May/June 2021 Annals of Family Medicine tip sheet

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Greater Presence of Family Physicians, Midwives May Be Key Component to Decreasing Cesarean Delivery Rates

Surgical cesarean births can expose new mothers to a range of health complications, including infection, blood clots and hemorrhage. As part of Healthy People 2020 and other maternal health objectives, the state of California exerted pressure to reduce cesarean deliveries, and statewide organizations established quality initiatives in partnership with those goals. In this study, researchers from Stanford University and the University of Chicago examined unit culture and provider mix differences on hospital and delivery units to identify characteristics of units that successfully reduced their cesarean delivery rates. The mixed-methods study surveyed and interviewed labor and delivery teams from 37 California hospitals that were participating sites in the California Maternal Quality Care Collaborative’s Supporting Vaginal Birth initiative. Respondents at successful hospitals included more family physicians and midwives, and physicians who had been in practice for less time. The study identified a number of unit culture factors that also predicted success. The authors conclude, “Family medicine, a discipline that strongly identifies itself as valuing patient-centered care and shared decision-making, may be in a unique position to contribute positively to this aspect of culture change on labor and delivery units.”

Culture That Facilitates Change: A Mixed Methods Study of Hospitals Engaged in Reducing Cesarean Deliveries

Emily C. White VanGompel, MD, MPH, et al

University of Chicago, Pritzker School of Medicine, Department of Family Medicine, Chicago, Illinois

https://www.annfammed.org/content/19/3/249

Psychotherapy, Paired With Pharmacotherapy, Is More Effective in Treating Depression Than When Kept Separate

Most patients with depression are treated in primary care, however, relatively few clinical trials for treating depression have focused on primary care. Researchers at the Vrije University Amsterdam examined the effects of the two major approaches to treating depression: psychotherapy and pharmacotherapy, as well as combined treatment and care-as-usual. The study integrated the results of 58 randomized controlled trials with a total of 9,301 patients. Results concluded that both psychotherapy and pharmacotherapy were significantly more effective than care-as-usual or waitlist control. However, they found no significant difference between psychotherapy and pharmacotherapy as stand-alone treatments. Combined treatment, particularly in studies that included cognitive behavioral therapy, was better than either pharmacotherapy or psychotherapy alone. Treatment in primary care should be organized to accommodate any of these treatments in response to patients’ preferences and values, the authors write.

Psychologic Treatment of Depression Compared With Pharmacotherapy and Combined Treatment in Primary Care: A Network Meta-Analysis

Pim Cuijpers, PhD, et al

Vrije University, Amsterdam, Department of Clinical, Neuro and Developmental Psychology and Amsterdam Public Health Research Institute; The Netherlands

https://www.annfammed.org/content/19/3/262

Newer Class of Fluoroquinolone Antibiotics May Present Reduced Risk of Tendon Ruptures

It’s widely understood that people taking a common class of antibiotics, like ciprofloxacin and levofloxacin, run the risk of tendonitis and tendon ruptures. However, a new analysis sheds light on newer, third-generation fluoroquinolones and suggests they may have a lower risk of Achilles tendon rupture. Researchers from Jichi Medical University in Tochigi, Japan, used health care administrative data to identify 504 patient cases of Achilles tendon ruptures with co-occurrence of antibiotics. They found that third-generation fluoroquinolones were not associated with an increase in Achilles tendon rupture. First- and second-generation fluoroquinolones, like ciprofloxacin and ofloxacin, were at elevated risk of tendon rupture, which was consistent with previous evidence. Third-generation fluoroquinolones include moxifloxacin, garenoxacin, sitafloxacin, prulifloxacin and pazufloxacin, some of which are not yet approved by the Food and Drug Administration in the United States. The authors note that further studies are required to determine the risks of third-generation fluoroquinolones for other rare adverse events, such as heart damage.

Association Between Third-Generation Fluoroquinolones and Achilles Tendon Rupture: A Self-Controlled Case Series Analysis

Takashi Chinen, MD, et al

Jichi Medical University, Department of Clinical Oncology, Tochigi, Japan

https://www.annfammed.org/content/19/3/212

Shared Medical Appointments Help Patients With Prediabetes

Researchers from the Cleveland Clinic and Takeda Pharmaceutical Company conducted a study to evaluate the effectiveness of shared medical appointments for people with pre-diabetes compared with a group of patients receiving usual care. Shared medical appointments are typically delivered in a medical clinic by physicians and other health care providers. Within the context of this study, shared medical appointments consisted of patients consulting with their doctors one-on-one and then joining a group of similar patients to set goals and review lab results with the same family physician and a diabetes educator. Researchers also assessed the impact of attending a shared medical appointment versus care-as-usual on chronic conditions such as high blood sugar, cholesterol and blood pressure.

