September/October 2018 Annals of Family Medicine tip sheet
Continuity Between Patient and Prescribing Physician Reduces Risky Opioid Prescriptions
An ongoing relationship between patients with long-term opioid use and the doctors who prescribe the medication is associated with fewer risky opioid prescriptions and fewer opioid-related hospitalizations. A retrospective cohort study analyzed data from Oregon's Prescription Drug Monitoring Program, Vital Statistics, and hospital discharge registry for more than 78,000 patients with long-term opioid use. Patients with higher continuity with the physician prescribing opioids received fewer risky prescriptions (based on multiple prescriber metrics) compared to patients in the lowest continuity quartile, and were less likely to be hospitalized for opioid-related causes. However, on average, patients with long-term opioid use had significantly lower continuity scores than patients with long-term use of a stimulant or benzodiazepine, suggesting that efforts are still needed to improve opioid prescribing continuity. This study, which adds to the limited literature on prescriber continuity and opioids, suggests that continuity with the prescribing physician is an important factor associated with reducing opioid harms.
Opioid-Prescribing Continuity and Risky Opioid Prescriptions
Sara E. Hallvik, MPH, et al.
HealthInsight Oregon, Portland, Oregon
Young Physicians Feel Unprepared to Treat Opioid Use Disorder with Buprenorphine
Few early career family physicians report being adequately trained to provide buprenorphine treatment for opioid use disorder and even fewer provide it in their practices. Analyses of data from 1,979 family physicians who completed residency in 2013 found that 10 percent (n=198) felt adequately trained during residency to provide buprenorphine, and seven percent (n=138) reported providing buprenorphine treatment in their current practice. Of those currently providing buprenorphine, 46 percent (n=63) reported they were prepared in residency to do so. However, more than two-thirds of those residency-trained to provide buprenorphine are not doing so in practice, suggesting logistical barriers to providing buprenorphine after graduation. According to the authors, promoting residency training in buprenorphine treatment and overcoming barriers to its provision in practice could increase access to addiction services.
Buprenorphine Provision by Early Career Family Physicians
Sebastian T. Tong, MD, MPH, et al.
Virginia Commonwealth University, Richmond, Virginia
Medical Homes with After-Hours Care Are Associated with Increased Emergency Department Use
Enrollment in a medical home mandated to provide after-hours care is associated with a small increase in emergency department visit rates. This finding comes from a large-scale study of all adults in Ontario, Canada, enrolled in medical homes between April 1, 2005 and March 31, 2012 (n=2,945,087). Researchers found that in the years before enrollment in a medical home, the emergency department visit rate increased by 0.8 percent per year, while after medical home transition the rate increased by 1.5 percent per year. Enrollment in a medical home was also associated with a decrease in the overall primary care visit rate but a small increase in continuity of care. The authors hypothesize that the decline in the primary care visit rate associated with medical home enrollment may help explain the counter-intuitive increase in emergency department visits. Canada's health care reforms were implemented in the context of a relatively fixed primary care workforce, and increased after-hours primary care may have been offset by a decrease in regular office hours. Another possible explanation is that introducing mandatory after-hours provision with medical homes fueled greater demand for health care. This study highlights the importance of prospectively evaluating reform efforts that aim to improve access to primary care after hours, the authors state.
Emergency Department Use and Enrollment in a Medical Home Providing After-Hours Care
Tara Kiran, MD, MSc, et al.
St. Michael's Hospital, Toronto, Ontario, Canada
Social Isolation is Associated With Negative Experience in Primary Care
Among older people, social isolation is associated with a negative experience as a primary care patient. A cross-sectional study in 28 primary care practices in Japan utilized screening tools to assess social isolation and patients' experiences of key domains of primary care: first contact, in which the primary care clinician is the patient's usual entry point into the health care system; longitudinality or duration of the patient-physician relationship; coordination of care by the primary care clinician; comprehensiveness of services available and provided; and community orientation of care. Among 465 patients age 65 years or older, social isolation was negatively associated with overall primary care assessment scores and was significantly associated with longitudinality, comprehensiveness of services provided, and community orientation. Comprehensiveness of services provided had the strongest association with social isolation. These findings, the authors suggest, can contribute to our understanding of how social isolation influences health. They call for targeted interventions for socially isolated elderly patients aimed at improving their experience of primary care.
Social Isolation and Patient Experience in Older Adults
,p>Shunichi Fukuhara MD, DMSc, et al.
