Public Release: 

November/December 2014 Annals of Family Medicine tip sheet

American Academy of Family Physicians

Two Techniques Make Swallowing Pills Easier

With previous research showing more than half of people experience swallowing difficulties when taking tablets or capsules, researchers in Germany demonstrate that two specific swallowing techniques notably improve the ease of swallowing tablets and capsules in patients with and without swallowing difficulties. In the first, the pop-bottle method, the tablet is placed in the mouth, the lips are tightly closed around the opening of a flexible plastic beverage bottle and the tablet is swallowed in a swift suction movement to overcome the volitional phase of swallowing. In the second, the lean-forward technique, capsules are swallowed in an upright position with the head bent forward. Researchers had 181 adults swallow 16 differently shaped placebos and rate their ease of swallowing. They then swallowed the two dosage forms they rated most difficult again using the appropriate technique. They found the pop-bottle method substantially improved swallowing of tablets in 60 percent of participants and the lean-forward technique in 89 percent. The authors conclude both techniques were remarkably effective in participants with and without reported difficulties swallowing pills and should be recommended regularly. Two Techniques to Make Swallowing Pills Easier

By Walter E. Haefeli, MD, et al
University of Heidelberg, Germany

Continuity of Care Associated with Reduced Mortality, Morbidity and Health Care Expenses

First Study to Show Direct Link Between Continuity and Mortality

Continuity of care, defined as a sustained partnership between patient and clinician, is considered a core element of high quality primary care, but its impact on mortality and health care costs is unclear. Seeking to determine the impact of continuity of care on mortality, health care costs and health outcomes in patients with newly diagnosed cardiovascular risk factors, researchers find clear and convincing empirical evidence that continuity of care is associated with reduced mortality, morbidity and health care expenses and may thus provide added value in the management of chronic conditions. Specifically, researchers studied a 3 percent random sample (n=1,162,234) of Korean National Health Insurance enrollees, 47,433 of whom had received new diagnoses of hypertension, diabetes, hypercholesterolemia or other complications in 2003 or 2004. Evaluating the association of three standard indices of continuity of care with patients' overall mortality, cardiovascular mortality, incident cardiovascular events and health care costs over five years, they found lower indices of continuity of care were associated with higher all-cause and cardiovascular mortality, cardiovascular events and health care costs. Specifically, the multivariable-adjusted hazard ratios for all-cause mortality, cardiovascular mortality, incident myocardial infarction and incident ischemic stroke, comparing participants with a continuity of care index below the median to those above the median were HR=1.12 (95 percent CI, 1.04-1.21), 1.30 (1.13-1.50), 1.57 (1.28-1.95) and 1.44 (1.27-1.63), respectively. Similar findings were obtained for other indices of continuity of care. The authors also found lower continuity of care was associated with increased inpatient and outpatient days and costs. The authors write that while the findings cannot be generalized to other conditions, the results suggest that continuity of care is a robust predictor of outcomes in patients for conditions with available preventive interventions. With the increasing fragmentation of health care systems and importance of cost containment, the authors assert that health care systems should be designed to support longer-term trusting relationships between patients and physicians, and health policies should encourage patients to concentrate their care with one physician. Impact of Continuity of Care on Mortality and Health Care Costs: A Nationwide Cohort Study in Korea

By BeLong Cho, MD, MPH, PhD, and Eliseo Guallar, MD, MPH, DrPH, et al
Seoul National University Hospital, South Korea and Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland

Hospitalized Women Willing to Share in the Cost of Inpatient Screening Mammograms

With 40 percent of hospitalized women not up to date with breast cancer screening, researchers examined whether and how much money hospitalized women would be willing to contribute toward the cost of an inpatient screening mammogram. Analyzing data from 193 hospitalized women amenable to inpatient screening, researchers found the majority, including those from low-income and high-risk groups, were willing to contribute money to offset the cost of screening mammography. Specifically, they found 72 percent of women were willing to pay an average of $83.41 in advance toward inpatient screening mammogram costs. The authors note this may not be a surprising finding because some of the barriers women face when attempting to have a mammogram (difficulty arranging transportation, forgetting to schedule the test, desire to avoid losing time at work, etc.) are irrelevant when having the mammography performed during hospitalization. The authors conclude it may be a wise policy to offer mammograms to nonadherent hospitalized women, especially those who are at high risk of developing breast cancer. Hospitalized Women's Willingness to Pay for an Inpatient Screening Mammogram