Over 24 months, patients who took part in shared medical appointments lost more weight than those who received usual care. By the conclusion of the study period, patients who attended shared medical appointments showed better outcomes in managing the aforementioned chronic conditions than those patients who received usual care.

Researchers concluded that shared medical appointments may provide an effective model of treatment for patients with pre-diabetes. As the diabetic epidemic continues, the authors call for more research using shared medical appointments to manage prediabetes in health care systems.

Shared Medical Appointments and Prediabetes: The Power of the Group

Aphrodite Papadakis, MD, et al

Department of Family Medicine, Cleveland Clinic, Cleveland, Ohio

https://www.annfammed.org/content/19/3/258

Interdisciplinary Consults Can Help Primary Care Doctors Effectively Manage Patients Living with Chronic Pain and Addiction

Between 11% to 40% of adults in the United States experience chronic pain, and primary care physicians may feel ill-equipped to effectively and safely care for patients with chronic pain, addiction or both. Researchers from Tufts University conducted a study to evaluate the effectiveness of an interdisciplinary consultation service that supports primary care physicians who care for patients experiencing chronic pain and addiction. The goal was to identify new and effective strategies that clinics can use to support PCPs.

From that interdisciplinary consultation service, the researchers collected and thematically analyzed 66 referral questions and 14 interviews with PCPs to better understand the types of support physicians would find most beneficial.

PCPs’ expressed needs included needing expertise in addiction, safe prescribing of opioids, non-opioid treatment options, communication strategies for difficult conversations, a comprehensive review of the case, and a biopsychosocial approach to management. Some additional needs were identified after interviews, including confirmation of their medical decision-making process, emotional validation, feeling more control, having an outside entity take the burden off the PCP for management decisions, boundary setting and reframing the visit to focus on the patient’s function, values and goals.

The authors concluded that an interdisciplinary consultation service can effectively support primary care physicians who care for patients battling pain and addiction. They then offer some potential strategies that health systems can use to support PCPs in this important role.

Multidisciplinary Approach for Managing Complex Pain and Addiction in Primary Care: A Qualitative Study

Randi Sokol, MD, MPH, MMedEd, et al, Department of Family Medicine, Tufts University School of Medicine, Boston, Massachusetts

https://www.annfammed.org/content/19/3/224

Antibiotics: Patient Expectations and Doctors’ Prescribing Habits May Contribute to Antimicrobial Resistance

Inappropriate antibiotic prescribing for upper respiratory tract infections contributes to antibiotic resistance, making some bacterial infections difficult to treat. This often leads to higher medical costs, prolonged hospital stays and increased mortality. Still, many physicians report prescribing antibiotics at their patients’ request. To address patients’ expectations for antibiotic prescribing for URTIs, researchers conducted an experiment in which study participants were assigned brief educational videos to watch on a tablet immediately prior to their appointment.

The authors randomized patients into three groups – one that viewed a presentation about the futility of antibiotic treatment of URTIs; a second group that viewed a presentation about the adverse effects associated with antibiotics; and a third control group that learned about the benefits of healthy diet/exercise. The researchers then measured the effects of the presentations on patients’ beliefs that antibiotics are helpful for URTIs; their expectations to be prescribed an antibiotic; and whether they were actually prescribed antibiotics for their URTIs. Participants who viewed either the futility or adverse effects presentations had greater reductions in their expectations of receiving antibiotics compared to the group that viewed the video about the benefits of healthy/diet and exercise. However, there was no significant difference between the three groups when it came to doctors actually prescribing antibiotics to patients. Researchers concluded that a brief, tablet-based waiting room intervention significantly changes participants’ expectations on receiving antibiotics for URTIs, but that future efforts to improve antibiotic prescribing need to involve both patients and their doctors.

Reducing Expectations for Antibiotics in Patients With Upper Respiratory Tract Infections: A Primary Care Randomized Controlled Trial

Anna Perera, MBChB, et al

University of Auckland, Department of Psychological Medicine, Auckland, New Zealand

https://www.annfammed.org/content/19/3/232

New Study Examines Connection Between Oral and General Health in Patients With Diabetes-Related Oral Health Issues

Individuals with diabetes are at greater risk of developing oral health issues, like gum disease, yet care for these linked health issues are usually disconnected, split between primary care and dental care. A research team from the University of Amsterdam developed an intervention that provided primary care-based oral health information and dental referrals for patients with diabetes. In a cluster randomized controlled trial, 764 patients from 24 primary care practices received either the oral health support or standard primary care. Participants were asked to rate their oral health quality of life, as well as their general health and any oral health complaints, at the start and end of the study. Analysis showed that individuals who received the primary care-based oral health support intervention had a significant increase in their self-reported oral health quality of life when compared with the control group. The authors conclude that, “patients with type 2 diabetes who attend primary diabetes care can benefit from extra attention to oral health.” They add, “It also further reflects the concept of oral health and general health being connected.”