Kyoto University, Kyoto, Japan
The Loss of Professional Connections and the Doctors' Dining Room
Historically, family physicians were part of a connected professional community sustained in large part through informal gatherings of clinicians in hospitals, clinics, and professional organizations. Family physician John Frey reflects on how, as an intern in the 1960s, the hospital dining room for doctors was his source of political and medical acculturation and socialization. The demise of doctors' dining rooms in subsequent years, he suggests, reflects the professional isolation that characterizes primary care practice today, with fewer opportunities to interact with colleagues, particularly those outside the physician's practice setting. For most medical professionals, he observes, lunch has become a solitary pursuit in front of a computer screen, rather than a shared collegial experience. Frey calls for more social interaction during medical training and more emphasis on being part of a community of professionals: "Not valuing time with other physicians or making informal conversations possible leads to a soulless efficiency and professional isolation that drains physicians of our ability to help ourselves, help each other and help patients," he writes.
Professional Loneliness and the Loss of the Doctors' Dining Room
,p>John J. Frey III, MD
University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
Editorial: Articles Provide New Insights into Loneliness, Social Isolation and Health
An editorial by Professor Timothy Daaleman suggests that the articles by Aoki et al (social isolation and patient experience) and Frey (loss of the doctors' dining room) provide a uniquely primary care perspective that adds new ways of thinking about loneliness, social isolation and health. By positing that factors in the medical encounter can be associated with social connectedness and that personal physicians may be a source of intimate connection for patients experiencing loneliness, the Aoki study connects directly to core tenets of primary care. "If continuity of care is associated with the improved receipt of preventive services and reduced hospitalizations, could the primary care environment and the tenor of continuity visits be mediators of health outcomes in lonely or socially isolated patients?" Daaleman asks. Frey's recollections not only raise important issues (physician loneliness and isolation) that have received insufficient attention in discussions of burnout and professional dissatisfaction; they also illustrate the physical and relational components of safe spaces that facilitate meaningful conversation and relationship-building. Taken together, these two articles provide insights for those researching social isolation and loneliness, for medical directors who can promote social connection, and for physicians experiencing professional isolation. In all of their endeavors, according to Daaleman,"it is our connectedness with others that matters."
The Long Loneliness of Primary Care
Timothy P. Daaleman, DO, MPH
University of North Carolina, Chapel Hill, North Carolina
Preliminary Research Suggests Possible Link Between Added Fructose and Allergies
New research provides preliminary evidence of a possible link between beverages that are high in free (or added) fructose and allergic symptoms or allergic sensitization in children and adolescents. Analyses of 860 children and 1,142 adolescents in the 2005-2006 National Health and Nutrition Examination Survey do not yield entirely consistent findings, but lend some support to an association between allergy and high intake of beverages with excess free fructose. After controlling for potential confounders, children who consumed non-diet fruit drinks at least five times per week had 2.5 times greater odds of allergic sensitization than children who consumed such beverages one to three times per month. The association was stronger among adolescents; those who consumed beverages with excess free fructose one to four times per week or at least five times per week were five times more likely to have allergic symptoms than those who seldom drank such beverages. Adolescents consuming apple juice at least five times per week were twice as likely to have allergic sensitization than those who seldom consumed such beverages. These findings provide some evidence for the hypothesis that there may be a link between intake of beverages high in free fructose and allergic symptoms or allergic sensitization in children and adolescents. Longitudinal studies are needed to confirm the causality and to clarify underlying mechanisms.
Excess Free Fructose Beverages and Allergy in Children and Adolescents: Results From NHANES 2005-2006 ,p>Xueyan Wang BS, et al
Beijing Shijitan Hospital, Beijing, China
a target="_blank" href="http://www.annfammed.org/content/16/5/408">http://www.annfammed.org/content/16/5/408
New Tool Helps Identify Patients at Risk of Substantial Impairment From Dizziness
A new tool can help primary care physicians identify older patients at risk of an unfavorable course of dizziness (i.e., six months of substantial dizziness-related impairment). The risk score, based on a validated prediction model, consists of four easily obtained predictors of dizziness: age, history of arrhythmia, score on the Dizziness Handicap Inventory (screening version), and looking up as a trigger for dizziness. The authors suggest that the tool can activate primary care physicians to target potential contributing factors for high risk of an unfavorable course of dizziness, even when the cause of dizziness is unknown.
Predicting an Unfavorable Course of Dizziness in Older Patients
Hanneke Stam, MD, et al
Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
Predicting an Unfavorable Course of Dizziness in Older Patients
>Editorial: The Promise and Challenges of Clinical Prediction Rules
A related editorial explores both the promise and challenges of clinical prediction rules. Clinical prediction rules have gained popularity as tools to standardize and increase the accuracy and consistency of clinicians' diagnostic and prognostic assessments and management decisions. If, however, they are to meet their promise and improve quality of care, the authors argue, they must be evaluated on relevant processes of care and patient outcomes. In light of the challenges in evaluating their effectiveness, it is important to select clinical prediction rules in relevant clinical domains with proven predictive accuracy for impact analysis, anticipate barriers to the impact of clinical prediction rules, and consider how best to implement these tools to improve care processes, patient outcomes and health system efficiency.
