Annals of Family Medicine media tip sheet

January/February 2019

Children’s Respiratory Symptoms Can Last Up to Three Weeks

Symptoms of children’s respiratory tract infections, including runny nose, dry cough, and sore throat, can seem never-ending. According to new research, it takes 23 days for 90 percent of children to recover from respiratory tract infection symptoms. Researchers used a novel online study design to follow 485 children in 331 families in Bristol, England as they fell ill with respiratory tract infections (n=197 respiratory tract infections) without requiring them to visit their family physician. Overall, median duration of symptoms was 9 days. For children three years of age or younger, median symptom duration was 11 days compared to seven days for older children. Children whose parents reported lower respiratory tract symptoms (such as wet cough and wheeze) had median symptom duration of 12 days compared to eight days for those who had only upper respiratory tract symptoms (such as runny nose and sore throat). Among children with only upper respiratory tract symptoms, the most persistent symptom was runny nose, while the fastest symptom to resolve was earache. For children with at least one lower respiratory tract symptom, all symptoms persisted for three weeks; runny nose and wet cough were the most severe symptoms. One in 12 parents sought help from their family physician. These findings, the authors suggest, could inform primary care practice, public health interventions, and, ultimately, parents regarding the concerning symptoms for which they should consult their primary care physician.

Respiratory Tract Infections in Children in the Community: Prospective Online Inception Cohort Study

Professor Alastair D. Hay, et al

University of Bristol, Bristol, United Kingdom

Repeated Inactive Flu Vaccine Does Not Have Negative Effects

Repeated inactivated influenza vaccine immunization in children with pre-existing medical conditions has no negative impact on, and may even enhance, long-term protection against respiratory illness. A study from the Netherlands examined data for 4,183 children aged 6 months to 18 years with pre-existing conditions who received inactivated influenza vaccine at least once from 2004-2015. Adjusted estimates showed lower odds for respiratory illness in immunized children with prior inactivated influenza vaccine compared to children immunized for the first time. These findings suggest that there is residual protection from earlier inactivated influenza vaccinations. This is particularly relevant for children with pre-existing medical conditions who receive inactivated influenza vaccines repeatedly during childhood.

Impact of Repeated Influenza Immunization on Respiratory Illness in Children With Preexisting Medical Conditions

Marieke L.A. de Hoog, PhD, et al

University Medical Center Utrecht, Utrecht, The Netherlands

Burnout Predicts Turnover in Clinicians, not Staff

Burnout is alarmingly high among primary care clinicians and staff, but is it related to turnover of personnel? New research finds that burnout contributes to turnover among primary care clinicians, but not staff. A study of 740 primary care clinicians and staff in two health systems compared 2013-14 survey data on burnout and employee engagement (the likelihood of recommending their clinic as a place to work) with 2016 employment roster data. Fifty-three percent of both clinicians and staff reported burnout, while only one-third (32 percent of clinicians and 35 percent of staff) reported feeling highly engaged in their work. By 2016, 30 percent of clinicians and 41 percent of staff no longer worked in primary care in the same healthcare system. Clinicians who reported burnout in 2013-14 were more likely to leave the health system by 2016, taking into account their clinical time and length of time they had worked in the system. In regression models, neither burnout nor employee engagement predicted turnover for staff. The high rates of turnover, the authors suggest, have important implications for patient care. Continuity of care, which is a fundamental principle of primary care, is difficult to maintain in environments with frequent clinician and staff turnover. Furthermore, turnover is expensive for health care organizations. Although reducing burnout may help decrease rates of turnover among clinicians, the authors urge health care organizations and policymakers concerned about primary care employee turnover to understand its multifactorial causes and develop effective retention strategies for clinicians and staff.

