May/June 2018 Annals of Family Medicine tip sheet
Screening Tool Improves Prediction of Developing Dementia
In people with a minor decline on the Mini-Mental-State-Examination–a widely used but limited test to screen for cognitive defects–follow-up with a simple visual screening tool can help identify those at increased risk for dementia. As part of a cluster-randomized controlled trial, researchers in the Netherlands analyzed the MMSE of 2690 older adult patients at baseline and two-year follow-up. The Visual Association Test, consisting of six cue cards and six target cards showing an unexpected visual association, was also analyzed at the two-year follow-up. A decline in MMSE scores of two points and three points were associated with an increased risk of developing dementia of 10 percent and 21 percent respectively, significantly higher than the overall risk of developing dementia. Groups with imperfect VAT scores (?5 out of six) had substantially higher percentages of incident dementia. An imperfect VAT score increased the predictive value of two and three point decreases on the MMSE from 10 percent to 14 percent and from 21 percent to 29 percent respectively. Given the importance of timely diagnosis of dementia, the authors suggest that the VAT may help identify older persons who need further cognitive examination, especially those with a minor decline in MMSE score.
Improving Prediction of Dementia in Primary Care
Susan Jongstra, MD, PhD, et al
University of Amsterdam, The Netherlands
Gap Between Educational and Promotional Content in Direct-to-Consumer TV Ads for Pharmaceuticals Widens
Although proponents suggest that direct-to-consumer prescription drug advertising is educational and motivating, a new analysis finds that the potential educational value of such advertising has declined. Compared to an analysis of direct-to-consumer television advertising published in 2007, this study found a significant decrease in the percentage of ads conveying information about the conditions being targeted, such as risk factors (decreased from 26 percent to 16 percent) and prevalence (decreased from 25 percent to 16 percent). Positive emotional appeals continued to be emphasized (94 percent of ads), with a decrease in the use of negative emotional appeals (from 75 percent to 51 percent), resulting in a more positive portrayal of the medication experience. Lifestyles portrayed in the ads emphasized how products can enable more recreational activities (69 percent of ads), while fewer ads suggested lifestyle change in addition to the product (decreased from 23 percent to seven percent). The authors suggest that portraying positive aspects of the post-medication experience, such as recreational activities, endurance, and social approval, may have motivational value, but may also imply off-label outcomes and encourage an inappropriately broad population to seek the advertised drug. According to the authors, improving the educational value of direct-to-consumer advertising is likely to require further regulatory action by the FDA, rather than reliance on self-regulation by the pharmaceutical industry
An Updated Analysis of Direct-to-Consumer Television Advertisements for Prescription Drugs
Janelle Applequist, PhD, et al
University of South Florida, Tampa, Florida
Broader Scope of Practice is Associated With Lower Risk of Burnout
Among physicians, family physicians report some of the highest levels of burnout. According to a new study, however, early career family physicians who provide a broader scope of practice report significantly lower rates of burnout. The study–a secondary analysis of the 2016 National Family Medicine Graduate Survey–found that those who practiced in more locations and performed a greater variety of procedures and clinical work were significantly less likely to report feeling burned out once a week or more. The strongest associations were in the practice of obstetrics and inpatient medicine, two areas with a decline in practice by family physicians in recent years. Specifically, the odds of reporting feeling burned out were 36 percent lower among those family physicians practicing obstetrics and 30 percent lower among those practicing inpatient medicine compared to their peers. Making house calls was also significantly associated with lower burnout. If future research confirms a causal relationship between scope of practice and physician wellness, the authors suggest, it would allow for new policy levers and incentives for systems and physicians to improve health care as well as their own health.
Burnout and Scope of Practice in New Family Physicians
Amanda K.H. Weidner, MPH, et al
University of Washington, Seattle, Washington
Resilience Training is Not Always the Solution to Burnout
Although many health systems have turned to resilience training as a solution to physician burnout, quality/safety researcher Alan Card, PhD, MPH, argues that such training alone is not enough. In a new essay, Card advocates for "picking the right tool for the job," i.e., selecting between two approaches to burnout based on a more nuanced understanding of the condition. Specifically, he distinguishes between two types of suffering related to burnout: unavoidable occupational suffering, i.e., the psychological stress and grief that are inherent in physicians' work, and avoidable occupational suffering: systems failures that can be prevented, such as overwork, a hostile work environment, or unsafe working conditions. For burnout caused by unavoidable psychological stress, resilience training may be a helpful tool. Burnout caused by systems failure, however, requires improved systems. Engaging physicians in the redesign of such systems will likely promote better mental health, he suggests. Card calls for health care organizations to offer resilience training, as well as peer support and stigma-free mental health treatment, in parallel with efforts to improve systems.