By Waseem Khaliq, MD, MPH, et al
Johns Hopkins University School of Medicine, Baltimore, Maryland

Novel Patient-Controlled Taping Method for the Treatment of Ingrown Toenails Averts Surgery

Two primary care clinicians in Japan share a novel taping method to treat and prevent ingrown toenails, the success of which has made taping the first-line treatment for every ingrown or problematically curved toenail seen in their practice. Of the 541 patients who were instructed in the use of the technique, 276 saw their symptoms and abnormal nail growth resolved and required no additional therapy. The remaining 265 patients required additional treatment such as nail bracing or surgery. Still, the authors note, most of those patients reported relief of pain with taping. With conventional taping methods, the authors point out, most patients are required to visit a clinic frequently for retaping and may discontinue taping because of discomfort and skin irritation. They assert the new taping method is both easy and comfortable for patients and prevents circulatory problems and dermatologic side effects. This novel, non-invasive, low-cost approach, the authors conclude, should be considered as a first-line treatment for ingrown toenails in the typical primary care population before cutting or removing the nail. Patient-Controlled Taping for the Treatment of Ingrown Toenails

By Koichi Tsunoda, MD, and Meiko Tsunoda, MD
National Hospital Organization, National Tokyo Medical Center, Japan

Implementing Health Risk Assessments in Primary Care: Reports from the My Own Health Report Implementation Trial

Primary Care Patients Report High Number of Behavior and Mental Health Risk Factors but Low Readiness to Change

Primary Care Practices Willing and Able to Implement Behavioral and Mental Health Assessments but Lack the Resources to do so Effectively

Two studies in the current issue of Annals report on findings from a pragmatic implementation trial to test the feasibility of implementing My Own Health Report, a new electronic or paper-based health behavior and mental health risk assessment and feedback system to support selective counseling and goal setting in primary care. Health risk assessments, now supported as part of the Medicare Annual Wellness Visit established by the Affordable Care Act, are important tools for understanding the frequency of behavioral risk factors that have implications for patients' health and wellbeing. The brief, patient-centered MOHR tool, which is based on existing well-validated measures, provides immediate feedback to patients on their risk factors and allows patients to identify and prioritize risk factors they are ready to change and want to discuss with their providers. It also includes a goal setting worksheet to assist patients in action planning to reduce risks. As part of the MOHR trial, researchers assessed how nine diverse primary care practices integrated MOHR into their workflows and reported on the frequency of patient health risks and patients' perceptions of importance, readiness to change and desire to discuss identified risks with providers.

In the first study, the authors analyzed the general, behavioral and psychosocial risk factors (body mass index, health status, diet, physical activity, sleep, drug use, stress, anxiety or work and depression) reported by 1,707 patients at the nine participating practices who completed the MOHR assessment. They found a consistently high number of health risks reported by patients -- an average of six per patient. More than half of patients (55 percent) reported six or more risk factors. Notably, despite the high number of health risks, over half were not ready to change any risk factors, and few wanted to discuss risk factors with their providers. Specifically, they found that on average, patients wanted to change 1.2 and discuss 0.8 risks. The most common risk was poor diet (93 percent) as represented by low fruit and vegetable consumption, frequent fast food consumption or frequent sugary beverage consumption, followed by overweight/obesity (80 percent). Patients were most ready to change BMI (33 percent) and depression (31 percent), and most wanted to discuss depression (42 percent) and anxiety or worry (35 percent). Interestingly, the authors point out that even those most "advantaged" groups (white, highly educated, employed) reported an average of 4.5 risks, which cut across all categories (physical, psychological and behavioral). The authors assert these findings present an obvious challenge given the small amount of time available for prevention in primary care and support the need for more integrated care. They conclude that these results highlight the need for routine administration of health risk assessments in primary care, the importance of real world approaches for implementing their findings and connecting patients and practices to appropriate resources, and the potential added value of including the patients' perspective in the allocation of these resources.