Burnout and Health Care Workforce Turnover

Rachel Willard-Grace, MPH, et al

University of California, San Francisco, San Francisco, California

Physicians More Satisfied When They Can Address Patients’ Social Needs

When primary care practices try to help patients address social and economic needs, their efforts might have an unexpected benefit. According to a new study, primary care physicians who practice in a setting prepared to manage patients with social needs have significantly higher job satisfaction than other physicians. Among 890 US physicians responding to the Commonwealth Fund’s 2015 International Health Policy Survey of Primary Care Doctors, those who reported working in a practice able to manage patients’ social needs had significantly higher job satisfaction, were more satisfied with amount of time spent with patients, and thought that the quality of medical care patients receive had improved. Feeling that it was easy to coordinate patients’ care with social services or other community resources was also significantly associated with higher job satisfaction, personal and relative income satisfaction, satisfaction with amount of time spent with patients, and outlook on patients’ quality of medical care. The authors call on health systems to include clinician satisfaction, which is closely tied to issues of burnout and retention, in their calculations of the costs and benefits of responding to patients’ social needs.

Practice Capacity to Address Patients’ Social Needs and Physician Satisfaction and Perceived Quality of Care

Matthew S. Pantell, MD, MS, et al

University of California, San Francisco, San Francisco, California

Psychological Therapies and Gradual Tapering Aid in Discontinuing Antidepressants

When discontinuing antidepressants, the risk of relapse or recurrence is significantly reduced by combining cognitive behavior therapy with gradual tapering of the medication. An analysis of existing research found that, at 2 years, risk of relapse or recurrence was lower with cognitive behavior therapy plus tapering (15-25 percent) compared to clinical management plus tapering (35-80 percent). Relapse/recurrence rates were similar for mindfulness-based cognitive therapy with tapering and maintenance antidepressants. In two studies prompting primary care clinician discontinuation with antidepressant tapering guidance, six percent and seven percent of patients discontinued, compared to eight percent for usual care. Six studies of psychological or psychiatric treatment plus tapering reported cessation rates of between 40 percent and 95 percent. Two studies reported a higher risk of discontinuation symptoms with abrupt termination of medication. The authors note that cognitive behavior therapy seems to improve discontinuation rates compared to primary care clinician management of tapering with brief guidance; however, patient access to such therapy may be limited. They call for exploration of psychologically informed digital support for discontinuing antidepressants to complement care provided by primary care clinicians.

Managing Antidepressant Discontinuation: A Systematic Review

Professor Tony Kendrick, et al

University of Southampton, Southampton, United Kingdom

Computerized Adaptive Testing Can Screen for Depression and Anxiety in Primary Care

Computerized adaptive testing is a valid tool for screening for major depressive disorder in primary care and offers a format that is well received by patients. New research compared computerized adaptive tests, which personalize assessments by adaptively varying questions based on previous responses, with widely used paper screening tools (Patient Health Questionnaire-9, Patient Health Questionnaire-2, and Generalized Anxiety Disorder-7), and semi-structured interview, which is generally considered the gold standard in psychiatric assessment. The diagnostic accuracy of the Computerized Adaptive Diagnostic Test for Major Depressive Disorder was similar to the PHQ-9 and higher than the PHQ-2. Compared to interview, the accuracy of the Computerized Adaptive Test-Anxiety Inventory was similar to the Generalized Anxiety Disorder-7 for assessing anxiety severity. Participants preferred using tablet computers (53 percent), compared to interview (33 percent) and paper-and-pencil questionnaires (14 percent). The majority of participants (64 percent) rated paper-and-pencil questionnaire as their least preferred screening method. The widespread use of electronic health records in primary care presents new opportunities to leverage electronic tools for screening, the authors suggest, while multidimensional item response theory, used in computerized adaptive testing, can increase the efficiency of assessing mental and physical health.