Physician Burnout: Resilience Training is Only Part of the Solution
Alan J. Card, PhD, MPH
University of California-San Diego School of Medicine, San Diego, California
Two Family Physicians Reflect on White Privilege in Health Care and the Need for Action
"Our medical system is structured to individually and systemically favor white physicians and patients in ways that white people are trained to ignore," states family medicine resident Max Romano, MD, MPH. Reflecting on his medical training, Romano describes how he, a white physician, has benefited from the racial privileges he has been afforded. Among the privileges he identifies are the pervasive belief that people of his race can become doctors; the ease with which he found professors and academic role models of his race during college and medical school; and patients' assumptions that, when he enters an examination room with a person of color, he is the physician in charge, even if that is not the case. He calls on other white physicians to speak out against the racism from which they have benefited and to work towards racial justice for clinicians and patients in the medical system.
White Privilege in a White Coat: How Racism Shaped My Medical Education
Max J. Romano, MD, MPH
MedStar Franklin Square Medical Center Family Medicine Residency, Baltimore, Maryland
In a related editorial, Joseph Hobbs, MD, chair of family medicine at the Medical College of Georgia, cautions against allowing concepts such as white privilege, unconscious and implicit bias, and institutional racism to provide a means for avoiding personal responsibility for racism. In the health care setting, recognition of white privilege is a first step, he states, and should be accompanied by individual and institutional efforts to eliminate privilege and disparities in quality of care based on race. He calls on health care professionals to be aware and take action: "To experience implicit or unconscious bias in the professional and personal settings of health care and fail to address it is a missed opportunity to facilitate change."
White Privilege in Health Care: Following Recognition With Action
Joseph Hobbs, MD
Medical College of Georgia at Augusta University, Augusta, Georgia
Social Challenges Are Associated With Poorer Health Outcomes
Among more than 600,000 primary care patients, half live with some degree of social challenge, which has a negative effect on the quality of care they receive. Researchers in Manitoba, Canada identified 11 social complexities, such as low income, mental health diagnosis, and involvement with the justice system. Fifty-four percent of patients had at least one social complexity, and four percent had more five or more. Social complexity was strongly associated with poorer outcomes on primary care indicators for prevention, e.g., breast cancer screening (OR 0.77, 99% CI); managing chronic disease, e.g., diabetes (OR 0.86, 99% CI); care of older adults, e.g., benzodiazepine prescriptions (OR 1.63, 99% CI); and use of health services, e.g., ambulatory visits (OR 1.09, 99% CI). Patients with more social complexities were less likely to receive preventive services and more likely to seek ambulatory or emergency care. To achieve better health equity for vulnerable patient populations, the authors recommend expanding interdisciplinary team-based care tailored to individual practices' patient populations and exploring alternative funding models that acknowledge the complexity of addressing social determinants of health in the primary care setting.
Association of the Social Determinants of Health With Quality of Primary Care
Alan Katz, MBChB, MSc, et al
University of Manitoba, Winnipeg, Manitoba, Canada
Patients and Caregivers Value Caring, Continuity, and Accountability in Care Transitions
In the transition from hospital to home, patients and caregivers seek clear accountability, continuity, and caring attitudes across the care continuum. One-hundred and thirty-eight patients and 110 family caregivers participating in focus groups and interviews identified three desired outcomes of care transition services: feeling prepared and able to implement care plans, unambiguous accountability from the healthcare system, and feeling cared for and cared about by clinicians. Five services or clinician behaviors were linked to these outcomes: providing actionable information; collaborative discharge planning involving patient and caregiver; using empathic language and gestures; anticipating the patient's need to support self-care at home; and providing uninterrupted care with minimal handoffs. When participants' desired outcomes were realized, they characterized care as excellent and trustworthy. In addition, caregivers experienced less distress and reported adherence to discharge plans increased. When desired outcomes were not met, patients and caregivers felt deserted by the health care system and perceived medical care as transactional and unsafe. Poor and fragmented care transition experiences, the authors suggest, can have substantial consequences, including creating patient and caregiver mistrust, anxiety, and confusion; precipitating family conflict; and contributing to inefficient care delivery, avoidable health system use, and delayed recovery. To ensure that care transitions are safe and supportive of patients' recovery, the authors state that health systems must better prepare patients and caregivers for self-care at home and design accessible means of ongoing care support when and where it is needed.