Implementation of an Oral Care Protocol for Primary Diabetes Care: A Pilot Cluster-Randomized Controlled Trial

Martijn J.L. Verhulst, Ph.D., MSc, et al

Vrije Universiteit, Department of Periodontology, Academic Centre for Dentistry, Amsterdam, The Netherlands

https://www.annfammed.org/content/19/3/197

Improving Smoking Cessation Counseling and Blood Pressure Quality Metrics in Primary Care Requires Both Operational Changes and Consideration of Local Context

In order to make meaningful gains in cardiovascular disease care, primary care medical practices should adopt a set of care improvements specific to their practice size and type, according to a new study from the national primary care quality improvement initiative EvidenceNOW. High blood pressure and smoking are among the biggest risk factors associated with cardiovascular disease. Primary care physicians help patients manage high blood pressure and provide smoking cessation interventions.

Researchers found that there is no one central playbook for all types of practices, but they did identify combinations of practice characteristics, amount of practice facilitation, and operational changes linked with improved cardiovascular disease care. Smaller, solo and clinician-owned practices that changed routine aspects of their process, such as training medical assistants to perform accurate blood pressure readings; allowing staff to take repeated blood pressure measures and note second readings in electronic medical records; and equipping clinicians with the tools to perform smoking screening and cessation referrals, were able to make substantial improvements.

In addition, working with a practice facilitator helped. Smaller practices that participated in a moderate amount of facilitation were able to make these improvements. However, for larger hospital or health system-owned practices and Federally Qualified Health Centers more facilitation was necessary, leading researchers to conclude that “making operational changes alone–in certain clinical settings–was insufficient to achieve meaningful improvements.” In practices that are part of larger, more complex systems, external facilitation along with prioritization of operational changes may be critical to successful quality improvement.

Improving Smoking and Blood Pressure Outcomes: The Interplay Between Operational Changes and Local Context Deborah J. Cohen, Ph.D., et al

Oregon Health & Science University, Department of Family Medicine, Portland, Oregon

https://www.annfammed.org/content/19/3/240

In a corresponding editorial titled “The Need for Coaches in a Clinical World”, Robert L. Phillips, Jr, MD, MSPH, of the American Board of Family Medicine, identifies a common thread running throughout five studies in the May-June 2021 issue Annals of Family Medicine. Dr. Phillips notes that practice facilitation is key to improving primary care at a systems level. Each study he discusses investigates a different, though widely experienced, medical issue, including cardiovascular disease, antibiotic resistance, chronic pain and addiction and cesarean births. He writes that these studies offer meaningful insights about facilitating behavior change, the importance of culture, and respecting complexity.

The Need for Coaches in the Clinical World

Robert L. Phillips, Jr, M.D., MSPH

American Board of Family Medicine, Lexington, Kentucky

https://www.annfammed.org/content/19/3/194

COVID-19 Pandemic Presents Opportunities to Ensure Health Care is Fully Person-Centered

The COVID-19 pandemic has forced many physicians to approach patient care in completely different ways. Elena Rosenbaum, MD, an associate professor in the Department of Family and Community Medicine at Albany Medical College in New York, believes this is a critical time to refocus and ensure that health care is person-centered, encompasses all modifiable health determinants, and helps individuals achieve health rather than primarily manage disease. This is especially important now that COVID-19 has emphasized the flaws of the current health care system and the health inequities that exist in this country.

Changing the US health care system is daunting, but Rosenbaum is optimistic that the challenges we have faced during the pandemic will help bring about meaningful reform. She writes about the need for a multi-pronged approach that eliminates fee-for-service payment and advocates for universal health care or alternative payment models that allow physicians to address lifestyle, behavior and social determinants of health with their patients. Rosenbaum also recognizes the benefits of telemedicine, which has given doctors a window into patients’ worlds and helped them stay connected to their most vulnerable patients. With the shift in how health care is administered, she believes now is the time for doctors to proactively reduce health disparities by examining and addressing systemic racism in medical care and collaborating with community members, public health experts and governments to break down health silos and bring about meaningful systemic change for our patients.

