May/June 2016 Annals of Family Medicine tip sheet

Prostate Cancer: Survival Misperceptions Are Potential Drivers of More Aggressive Treatment Choice

Researchers find most men with localized prostate cancer underestimate their life expectancy without treatment and overestimate the gain in life expectancy with surgery or radiation – misperceptions that may lead to overtreatment, decisional regret and decreased post-treatment quality of life. A survey of 260 men aged 75 or younger with newly diagnosed LPC showed that without any treatment, 33 percent of patients expected they would live less than 5 years, 41 percent five to 10 years, 21 percent 10 to 20 years, and 5 percent more than 20 years. With their chosen treatment (surgery, radiation or watchful waiting/active surveillance), 3 percent of patients expected to live less than five years, 9 percent five to 10 years, 33 percent 10 to 20 years and 55 percent more than 20 years. While only 25 percent of all patients in this study expected to live more than 10 years, the authors note that a recent update of the largest and longest-followed active surveillance cohort of men diagnosed with LPC showed 98 percent and 94 percent prostate cancer-specific survival rates at 10- and 15-year follow-up respectively. Moreover, while the patients who chose surgery in this study expected to gain 12 years of life from active treatment, recently published data showed surgery does not significantly improve prostate cancer-specific survival compared with observation after 10 years follow-up. Furthermore, men who perceived their cancer as more serious expected more benefit from their chosen treatment regardless of their objective cancer risk level. These unrealistic expectations, the authors write, are of particular concern because men who choose active treatment have survival almost identical to that of those who choose observation, yet active treatment is associated with high rates of impotence and incontinence. They conclude there is an urgent need for interdisciplinary and cross-specialty communication with patients who have prostate cancer. In collaboration with oncology specialists, primary care physicians, they note, are often best positioned to help patients develop realistic life expectancy estimates and associated treatment goals.

Patients' Survival Expectations With and Without Their Chosen Treatment for Prostate Cancer
By Jinping Xu, MD, MS, et al
Wayne State University, Detroit, Michigan

Self-Measured Waist Circumference Has High Rate of Underestimation

Although waist circumference can be used as an effective screen for metabolic and weight-related problems, logistic issues inhibit its routine use in outpatient practice settings. Assessing whether self-measured waist circumference by patients provided with written and pictorial instructions for self-measurement might be sufficiently accurate to replace professionally measured waist circumference, researchers find self-measurements have a high false negative rate with a worrisome proportion of patients misclassifying themselves as low risk. Analysis of self- and professionally measured waist circumference data on 585 women and 165 men showed the false-negative rate of self-measurements approached or exceeded 20 percent for some groups at high risk for poor health outcomes. Specifically, they found 11 percent of normal-weight and 52 percent of overweight women had professionally measured waist circumference putting them in a high risk category for metabolic syndrome; however 57 percent and 18 percent of these women, respectively, undermeasured their waist circumference as falling below that cutoff. Fifteen percent and 84 percent of overweight and class I obese men, respectively, had a professionally measured waist circumference putting them in a high-risk category, however 23 percent and 16 percent of these men, respectively, undermeasured their waist circumference as falling below that cutoff. The authors conclude that these findings demonstrate that self-measured waist circumference has an unacceptably high rate of underestimation, and they call for further research on how to improve instruction, techniques or measuring devices.

Self-Measured vs Professionally Measured Waist Circumference
By Teresa B. Jensen, MD, et al
Mayo Clinic, Rochester, Minnesota

Diagnosing Pulmonary Embolism in Primary Care: Wells Rule More Efficient Than Physician's Own Probability Estimate

Formal prediction models are often regarded as a more accurate way to estimate disease probability when compared with a physician's intuitive probability estimate, yet physicians contend standardized prediction models do not allow for the incorporation of individual characteristics. Against that backdrop, researchers in the Netherlands compare the diagnostic performance of gestalt and the Wells decision rule for safely and efficiently ruling out pulmonary embolism in primary care. Analyzing data on 598 adult patients with suspected PE presenting in Dutch primary care, researchers found both gestalt and the Wells rule were safe for ruling out PE when combined with D-dimer testing, however the Wells rule was more efficient at ruling out PE in a larger proportion of patients. While family physicians were very capable of identifying patients at both ends of the probability spectrum, for a large group of patients at intermediate risk, application of the Wells rule and D-dimer testing optimized risk stratification better than using gestalt alone. Specifically, the authors found both gestalt and Wells rule had good overall discriminative ability with c statistics of 0.77 and 0.80, respectively; however the number of patients who needed to be referred for objective testing was substantially lower using the Wells rule (efficiency = 45 percent versus 25 percent). These findings, they conclude, support the use of a prediction model, but leave room for relying on gestalt if disease presence or absence is highly likely or unlikely.

