistically significant increase in female authorship of published research over time, with a 13-point jump in original research with female senior authors, from 29 percent in 2008 to 42 percent by 2017. In that same time period, the gender composition of the journals' editorial boards remained roughly the same. Published research was more likely to be male led if it did not have grant funding or if there were no other co-authors. This study's authors discuss the importance of increasing female representation in peer-reviewed publications, closing the gender gaps in the highest levels of academic medicine, and ensuring appropriate representation of thoughts and ideas in the field of family medicine.

Has Female Authorship Distribution in Family Medicine Research Evolved Over Time?
Yalda Jabbarpour, MD, et al
Robert Graham Center, Washington, D.C.

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:
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,

Media Contact:
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Annals of Family Medicine
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