Public Release:  July/August 2014 Annals of Family Medicine tip sheet

American Academy of Family Physicians

High Prevalence of Unsafe All-Terrain Vehicle Ridership Among Adolescents in Iowa

More youth are killed every year in the United States in all-terrain vehicle crashes than on bicycles, and since 2001, one-fifth of all ATV fatalities have involved victims aged 15 years or younger. To better understand ATV riding practices among adolescents, researchers surveyed 4,684 youths aged 11 to 16 years at 30 schools across Iowa and found the vast majority reported having ridden an ATV, and most practiced unsafe riding behaviors and had experienced at least one crash. Specifically, the researchers found that regardless of rurality, 77 percent of students reported having been on an ATV, with 38 percent of those riding daily or weekly. Among ATV riders, 57 percent had been in a crash. Moreover, most riders had engaged in risky behaviors, including riding with passengers (92 percent), on public roads (81 percent), and always or almost always without a helmet (64 percent). Almost 60 percent reported engaging in all three behaviors, and only 2 percent engaged in none. The authors conclude that given this widespread use and the potential considerable morbidity of pediatric ATV crashes, prevention efforts, including anticipatory guidance by primary care clinicians serving families at risk, should be a higher priority.

A School-Based Study of Adolescent All-Terrain Vehicle Exposure, Safety Behaviors, and Crash Experience
By Charles A. Jennissen, MD, et al
University of Iowa Carver College of Medicine, Iowa City

Pregnancy Loss Associated with Development of Cardiovascular Disease in Adulthood

Women with a history of miscarriage or stillbirth appear to be at increased risk of cardiovascular disease. Analyzing data on a sample of 77,701 women, 30.3 percent of whom reported a history of miscarriage, 2.2 percent a history of stillbirth and 2.2 percent a history of both, researchers found the multivariable adjusted odds ratio for coronary heart disease for one or more stillbirths was 1.27 (95 percent CI, 1.07-1.51) compared with no stillbirth; for women with a history of one miscarriage, the odds ratio was 1.19 (95 percent CI, 1.08-1.32); and for women with a history of two or more miscarriages, the odds ratio was 1.18 (95 percent CI, 1.04-1.34) compared with no miscarriage. They did not find a significant association of ischemic stroke and pregnancy loss. The association between pregnancy loss and CHD appeared to be independent of hypertension, body mass index, waist-to-hip ratio and white blood cell count. The authors write that these findings contribute to the growing body of evidence that the metabolic, hormonal and hemostatic pathway alterations that are associated with pregnancy loss may contribute to the development of CHD in adulthood. They recommend that women with a history of miscarriage or a single stillbirth be considered candidates for closer surveillance and/or early intervention by their primary care physician so that risk factors can be carefully monitored and controlled (including monitory of CVD risk factors - diabetes, hypertension, cholesterol, obesity, smoking and diet).

Risk of Cardiovascular Disease Among Postmenopausal Women with Prior Pregnancy Loss: The Women's Health Initiative
By Donna R. Parker, ScD, et al
Memorial Hospital of Rhode Island, Pawtucket

Electronic Messaging and Phone Encounters Increase Office Visit Use Among Diabetic Patients

Contrary to some expectations, increases in electronic and phone messaging are associated with an increase in primary care office visits, finds this study of more than 18,000 adult diabetic patients. Analyzing patient data before, during and after a patient-centered medical home redesign in an integrated delivery system, researchers found the average quarterly number of primary care contacts increased 28 percent overall between the pre- and post-redesign periods, largely driven by increased secure messaging. While the rate of office visit use declined by 8 percent over the course of the study, patient-level analysis estimated that a 10 percent increase in copay-free secure message threads was associated with a 1.25 percent increase in office visits, and a 10 percent increase in telephone encounters was associated with a 2.74 percent increase in office visits. The authors posit that secure messages and telephone encounters probably stimulated demand by reducing access barriers and allowing patients to address previously unmet needs. These findings suggest that chronically ill patients do not use new forms of copay-free communication as an alternative to in-person visits.