Ruling Out Pulmonary Embolism in Primary Care: Comparison of the Diagnostic Performance of "Gestalt" and the Wells Rule
By Janneke M. T. Hendriksen, MD, et al
University Medical Center Utrecht, The Netherlands

Having Patients Articulate Quality of Life Goals on Pre-Encounter Forms Does Not Result in More Patient-Centered Visits

Studying whether patients could encourage their primary care physicians to be more patient-centered by using pre-encounter forms to alert their physicians to quality of life goals and concerns, researchers found the intervention questionnaire surprisingly led to little focus on quality of life during physician visits, when compared to a control questionnaire that simply asked about symptoms. The randomized controlled trial comparing the impact of two different pre-visit questionnaires on the content of 64 patient-physician encounters in a family medicine practice finds that although patients effectively articulated their quality of life goals on paper, quality of life was mentioned in only two of the 64 encounters, once by a patient and once by a physician. In neither case was the QOL information used in decision making, and perhaps most startling, directly observed empathy was greater in encounters in the control group, compared to the intervention group. The authors conclude that recording QOL goals on paper did not prime patients nor physicians to alter the process or content of the clinical encounters suggests that the QOL information itself is hard to incorporate into the encounter. They posit this could be because patients prefer that physicians open up the QOL discussion or because there is no logical place to bring up meaningful life activities within the standard medical encounter. With previous research showing that patient participation in clinical decision making improves outcomes, including quality of life, they call for training and pre-visit coaching for both patients and physicians to adopt this new behavior.

Encouraging Patient-Centered Care by Including Quality-of-Life Questions on Pre-Encounter Forms
By Becky A. Purkaple, MD, BA, BS
University of Oklahoma College of Medicine, Oklahoma City

Positive Effects of Health Coaching Endure in Year After Intervention

With the majority of health coaching research focused on effects limited to the period of active intervention, little is known about the persistence of any positive effects after the end of health coaching. To help fill this knowledge gap, researchers from the University of California San Francisco followed up on a 12-month randomized controlled trial of a health coaching intervention for patients with poorly controlled diabetes, hypertension and/or high cholesterol. While the initial study found the intervention significantly improved achievement of clinical goals (systolic blood pressure, LDL cholesterol and hemoglobin A1c) at 12 months, this follow-up showed that up to one year after health coaching, patients in the study's intervention arm experienced only minimal declines in clinical goals with the exception of hemoglobin A1c. Specifically, they found the proportion of patients in the coaching arm of the trial who achieved at least one clinical goal at 12 months dropped only slightly from 47 percent at 12 months to 46 percent at 24 months. Similarly, almost the same proportion achieved the secondary outcome of meeting all clinical goals for which they were eligible on study entry at 12 months (36 percent) and 24 months (34 percent). A similar pattern was seen for systolic blood pressure and LDL cholesterol, but the proportion at goal for hemoglobin A1c dropped from 53 percent to 36 percent. The authors conclude these findings suggest that most improved clinical effects are maintained up to one year after receiving health coaching.

What Happens After Health Coaching? Observational Study 1 Year Following a Randomized Controlled Trial
By Anjana E. Sharma, MD, et al
University of California, San Francisco

Presentation and Diagnosis of Recurrent Disease in Colon Cancer Survivors

In order to help prepare Dutch primary care physicians for a future role as coordinators of colon cancer follow-up care, researchers in the Netherlands evaluate how recurrent colon cancer presents and is diagnosed during the first five postoperative years. The study of 446 patients who were treated for colon cancer with curative intent, finds 74 (17 percent) developed recurrent disease. Fifty-eight percent of recurrences were detected during scheduled follow-up visits with 95 percent of patients asymptomatic at the time of detection; 42 percent of recurrences were found during non-scheduled interval visits, with 84 percent of patients presenting with well-known symptoms (abdominal pain, altered defecation and weight loss). Patients with asymptomatic recurrences had a significantly higher overall survival rate compared with patients with symptomatic recurrences, which were more often multisite recurrences. Tumor marker testing, imaging and colonoscopy identified all of the recurrences. The authors conclude that primary care physicians who take care of colon cancer patients should be aware of the relatively high rate of symptomatic recurrences and of typical presenting symptoms.

Symptomatic and Asymptomatic Colon Cancer Recurrence: A Multicenter Cohort Study
By Laura A. M. Duineveld, MD, et al
University of Amsterdam, The Netherlands

Rural Female Family Physicians Outline Personal and Professional Strategies for Successful Work-Life Balance

Women are an essential component of the rural physician workforce, yet female family physicians experience unique challenges in maintaining work-life balance while practicing in rural communities. Seeking to better understand the personal and professional strategies that enable women in rural family medicine to balance work and personal demands and achieve long-term career satisfaction, researchers interviewed 25 women family physicians practicing in rural communities in the United States. They found that supportive employers, relationships and patient approaches provide a foundation for successful careers. The participants described using the following strategies to achieve work-life balance: 1) reduced or flexible hours; 2) supportive relationships with spouses, partners, parents or other members of the community enabling them to be readily available to their patients; and 3) maintaining clear boundaries around their work lives, helping ensure adequate time for parenting, recreation and rest. The authors conclude their findings suggest that female physicians considering rural practice may be more satisfied and successful if they seek flexible employers and choose communities where support is available, or if they look for ways to build support networks as they are choosing practice settings. They may also benefit from developing strategies to negotiate boundaries with patients and developing skills to maintain their wellness.