Clinical Prediction Rules: Challenges, Barriers, and Promise
Emma Wallace MB, PhD et al
Royal College of Surgeons in Ireland, Dublin, Ireland
Documenting Social Determinants of Health in EHRs is Feasible but Challenging
A growing awareness that social factors–the conditions in which people live, work and play–influence health suggests that it is crucial to document such information in patients' electronic health records. A new study has found that adopting EHR tools to systematically document social determinants of health in primary care is feasible, but substantial barriers exist. In this pilot study, researchers implemented social determinants data tools in three Pacific Northwest community health centers. Among 1,130 patients for whom social determinants data were collected, 97 to 99 percent (n=1,098) had one or more social need documented in the EHR, with 210 (19 percent) receiving an EHR-documented social determinants referral. Fifteen to 21 percent of patients with a documented social need wanted help from the clinic to address the need. Although the study identified many barriers to implementing and designing tools and workflows, participating community health centers successfully documented social determinants in the EHR and continued to do so post-study. The authors explain that, to meet the growing national emphasis on documentation of social determinants of health in EHRs, a wide range of factors and substantial gaps in knowledge must be addressed.
Adoption of Social Determinants of Health EHR Tools by Community Health Centers
Rachel Gold, PhD, MPH, et al.
Kaiser Permanente, Portland, Oregon
Health Care Organizations Use Complex Interventions to Help Patients Find Employment
Employment status is a key social determinant of health. According to a new analysis, when health care organizations try to help patients find employment, they do so through innovative, complex interventions. Researchers in Toronto conducted a systematic review of 88 existing studies of interventions in a variety of health settings (e.g., primary care practices, hospitals, emergency departments, community health centers, and health centers in prisons) to help unemployed patients gain employment. Most articles (89 percent) focused on people with mental illness. The majority of studies (74 percent) succeeded in helping patients gain employment. Characteristics of successful interventions included, (1) a collaborative multidisciplinary team with regular communication, (2) a comprehensive package of services, (3) individualized components, (4) a holistic view of health and social needs, and (5) prospective engagement with employers. The authors suggest that primary care practices can begin addressing employment issues by raising awareness of employment as an important social determinant of health, training staff (e.g., social workers, community health workers and system navigators) to provide employment support, and building relationships with employment services. The authors call for research to evaluate the long-term impact of employment interventions across different health care settings and with diverse patients.
Employment Interventions in Health Settings: A Systematic Review and Synthesis
Andrew D. Pinto MD, CCFP, FRCPC, MSc, et al.
The Upstream Lab, St. Michael's Hospital, Toronto, Ontario, Canada
POEMs Illustrate Breadth and Evolution of Primary Care Practice
POEMs (Patient Oriented Evidence that Matters) are studies that address a relevant clinical question, demonstrate improved patient-oriented outcomes, and have the potential to change practice. This report identifies POEMs in each of the last 20 years that were highest ranked by the originators of POEMs for having recommended a major and persistent change in practice. POEMs have recommended novel effective interventions (e.g., beta-blockers in heart failure and a longer interval between Pap smears for most women), abandoning ineffective practices (e.g., routinely recommending hormone replacement therapy for postmenopausal women), and abandoning potentially harmful practices (e.g., intensive blood sugar control for patients with type 2 diabetes mellitus and aggressive therapy for low-grade prostate cancer). These POEMs illustrate the breadth of practice change in primary care and the need for family physicians to have a systematic approach to keeping up with the medical literature.
Top 20 POEMs of the Past 20 Years: A Survey of Practice-Changing Research of Family Physicians
Mark H. Ebell MD, MS, et al.
University of Georgia, Athens, Georgia
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:
- Humanistic Pocket Tool for Compassionate Care – Clinicians caring for homeless veterans have developed techniques, summarized on a pocket card, to remain respectful, empathic and compassionate when interacting with patients with complex behavioral, social or psychosocial issues. http://www.annfammed.org/content/16/5/467.full
- Lessons Learned from Rapid Scaling of Integrated Behavioral Health – Rapid implementation of a system-wide integrated behavioral health program requires strong backing from leadership, buy-in from management and frontline workers, interdisciplinary coordination, a shift in workplace culture, and persistence. http://www.annfammed.org/content/16/5/464.full
- A Simple Effective Technique for Taking an Adolescent Sexual History – Using a pen and exam table paper, a physician creates a simple visual aid during adolescent visits to acquire sexual history information in a comfortable, efficient, and thorough manner. http://www.annfammed.org/content/16/5/465.full
- Mentored Training Positions For Early Career GPs – In Scotland, early career general practitioners can spend two years in a supportive primary care practice developing their skills and receiving mentored training in an additional field e.g., medical education, geriatrics or palliative care. http://www.annfammed.org/content/16/5/466.full
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.