Changes in Office Visit Use Associated With Electronic Messaging and Telephone Encounters Among Patients With Diabetes in the PCMH
By David T. Liss, PhD, et al
Northwestern University Feinberg School of Medicine, Chicago, Ill.

High Patient Satisfaction with Shared Medical Appointments

Shared medical appointments, in which multiple patients are seen as a group by a health care team for physical exams, follow-up care or management of chronic conditions, represent a potential innovation to improve access, cost, disease management outcomes and patient-centeredness in primary care. Analyzing satisfaction levels among more than 1,800 patients seen at a large multispecialty group practice between 2008 and 2010, researchers found patients attending group appointments reported greater overall satisfaction compared with those attending individual primary care office visits. Specifically, SMA patients were more likely to rate their overall satisfaction with care as "very good" compared to usual care patients (OR = 1.26; 95 percent CI, 1.05-1.52). Further analysis of patient-centered medical home elements revealed SMA patients rated their care as more accessible (OR = 1.49; 95 percent CI, 1.21-1.92) and more sensitive to their needs (OR = 1.34; 95 percent CI, 1.08-1.65). Usual care patients, however, consistently reported higher levels of satisfaction with their relationship with their clinician, including time spent and communication during the encounter, compared with SMA peers. The authors conclude that in an understaffed primary care system facing growing numbers of eligible patients, SMA adoption may accommodate a greater number of patients in a timely fashion. They call for additional research to examine satisfaction with group visits over time and identify strategies to enhance patient-clinician communication within shared medical appointments.

Influence of Shared Medical Appointments on Patient Satisfaction: A Retrospective 3-Year Study
By Leonie Heyworth, MD, MPH, et al
VA Boston Healthcare System, Mass.

Ontario Pay for Performance Program Does Not Improve Cancer Screening Rates

Although pay-for-performance has been touted as one of the most promising approaches for reducing health system cost and improving quality, researchers in Canada find a large-scale pay-for-performance scheme for primary physicians in Ontario had limited impact on cancer screening rates three years after its widespread introduction despite substantial expenditures. Analyzing administrative data to determine cervical, breast and colorectal cancer screening rates and incentive costs between 2007 when the pay-for-performance screening incentives were introduced and 2010, researchers found no significant step change in the screening rate for any of the three cancers the year after incentives were introduced. Specifically, they found colon cancer screening was increasing at a rate of 3 percent per year before the incentives were introduced and 4.7 percent per year after. The cervical and breast cancer screening rates did not change significantly from year to year before or after the incentives were introduced. Yet, between 2006-2007 and 2009-2010, a total of $28.3 million, $31.3 million and $50 million in incentive payments were paid to physicians for cervical, breast and colorectal cancer screening, respectively. Additionally, the authors found that for all three types of cancer screening, disparities in screening related to neighborhood income persisted over time. The authors hypothesize that the size and structure of Ontario's incentive program played key roles in limiting its impact. They point out that preventive care incentives were among the largest financial incentives introduced for primary care physicians in Ontario but constituted only about 3 percent of their gross income. By contrast, in a pay-for-performance scheme for primary care physicians in the United Kingdom, which was found to accelerate improvements in the quality of care for some chronic diseases, incentive payments made up approximately 25 percent of physicians' income. Given these findings, which are in keeping with other published studies finding limited evidence for the effectiveness of pay-for-performance schemes in improving cancer screening, the authors conclude policy makers should consider other strategies for improving rates of cancer screening and reducing gaps in care.