Rural Women Family Physicians: Strategies for Successful Work-Life Balance
By Julie Phillips, MD, MPH, et al
Michigan State University College of Human Medicine, Grand Rapids

UK Researchers Develop and Validate New Instrument for Comprehensively Measuring Patient-Reported Safety in Primary Care

Despite the growing interest in patient safety, major gaps remain in the understanding of primary care patient safety, in part due to the lack of appropriate measurement methods, limiting the ability to obtain reliable and repeatable rates of events. Existing instruments, the authors note, largely focus on a small number of relevant dimensions, mostly related to medication problems, and do not allow for a comprehensive assessment of safety. In an effort to fill this gap, researchers in the United Kingdom developed and validated an instrument for comprehensively measuring patient-reported experiences and outcomes of safety in primary care. The final version of Patient Reported Experiences and Outcomes of Safety in Primary Care (PREOS-PC) covers five domains, eight scales and 58 items. Results from psychometric analysis support the instrument's internal consistency and validity, though findings for test-retest reliability were mixed. The authors call for further testing and work before general application of the instrument in practice.

Measuring Patient Safety in Primary Care: The Development and Validation of the "Patient Reported Experiences and Outcomes of Safety in Primary Care" (PREOS-PC)
By Jose M. Valderas, PhD, et al
University of Exeter, United Kingdom

Smoking Cessation Intervention Increases Rates of Tobacco Treatment Delivery in Primary Care Practice

Implementation of a multicomponent smoking cessation intervention in primary care practice was successful in increasing the rates of tobacco treatment delivery. The Ottawa Model for Smoking Cessation, which uses the three A's – Ask (identify smoking status), Advise (counsel patients to quit smoking) and Act (assist with cessation), was tested in 32 primary care practices with 481 clinicians and 3,870 patients. Researchers found rates of delivery of the three A's increased significantly following program implementation (Ask: 55 percent vs. 71 percent; Advise: 46 percent vs. 64 percent; Act: 35 percent vs. 54 percent). Evaluation showed that high quality implementation of the program was associated with higher rates of the three A's delivery, reinforcing the importance of ensuring fidelity to the implementation model. They also found that providers were significantly more likely to address tobacco use during periodic exams, indicating that clinicians may be missing opportunities when patients present for other reasons. The authors conclude the results of this evaluation lend support to existing evidence regarding the effectiveness of multicomponent interventions in influencing tobacco treatment delivery in primary care settings.

Increasing Rates of Tobacco Treatment Delivery in Primary Care Practice: Evaluation of the Ottawa Model for Smoking Cessation
By Sophia Papadakis, PhD, et al
University of Ottawa Heart Institute, Ontario, Canada

Reflection: Primary Care Physician Describes the Sticker Shock He Faced When Using a High Deductible Plan for Urgent Medical Care

A primary care physician shares his family's experience attempting to navigate urgent medical decisions in a high-deductible health plan and how he resolved that it is unrealistic to price-shop in urgent and emergent situations. He describes how in accessing urgent care for his child's arm fracture, he unknowingly encountered 10-fold pricing variation for a plain film x-ray – a routine, low-cost technology. He asserts that if insurers are going to sell high-deductible health plans, they need to do a better job identifying outlier prices and making those prices part of their negotiations with providers. Moreover, he contends that physicians also need access to better pricing information – ideally situated within the electronic health record – to make prices part of routine discussions so that patients can avoid unnecessary and potentially disruptive out-of-pocket expenses.

Sticker Shock: The Experience of a Health Consumer
By David Grande, MD, MPA
University of Pennsylvania, Philadelphia

Reflection: Family Physician Reflects on How She Was Affected by Her Patient's Racist Rant

A black female family physician shares a personal experience in which a racist rant by a patient seemingly reversed the usual power dynamic. She describes the resilience she has developed over time and the tools and strategies she has used over the years to handle the aggressions she has experienced from patients, colleagues and institutions.

Racism in Medicine: Shifting the Power
J. Nwando Olayiwola, MD, MPH, FAAFP
San Francisco General Hospital, California

Reflection: Family Physician Relates the Story of her Dad's Last Week and How it Revealed Why She Became a Doctor

A family physician shares how wearing both her daughter and doctor hats brought meaning to her and help to her father as they made decisions and avoided unhelpful interventions during the last week of his life. She describes how the unique combination of professional and personal knowledge enabled her to help her father choose the end-of-life path that was right for him. She posits that everyone should have someone – or a team of family, friends and health care professionals, including a primary care clinician – who together offer that special combination of professional and personal knowledge and can serve as navigators and advocates in the hospital and out of the hospital, in sickness and in health.

Dad's Last Week
By Jennifer E. DeVoe, MD, DPhil
Oregon Health & Science University, Portland

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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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