Care Transitions From Patient and Caregiver Perspectives
Suzanne E. Mitchell MD, MS, et al
Boston University School of Medicine, Boston, Massachusetts
Case Management Reduces Psychological Distress in Frequent Users of Health Care
Research has shown that frequent users of health care services tend to have higher levels of psychological distress. A new study finds that case management reduces psychological distress and creates a sense of security in patients who frequently use health services. In a randomized controlled trial of 247 patients, the intervention group (n=126) received six months of case management including evaluation of patients' needs and resources, a service plan tailored to patients' priorities, care coordination between healthcare and community partners, and self-management support for patients and families. Compared with usual care, the intervention reduced psychological distress (OR 0.43, 95% CI, 0.19-0.95) but had no effect on patient activation. In addition, interviews were conducted with 25 intervention group patients, six case management nurses, and nine health managers, and focus groups were held with eight patients' spouses and 21 participating family physicians. Overall, stakeholders had positive perceptions of the case management intervention. Many noticed that improved accessibility and self-management support led to a sense of security and better self-management of patients' health. The authors note that future research is needed to evaluate the effect of a case management intervention on the use and cost of services and to assess if a longer intervention would result in a change in self-management.
Case Management in Primary Care for Frequent Users of Health Care Services: A Mixed Methods Study
Catherine Hudon, MD, PhD, et al
Université de Sherbrooke, Québec, Canada
Free Children's Visits Increase Care and Workforce Burden
In July 2015, all children under six years of age gained free access to daytime and out-of-hours general practice services in the Republic of Ireland, resulting in a 25 percent increase in utilization. Comparing the year prior to the introduction of free GP care with the following year, daytime general practitioner visits by children under six years increased from 9,789 to 12,600, while out-of-hours visits increased from 15,087 to 18,958. In the post-period, nine percent more children were seen at least once in daytime services and 20 percent more children were seen at least once out-of-hours. While visits by patients of all ages increased in the post-period, children under age six were responsible for a disproportionate increase in service utilization, accounting for 45 percent of additional daytime visits and 73 percent of additional out-of-hours visits. Given the inevitable increase in service utilization that accompanies the availability of free care, and with indications that Ireland's GP workforce may soon struggle to meet demand, the authors call for careful workforce planning if state-funded general practice care is extended to other groups.
Free Children's Visits and General Practice Attendance
Michael Edmund O'Callaghan, MICGP, MSc, et al
Trinity College Dublin, Dublin, Ireland
New Model Defines Successful Nurse Practitioner-Physician Co-Management
Co-management of patients by more than one primary care clinician is among new models of care designed to meet the demand for high quality patient care. A new co-management model lays the groundwork for potential care partnerships between nurse practitioners and physicians. It finds that effective nurse practitioner-physician co-management requires three core attributes: effective communication, mutual respect and trust, and a shared philosophy of care. These attributes must be supported by a practice environment and policies that recognize nurse practitioners as autonomous primary care clinicians, as well as the willingness of nurse practitioners and physicians to co-manage patients. The authors find that effective nurse practitioner-physician co-management can reduce the primary care clinician's workload, including both clinical care and administrative tasks, thus reducing burnout and fatigue. They suggest that combining the experience and expertise of clinicians from nursing and medicine can result in better care.