In the second article, the authors examine the nine primary care practices' experiences implementing the MOHR assessment tool and find that although the practices were willing and able to implement the behavior and mental health assessments, most lacked the capacity and infrastructure to do so without additional support once the trial ended. Assessing how the practices integrated the electronic or paper-based MOHR into their workflows, what additional practice staff time it required and what percentage of patients completed the assessment, they found that most practices (60 percent) agreed to adopt MOHR, and half of the 3,591 patients who were approached completed the assessment. They found that reach varied by implementation strategy, with higher reach when MOHR was completed by staff than by patients (71 percent vs. 30 percent). The authors point out that the observed reach of 50 percent was double the health risk assessment completion rates previously published by large health systems (22 percent) and on par with worksite completion rates coupled with economic incentives (40 to 64 percent). Moreover, the practices were successful in getting patients of all ethnic, racial and socio-economic levels to participate in MOHR. Analysis revealed that fielding MOHR increased staff and clinician time an average of 28 minutes per visit. Consequently, no practices were able to sustain the complete MOHR assessment without adaptations after study completion. The authors point out that most primary care practices are overwhelmed by competing demands, and typical office visits provide little time to address health risk information. They assert that more substantial practice transformation will be necessary to integrate MOHR-like assessments routinely into primary care, and current incentives, such as the mandate to include health risk assessments as part of wellness care, are insufficient to facilitate this practice change. Merely mandating that health risk assessments be added to an already packed wellness visit, they conclude, simply increases the chances that practices will do it poorly or not at all.

Frequency and Prioritization of Patient Health Risks From a Structured Health Risk Assessment

By Siobhan M. Phillips, PhD, MPH, et al
Northwestern University, Chicago, Illinois

Adoption, Reach, Implementation and Maintenance of a Behavioral and Mental Health Assessment in Primary Care

By Alex H. Krist, MD, MPH, et al
Virginia Commonwealth University, Richmond

Reducing the Burden of Medical School Debt May Promote Larger Primary Care Workforce

High medical school debt deters graduates of public medical schools from pursuing careers in primary care, but does not appear to influence private school graduates in the same way. Analysis of data from 136,232 physicians who graduated from allopathic U.S. medical schools between 1988 and 2000 found physicians who graduated from public schools were most likely to practice primary care and family medicine at graduating educational debt levels of $50,000 to $100,000. At higher debt, graduates' odds of practicing primary care or family medicine declined. In contrast, private medical school graduates were not less likely to practice primary care or family medicine as debt levels increased. They authors offer two possible explanations for this curve: 1) graduates with little or no debt may be less likely to choose primary care because they often come from wealthier families, and 2) public school graduates with very high debt are less likely to choose primary care because they perceive a need for the higher financial return of specialization to finance their debt. The authors conclude that reducing the debt of selected medical students may be effective in promoting a larger primary care physician workforce.

A Retrospective Analysis of the Relationship Between Medical Student Debt and Primary Care Practice in the United States

By Julie Phillips, MD, MPH, et al
Michigan State University College of Human Medicine, East Lansing

Researchers Propose Adding a Fourth Dimension to the Triple Aim -- Improving the Work Life of Those Who Deliver Care

Thomas Bodenhimer, MD, and Christine Sinsky, MD, seeing the essential and underappreciated peril imposed by health care workforce burnout and dissatisfaction, suggest adding the goal of improving the work life of health care providers as a fourth element necessary to achieve the triple aim of enhancing patient experience, improving population health and reducing costs. Burnout, they assert, is associated with lower patient satisfaction and reduced health outcomes, and may increase costs. They offer several practical steps health care organizations can take to address this proposed fourth aim.