Validation of the Computerized Adaptive Test for Mental Health in Primary Care

Neda Laiteerapong, MD, et al

The University of Chicago, Chicago, Illinois

New Family Physicians Feel Better Prepared but Report a Narrower Scope of Practice

Recent family medicine residency graduates feel better prepared to provide a variety of procedures and clinical services than their predecessors but report a narrower scope of practice. These findings are the result of a University of Washington survey of family medicine graduates in affiliated programs in five states, with a focus on two cohorts: those who graduated residency between 2010 and 2013 (n=408) and an earlier cohort who graduated between 1996 and 1999 (n=293). The survey addressed 26 services and procedures that graduates might provide in their practice and how prepared they feel to provide those services. Researchers found that the earlier cohort had a similar or significantly higher proportion of graduates practicing almost all listed procedures and services compared to the later cohort; only OB ultrasound and end-of-life care were more common among more recent graduates. The pattern of findings was reversed when comparing graduates who felt more than adequately prepared for practice; a greater proportion of those in the later cohort reported feeling prepared in most areas compared to earlier graduates. For example, 52 percent of the earlier cohort reported providing nursing home care, compared to 33 percent of the later cohort, but 59 percent of the later cohort felt more than adequately prepared to provide such care, compared to 27 percent of earlier graduates. According to the authors, these findings suggest that training has improved over the last decade, but that scope of practice is declining for reasons unrelated to training. Changes are likely due to a variety of factors, including the evolution of clinical practice and differences in practice size and type, including a trend toward larger, multispecialty groups in which family physicians may not be required (or allowed) to practice a wide array of procedures. The decline in scope of practice, the authors state, has negative implications for the breadth and richness of physician practice and for patients’ access to and quality of care. According to the authors, family medicine educators may need to adapt their training to a new generation of practice realities and physician preferences.

Changes in Preparation and Practice Patterns Among New Family Physicians

Amanda K.H. Weidner, MPH, et al

University of Washington, Seattle, Washington

Ultrasound Is an Increasingly Important Tool in Family Medicine/General Practice

Family physicians and general practitioners perform ultrasonography for a variety of conditions and with satisfactory levels of accuracy. This is according to an analysis of existing research, the first comprehensive systematic review of the use of ultrasonography by family physicians and general practitioners. Ultrasonography has been used for a variety of different conditions, most often focused on abdominal and obstetric ultrasound scans. The extent of training programs varied from 2-320 hours. Competence in some types of focused ultrasound scans could be attained with only few hours of training. Focused point-of-care ultrasound scans were reported to have a higher diagnostic accuracy and cause less harm than more comprehensive ultrasound scans or screening examinations. In studies assessing quality, participants generally scanned with a satisfactory level of accuracy, with quality depending on the extent of the examination and the anatomical area being scanned. Some focused scans had higher levels of diagnostic accuracy, required less training and were associated with less harm, whereas more extensive examinations were associated with lower quality scans and potential harms. The authors anticipate that point-of-care ultrasound will be increasingly important for family physicians/general practitioners in diagnosis, choice of treatment, and referral. These study results, they note, can help inform curricula and future exploration of the use of point of care ultrasound in family medicine/general practice.

Point-of-Care Ultrasound in General Practice: A Systematic Review

Camilla Aakjær Andersen, MD, et al

Aalborg University, Aalborg East, Denmark

Could Integration of Social and Medical Care Worsen Health and Increase Health Inequity?

At a time when health care is increasingly focused on the relationship between patients’ social and medical needs, a provocative new essay proposes that this focus may have unintended consequences. In fact, the authors state, there is a risk that some of these efforts could worsen health and widen health inequities. Examples include attempts by the Centers for Medicare & Medicaid Services (CMS) to encourage states to explore work requirements as a condition for Medicaid eligibility, with a rationale based on the health benefits of work and work promotion. According to the authors, such efforts could reduce access to health care by serving as a disincentive to Medicaid enrollment. Other examples include the growing use of social data for commercial health care purposes, which could augment insurance coverage bias and exclusion; and new research on how social deprivation affects biological susceptibility to mental and physical illness, which could shift issues like poverty from the social to the medical realm. To address these issues, the authors call for, “A new dialogue…about both the opportunities and potential consequences of bringing information about patients’ social circumstances into a market-based health care system.”

Integrating Social and Medical Care: Could it Worsen Health and Increase Inequity?