Nurse Practitioner-Physician Co-Management: A Theoretical Model to Alleviate Primary Care Strain
Allison A. Norful PhD, RN, ANP-BC
Columbia University School of Nursing, New York, New York
Overcoming "The Desert Experience for Mind and Soul" by Rediscovering Hope
When family physician Timothy Daaleman felt a "greyness" shading his practice of medicine–a restlessness and lack of meaning in his work–he sought insight in the ancient concept of acedia. Acedia, which dates back to the fourth-century, is characterized by lack of caring and typically afflicts those in mid-life. Intrigued, Daaleman, a mid-career physician, found that other physicians in his cohort reported the lowest satisfaction with their specialty choice and work-life balance and highest rates of emotional exhaustion and burnout. He reasoned that acedia and burnout could be part of a continuum of professional and personal challenges facing doctors across their careers. As he continued caring for patients, however, he developed a new understanding of hope, one that strengthened his capacity to trust and helped him "see light in the midst of such darkness."
The Mid-Career Demon
Timothy P. Daaleman, DO, MPH
University of North Carolina, Chapel Hill, North Carolina
Community Health Workers Provide Range of Services
Community health workers in primary care provide clinical services, community resource connections, and health education and coaching. As trained individuals with limited or no formal medical education, they are widely considered to have the potential to enhance primary care access and quality, but remain underutilized. An analysis of existing research finds that community health worker functions include care coordination, health coaching, social support, health assessment, resource linking, case management, medication management, remote care, follow-up, administration, targeted health education, and health literacy support. A cost-effective workforce that includes primary care community health workers could help overburdened care teams. The authors suggest that decisions about how to best utilize community health workers be based on needs of patients and care teams, clinical workflow, and financial viability.
Roles and Functions of Community Health Workers in Primary Care
Andrea L. Hartzler, PhD, et al
University of Washington, Seattle
Centralized Infrastructure Facilitates Medical Education Research
The Council of Academic Family Medicine Educational Research Alliance has enabled a large number of research teams to conduct meaningful scholarship with a fraction of the usual time and energy. CERA regularly conducts omnibus surveys of key family medicine education leaders, a process that includes collaboration with experienced mentors, centralized institutional review board clearance, pilot testing, and centralized data collection. As of October 2017, CERA completed 30 omnibus surveys resulting in more than 75 scientific presentations and more than 55 peer reviewed publications. By creating an infrastructure capable of overcoming some of the key barriers to conducting research, CERA has increased family medicine's research productivity and increased the number of family medicine faculty participating in research, including scholars with less experience and/or fewer resources. The authors state that the CERA model could be replicated in other specialties to facilitate collaborative research.
Creating a Centralized Infrastructure to Facilitate Medical Education Research
Dean A. Seehusen, MD, MPH, et al
Eisenhower Army Medical Center, Fort Gordon, Georgia
Innovations in Primary Care: A Patient Profile to Build the Patient-Physician Relationship
Innovations in Primary Care are brief one-page articles that describe novel innovations from health care's front lines. In this issue:
- The Patient Profile: Improving Treatment Adherence – A family medicine practice uses information provided by patients (e.g. health beliefs, personality type, learning style, communication preferences, and health literacy level) to guide patient care. http://www.annfammed.org/content/16/3/271.full
New Supplement Publishes Findings From EvidenceNOW: Advancing Heart Health in Primary Care
The Annals of Family Medicine has released early findings from EvidenceNOW, the Agency for Healthcare Research and Quality's multimillion dollar initiative to help primary care practices more rapidly improve the heart health of Americans. Aimed at reducing the research-to-practice delay in implementing cardiovascular disease prevention, EvidenceNOW engaged 1,500 small and medium-size primary care practices and nearly 8 million patients across the United States. Study findings, which appear in a recent Annals supplement, include the following.
- Recruiting Practices is Costly Recruiting practices for large scale quality improvement initiatives is difficult and costly ($5,529 per enrolled practice on average), and even more expensive for practices with no prior relationship with the study team.
Engaging Primary Care Practices in Studies of Improvement: Did You Budget Enough for Practice Recruitment? by Lyle J. Fagnan, MD, et al, Portland Oregon
- Hospital Ownership of Practice May Reduce Burnout Among staff in small to medium-size primary care practices, hospital ownership is associated with positive perceptions of work environment and lower burnout.
Effect of Practice Ownership on Work Environment, Learning Culture, Psychological Safety, and Burnout, by Alison Cuellar, PhD, et al, Fairfax, Virginia
- Solo Practices Outperform Groups in Meeting ABCS Targets Solo primary care practices in New York City are more likely than group practices to meet practice guidelines for reducing cardiovascular risk.