Effect of Payment Incentives on Cancer Screening in Ontario Primary Care
By Tara Kiran, MD, MSc, et al
Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario Canada

Effects of Medical Home Transformation on Job Satisfaction Mixed

Improving job satisfaction in primary care practices is one of the aims of medical home transformation, yet analysis of data from 20 primary care practices participating in medical home projects found inconsistent changes in job satisfaction in the 30 months after the changes were implemented. Researchers evaluated data from clinicians and staff at 20 primary care practices in Colorado and Rhode Island that participated in medical home pilot projects between 2009 and 2011. They found that between baseline and 30 months job satisfaction improved in Rhode Island but not in Colorado. Considering the modest and variable impact of medical home intervention on clinician satisfaction, the authors suggest that the benefits of intervention to clinicians and staff may have been counteracted by the stresses of transformation. For both pilot projects, reported difficulties in providing safe, high-quality care decreased during the study period, but emphasis on quality and the level of chaos did not change significantly. Further analysis revealed that fewer difficulties in providing safe, high-quality care and more open communication was associated with greater job satisfaction; in contrast, greater office chaos and an emphasis on electronic information were associated with greater stress and burnout. The authors conclude that medical home transformations that emphasize quality and open communication while minimizing office chaos may have the best chances of improving job satisfaction.

Practice Environments and Job Satisfaction in Patient-Centered Medical Homes
By Shehnaz Alidina, MPH, SD
Harvard School of Public Health, Boston, Mass.

Literature Review Finds Large Number of Primary Care Clinical Prediction Rules, Few of Which Have Been Thoroughly Evaluated

Researchers working toward the development of an international web-based register of clinical prediction rules relevant to primary care identify 434 unique and relevant rules, of which slightly more than half have been validated at least once, and less than 3 percent have been subjected to an analysis of impact on the process or outcome of clinical care. Conducting an electronic search of the literature between 1965 and 2009, researchers found 745 articles, many of which contained more than one clinical prediction rule study, resulting in 989 studies. In all, 434 unique rules had gone through derivation; however, only 55 percent had been validated and merely 3 percent had undergone impact analysis. The rules most commonly pertained to cardiovascular disease, respiratory, and musculoskeletal conditions. These findings, they assert, support the development of an international register of prediction rules coded by clinical domain and stage of development in order to help guide areas for needed research and identify those that are ready for use at the point of patient care.

Developing an International Register of Clinical Prediction Rules for Use in Primary Care: A Descriptive Analysis
By Tom Fahey, MD, et al
Royal College of Surgeons in Ireland, Dublin

Technology-Based Strategy Reduces the Number of Patients with Undiagnosed Hypertension

Researchers describe the development and evaluation of a technology-based strategy to screen for undiagnosed hypertension among patients in 23 primary care practices, and the implementation of a continuous quality improvement process initiative to improve the accuracy of hypertension diagnosis. In the two-phase initiative, researchers first reviewed electronic health records and identified 1,432 patients at risk for undiagnosed hypertension and invited those patients to complete an automated office blood pressure protocol to obtain multiple blood pressure measurements. In phase two, they instituted a quality improvement process that included regular physician feedback and office-based computer alerts to further evaluate the 1,033 at-risk patients not screened in phase one. The initiative successfully identified patients at risk for undiagnosed hypertension and classified most patients based on their AOBP reading. Specifically, the quality improvement initiative reduced the rate of being at risk for undiagnosed hypertension over a 30-month follow-up period by more than 72 percent. By the end of the follow-up period, 293 patients (28 percent) had not yet been classified and remained at risk for undiagnosed hypertension. The authors assert their experience suggests these strategies not only have the potential to eliminate undiagnosed hypertension, they also may be applicable to other common undiagnosed chronic diseases. Similar methods, they add, can be adapted to access and inform clinicians and patients on blood pressure control after the diagnosis of hypertension.

A Technology-Based Quality Innovation to Identify Undiagnosed Hypertension Among Active Primary Care Patients
By Michael K. Rakotz, MD
Feinberg School of Medicine, Northwestern University, Chicago, Ill.