Laura M. Gottlieb, MD, MPH, et al

University of California, San Francisco, San Francisco, California

Incorporating Community Organizing Into Clinical Practice

A family physician reflects on her journey from community organizer to primary care clinician. As a clinician, she remains inspired by community organizing–a model for driving social change and improving public health–but has found it challenging to incorporate into clinical practice. She proposes a model for how clinicians and practices can proactively partner with community organizing groups and facilitate referrals to help patients directly engage in transforming the root causes of their health challenges. This model shifts the focus from the patient as an individual agent of change to the community and offers important lessons to clinicians interested in community health equity.

When “Patient-Centered” is Not Enough: A Call for Community-Centered Medicine

Juliana E. Morris, MD, EdM

University of California, San Francisco, San Francisco, California

The Past, Present and Future of Research in Primary Care

Two articles in the this issue of Annals of Family Medicine explore the history of research in family medicine and primary care, while a third considers its future.

Low- and Middle-Income Countries Establish Primary Care Research Priorities

In low- and middle-income countries, primary care research priorities include integration of care at the public/private interface, secondary care, community services, and models of care and finance to promote equitable access to care. These priorities were developed by a three-round modified Delphi expert panel of primary care practitioners and academics in low- and middle-income countries sampled from global networks using web-based surveys. They generated an initial list of more than 1,000 research ideas, which researchers synthesized into 36 organizational and 31 finance questions. The final four prioritized questions on organization address primary/secondary care transitions, horizontal integration within a multidisciplinary team, integration of private and public sectors, and ways to support successfully functioning primary health care teams. Corresponding finance questions address payment systems to increase access and availability of primary care, mechanisms to encourage governments to invest in primary care, the ideal proportion of a health care budget devoted to primary care, and factors to improve workforce distribution. Panelists have developed country-specific research implementation plans for prioritized questions, which will be presented to potential research funders.

Primary Care Research Priorities in Low- and Middle-Income Countries

Professor Felicity Goodyear-Smith, et al

University of Auckland, Auckland, New Zealand

Research Publications About Primary Care Have Increased But Remain a Small Proportion of Total

Since 1974, the number of research publications addressing primary care has increased, but still represents a small proportion of publications in the MEDLINE database. According to a bibliometric analysis of research output in 21 countries between 1974 and 2017, the United States and the United Kingdom had the highest volume of research publications about primary care, followed by Canada and Australia. There was significant growth in publications from countries in Southern, Eastern and Western Europe. During the same time period, the United Kingdom and Australia had the largest share of publications in primary care among all publications that appeared in MEDLINE. When compared to the total number of MEDLINE publications in 2017, however, primary care publications still represented only a small proportion of the total. The authors suggest that examining factors associated with increased research output may help define priorities in primary care research.

Development of Primary Care Research in North America, Europe, and Australia From 1974 to 2017

Gladys Ibanez, MD, PhD, et al
INSERM, Institut Pierre Louis d’épidémiologie et de Santé Publique, Paris, France

Early Attitudes Toward Research in Family Medicine Reflected the Specialty’s Countercultural Roots

While family medicine research has experienced tremendous growth in the past five decades, research was not a priority when the specialty was established in 1969. An examination of archival and secondary sources suggests that the priority placed on research in family medicine’s early years was due to internal and external factors, including family physicians’ desire to differentiate themselves from the prevailing specialty environment; lack of a clear identity for the new specialty; the non-laboratory nature of family medicine research; reliance on information from other specialties; and a focus on establishing an academic presence. A strong culture of generalist knowledge is crucial in assuring family medicine’s future and strengthening its ability to improve the health of individuals, families, and communities, the author suggests.

Unfinished Business: The Role of Research in Family Medicine

Robin S. Gotler, MA

Case Western Reserve University, Cleveland, Ohio

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:

  • Expanding the Use of Botulinum Toxin in Primary Care for Chronic Migraine – Primary care and neurology departments partnered to train and credential primary care clinicians to provide patients with botulinum toxin injections for chronic migraine headaches.
  • Partnering Research Fellows and Clinicians in Practice Settings – A family medicine postdoctoral research fellowship places researchers alongside clinicians in clinical settings, providing on-site research expertise for clinicians wanting to transform clinical questions into research and quality improvement projects.

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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.

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