Quality of Cardiovascular Disease Care in Small Urban Practices, by Donna Shelley, MD, MPH, et al, New York, New York
- Major Disruptions Are Frequent in Primary Care Among 208 primary care practices, two-thirds experienced one or more major disruptive events, such as personnel changes or relocation, adversely affecting quality improvement efforts.
The Alarming Rate of Major Disruptive Events in Primary Care Practices in Oklahoma, by James W. Mold, MD, MPH, et al, Oklahoma City, Oklahoma
- Which Practices Use QI? Small to medium-size practices with quality improvement systems (e.g., registries) are most likely to use QI strategies; practices with fewer major disruptions are more likely to use QI strategies to improve cardiovascular preventive services.
Use of Quality Improvement Strategies Among Small to Medium-Size US Primary Care Practices, by Bijal Balasubramanian, MBBS, PhD, et al, Dallas, Texas
- Leadership and Adaptive Reserve Not Associated With Blood Pressure Control Primary care leadership and practice resilience can strengthen organizational culture. In small primary care practices, however, practice adaptive reserve and leadership capability are not associated with baseline blood pressure control.
Organizational Leadership and Adaptive Reserve in Blood Pressure Control: The Heart Health NOW Study, by Kamal H. Henderson, MD, Chapel Hill, North Carolina
- Interventions to Decrease Cardiovascular Disease Are Not One-Size-Fits-All In a study spanning four culturally different communities, tailored recruitment materials were developed to facilitate community engagement.
A Community Engagement Method to Design Patient Engagement Materials for Cardiovascular Health, by Aimee F. English, MD, et al, Denver, Colorado
- Practice Leaders' and Facilitators' Perspectives on QI Practice facilitators and practice leaders agreed on the value of a facilitated quality improvement program, but reached different judgments on practices' intensity and pace of change.
Practice Facilitators' and Leaders' Perspectives on a Facilitated Quality Improvement Program, by Megan McHugh, PhD, et al, Chicago, Illinois
Supplement Editorials and Overviews
- What Do Small Primary Care Practices Need to Transform? In order to transform amidst the many demands they face, primary care practices require a new set of conditions. According to editorialist Lawrence Casalino, MD, PhD, practices need more time and resources (through less time-consuming electronic health records, reduced reporting requirements, and more equitable reimbursement); reimbursement that is partly prospective rather than wholly fee-for-service; financial rewards for good performance on quality, cost, and patient experience; and shared resources for improving care.
Technical Assistance for Primary Care Practice Transformation: Free Help To Perform Unpaid Labor?, by Lawrence P. Casalino MD, PhD, New York, New York
- Tenets for Primary Care Practice Transformation Editorialist Asaf Bitton, MD, MPH, outlines four principles for primary care practice transformation. He calls on practices to: 1) look beyond short-term fixes to large-scale, holistic practice change; 2) pace themselves, making change over time; 3) focus on the most beneficial primary care outcomes for patients and communities; 4) work on the change process as a team.
Finding a Parsimonious Path for Primary Care Practice Transformation, by Asaf Bitton, MD, MPH, Boston, Massachusetts
- EvidenceNow: Insights Into Implementation Research EvidenceNow grew out of a rapidly changing primary care landscape and the urgent need for knowledge about practice transformation. This article describes AHRQ's decision-making processes as they designed the initiative's structure, which allows for local adaptation under a national umbrella, and their focus on producing evidence-based tools and improvement resources that will be applicable to most primary care practices in the United States.
EvidenceNow: Balancing Primary Care Implementation and Implementation Research, by David Meyers, MD, et al, Rockville, Maryland
- Supporting New Models of Care for Primary Care Practice Now more than ever, primary care practices are expected to meet the needs of a complex and aging population, often under significant time constraints and regulatory burdens. Early findings from EvidenceNOW will help pave the way to delivery of higher quality, comprehensive, team-based, patient-centered care, while helping primary care practices use health information technology to effectively manage population health and ongoing practice improvement.
The Capacity of Primary Care for Improving Evidence-Based Care: Early Findings From AHRQ's EvidenceNOW, by Sarah J. Shoemaker, PhD, PharmD, Cambridge Massachusetts
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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