From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider

By Thomas Bodenheimer, MD, and Christine Sinsky, MD
University of California at San Francisco and Medical Associates Clinic and Health Plan, Dubuque, Iowa

Potential of Health Information Technology to Help Patients Obtain and Maintain Insurance Coverage

Angier and colleagues identify health information technology as an untapped resource to support practice-based efforts to help patients obtain and maintain health insurance coverage. In the commentary, they present guiding principles for harnessing health information technology to support insurance enrollment and retention. They also describe insurance support tools that could be used to conduct 'inreach' and 'outreach' with patients around health insurance, similar to how health information technology is used to manage chronic disease and panels of patients, and to improve population health outcomes.

Health Information Technology: An Untapped Resource to Help Keep Patients Insured

By Heather Angier, MPH, et al
Oregon Health & Science University, Portland

Geriatric Screening Tool Identifies Adults With Disability But Does Not Appear to Improve Outcomes Researchers in New Zealand assessed the effectiveness of a case-finding strategy, which uses a screening survey -- the Brief Risk Identification Geriatric Health Tool (BRIGHT) -- the first in a two-step process to identify older adults with disability and refer them to geriatric services if necessary, with the goal of reducing disability and improving outcomes among older patients. The three-year randomized trial involving 8,308 elderly patients at 60 primary care practices in New Zealand showed the BRIGHT screening intervention successfully identified older adults in need and increased residential care placement, but did not reduce the use of acute hospital services. Specifically, researchers found after 36 months that participants in the intervention group who used the annual screening tool were more likely than those in the control group to have been placed in residential care (8 percent vs. 6 percent). Moreover, intervention patients had smaller declines in average scores for physical health-related quality of life (1.6 vs. 2.9 points) and psychological health-related quality of life (1.1 vs. 2.4 points). Hospitalization, disability and use of services, however, did not differ between groups. The authors conclude the case-finding strategy was effective in increasing identification of older adults with disability, but there was little evidence of improved outcomes. They call for further research to test primary care integration strategies.

The Cluster-Randomized BRIGHT Trial: Proactive Case Finding for Community-Dwelling Older Adults

By Ngaire Kerse, MBChB, PhD, et al
University of Auckland, New Zealand

Promising New Measure of Continuity of Care Based on Readily Available Administrative Data

Researchers propose and assess two new measures of continuity of care, both versions of known provider continuity, which are easily measured in administrative databases. The measures capture the concentration of care from year to year with multiple physicians (KPC-MP) or a particular physician (KPC-PP), making them a potentially valuable and low-cost way to follow the effects of changes favoring group practice on continuity of care. Analyzing survey and medical records data from 765 patients with diabetes or cardiovascular disease attending 28 primary care clinics in Quebec, Canada, researchers found KPC-MP was significantly related to a validated measure of overall care coordination and a combined continuity score summarizing five different validated survey measures. This finding, the authors note, represents the first time a continuity measure that can be obtained from administrative databases has been found to be associated with a patient-reported measure of care coordination. Conversely, KPC-PP (year-to-year continuity with the physician seen most often) did not appear strongly related to patient-perceived measures of continuity. In the era of major primary care reorganization involving multiple health care professionals, KPC measures based on administrative databases, they conclude, could become a valuable way to do research on continuity.

Validation of Two New Measures of Continuity of Care Based on Year-to-Year Follow Up With Known Providers of Health Care

By Pierre Tousignant, MD, MSc, et al
Montreal Health and Social Services Agency, Quebec, Canada

Implementing Care Coordination for Patients With Multiple Chronic Medical Conditions

Bayliss and colleagues discuss the upcoming change by the Centers for Medicaid and Medicare Services that will offer physicians the opportunity to submit claims for monthly care coordination services for Medicare fee-for-service patients with two or more chronic conditions. They outline several evidence-based practices stakeholders should systematically incorporate into multiple chronic condition care coordination to optimize patient-centered outcomes, and they posit priority questions that will inform ongoing implementation efforts. The authors conclude that integrated, continuous, patient-centered care is a foundational principle of family medicine and that this new benefit is a step in creating payment reform that can support such high quality primary care.

Implementing Patient-Centered Care Coordination for Individuals With Multiple Chronic Conditions

By Elizabeth A. Bayliss, MD, MSPH, et al
Kaiser Permanente Institute for Health Research, Denver, Colorado


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,

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