Study of Intervention to Reduce Antibiotic Prescribing Demonstrates the Utility of Electronic Health Records for Conducting Large Cluster Randomized Trials

Because implementing cluster randomized trials can be logistically challenging, costly and time-consuming, researchers sought to evaluate the feasibility of conducting intervention research remotely using primary care electronic health records. Specifically, the authors looked at the effectiveness of electronically delivered decision support tools at reducing antibiotic prescribing for respiratory tract infections in a randomized trial of 603,409 primary care patients in England and Scotland. Intervention arm practices used decision support tools remotely installed and delivered during consultations that were activated when family physicians entered a medical code for the respiratory tract infection. The tools provided information for education and decision support, including a summary of antibiotic prescribing recommendations, a patient-information sheet, summary of research evidence concerning no-antibiotic or delayed-antibiotic prescribing strategies, information on the definite indications for antibiotic prescription and information and evidence on the risks from nonprescribing. The researchers found the use of the intervention and its effect on care were low - one quarter of intervention family practices made little or no use of the intervention, and antibiotic prescribing was only slightly lower at practices that made greater use of the intervention (a 1.85 percent reduction in the proportion of consultations with antibiotics prescribed). Despite the limited impact, however, the study demonstrates that cluster randomized trials can be conducted remotely through electronic health records. Using electronic health records in intervention research, the authors assert, has the potential to allow large studies to be conducted at a low cost in settings where care is routinely delivered, making it suitable for the evaluation of important clinical and public health interventions.

Utilizing Electronic Health Records for Intervention Research: A Cluster Randomized Trial to Reduce Antibiotic Prescribing in Primary Care (eCRT Study)
By Alex Dregan, et al
King's College London, United Kingdom

Researchers Develop and Validate EHR-Based Diagnostic Algorithms to Identify Common Primary Care Conditions

Valid diagnostic algorithms can be used to identify chronic conditions from electronic health record data for both research and public health purposes. Researchers reviewed 1,920 patient charts from The Canadian Primary Care Sentinel Surveillance Network, Canada's first national EHR data repository, and validated algorithms for eight common chronic conditions in primary care: chronic obstructive pulmonary disease, dementia, depression, hypertension, osteoarthritis, parkinsonism and epilepsy. The diagnostic algorithms showed excellent sensitivity, ranging from 78 percent (osteoarthritis) to more than 95 percent (diabetes, epilepsy and parkinsonism). Specificity was greater than 94 percent for all diseases. Positive predictive values ranged from 72 percent (dementia) to 93 percent (hypertension); negative predictive values ranged from 86 percent (hypertension) to greater than 99 percent (diabetes, dementia, epilepsy, and parkinsonism). The authors conclude this work shows CPCSSN has developed valid primary care EHR case definitions for identifying patients with these eight common chronic conditions. These case definitions can be used for a variety of data-driven activities in primary care, including surveillance, routine practice evaluation, feedback and quality improvement, and research.

Validating the 8 CPCSSN Case Definitions for Chronic Disease Surveillance in a Primary Care Database of Electronic Health Records
By Tyler Williamson, PhD, et al
Queen's University, Kingston, Ontario, Canada

The Overwhelming Experience of Being a Medical Student, Every Past Experience is a Future Tool

Reflecting on his experience being a medical student overwhelmed by the vast amounts of knowledge and crushing feeling of inadequacy, Timothy Gallagher offers other medical students reassurance through a lesson learned from one of his patients during his clinical rotation. Gallagher relates the story of Ms. Jones, who over her lifetime held myriad jobs from store clerk, singer songwriter and construction worker to window display dresser, home health aide and paralegal. From her, he learned not to feel overwhelmed by his chosen career. He counsels other medical students that every past experience is a future tool, and everyone has a skill set from which to build. It is important to anchor yourself in that skill set, he writes, and use it as a stable platform from which to venture into areas where you may feel less confident.

The Immortality of Ms Jones
By Timothy Gallagher
New York University School of Medicine

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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 online discussions for each published article can be accessed free of charge on the journal's website, http://www.annfammed.org.

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