A Thoughtful Rebirth of Health Care: Lessons From the Pandemic

Elena Rosenbaum, MD

Department of Family and Community Medicine, Albany Medical College, Albany,York

https://www.annfammed.org/content/19/3/274

Personal, Environmental, Workplace and Population Factors Influence Family Physicians’ Practice Scope

Although new family medicine graduates intend to provide a broader scope of practice than their senior counterparts, individual family physicians’ scope of practice has been decreasing, with fewer family physicians providing basic primary care services, such pediatric and prenatal care. Russell et al conducted a study to explore family medicine graduates’ attitudes and perspectives on modifiable and non-modifiable factors that influenced their scope of practice and career choices. The authors conducted five focus group discussions with 32 family physicians and explored their attitudes and perspectives on their desired and actual scope of practice. Using a conceptual framework to understand the influences on practice scope, the authors found that personal factors played a role on desired scope while workplace, environmental and population factors influenced actual practice scope. Stressors that occurred in these four categories often caused family physicians to narrow their scope of practice. Understanding personal, environmental, workplace and population factors that influence practice scope can inform specific interventions that create desirable jobs for family physicians and improve their ability to meet changing population needs. Supportive factors of a broader-scope practice include training and access to additional medical education after training; access to mentors; strong organizational leadership; and team-based care.

Drivers of Scope of Practice in Family Medicine: A Conceptual Model

Amy Russell, MD, et al

University of North Carolina Health Sciences at Mountain Area Health Education Center and HCA Healthcare, Asheville, North Carolina

https://www.annfammed.org/content/19/3/217

Health Care Industry Has Ways to Go Before Reaching Its Goal of Translating Care Into Clinical Quality Data

Family physicians provide nearly 20% of all clinical outpatient visits, translating to 200 million visits in the US annually, according to the Centers for Disease Control and Prevention. Frontline clinicians continue to report failures of certified electronic health records to meet federal certification requirements and electronic reporting needs.

Researchers created the Trial of Aggregate Data Exchange for Maintenance of certification and Raising Quality, a randomized controlled trial, to assess whether quality measure reporting could be made a byproduct of clinical care and quality improvement. They recruited family physicians from four health systems. A total of 256 family physicians participated. Of 19 measures negotiated for use, five were used by all systems. The researchers identified 15 types of errors, including breaks in data delivery; changes in measures; and nonsensical measure results. Only one system had no identified errors.

The study concluded that the secure transfer of standardized, physician-level quality measures from the four health systems, despite their having mature processes in place, proved difficult. There were many errors that required human intervention and manual repair, which precluded full automation. The study reconfirms that despite widespread health information technology adoption and federally meaningful use policies, health care remains far from reaching its goals of making clinical quality reporting a reliable byproduct of care.

Clinical Quality Measure Exchange Is Not Easy

Robert L. Phillips, MD, MSPH, et al

American Board of Family Medicine, Lexington, Kentucky

https://www.annfammed.org/content/19/3/207

Medical Student Learns Firsthand the Power of Long-Term Patient-Physician Relationships and Difficulties When They End

Melissa B. Hill, BS, a medical student at Icahn School of Medicine at Mount Sinai, writes a first-person narrative about her relationship with a pregnant patient with whom she connected while participating in a medical school program supporting expectant mothers with limited support systems during their pregnancies. Hill writes that, though she learned in her preclinical “doctoring” courses how to build quick connections with patients, her training didn’t teach her how to manage meaningful, emotionally complex connections she might form with patients during longitudinal rotations. She notes how she invested an “enormous amount of time and invested a great deal emotionally” following and supporting the pregnant patient but lacked guidelines on how to end the partnership, causing her to feel like she was abandoning a good friend. As Hill reflects on the end of this particular relationship, she writes that she learned to appreciate the power of the longitudinal physician-patient relationship and that taking care of patients also requires that she take care of herself.

It’s Not You, It’s Me: Learning to Navigate the Patient-Physician Relationship

Melissa B. Hill, BS

Icahn School of Medicine at Mount Sinai, New York City, New York

https://www.annfammed.org/content/19/3/271

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:

Nonprofessional Health Workers on Primary Health Care Teams in Vulnerable Communities– Nonprofessional health mediators were recruited from disadvantaged and rural Roma Hungarian communities to contribute to primary care teams. Cross-sectional health surveys found that the health of the community workers improved over time, with significant improvements in stress and smoking cessation.

https://www.annfammed.org/content/19/3/277

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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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