Public Release: 

January/February 2015 Annals of Family Medicine tip sheet

American Academy of Family Physicians

Few Rural Physicians Trained to Provide Treatment for Opioid Use Disorder

Amid rising rates of opioid use disorder and related unintentional lethal opioid overdoses, particularly in rural areas of the United States, researchers examine the distribution of physicians with Drug Enforcement Administration waivers to prescribe buprenorphine-naloxone, an effective treatment for opioid use disorder. Analyzing data for physicians on the DEA's DATA Waived Physician List as of July 2012, they find only 2.2 percent of American physicians had obtained the waivers required to prescribe buprenorphine. Notably, 90 percent of those physicians were practicing in urban counties, leaving the majority of U.S. counties (53 percent) - most of them rural - with no physician who could dispense buprenorphine. Although primary care physicians are the predominant providers of health care in rural America, very low percentages of family physicians and general internists (3 percent) had obtained a DEA waiver. Most U.S. counties, therefore, had no physicians who had obtained waivers to prescribe buprenorphine-naloxone, resulting in more than 30 million persons who were living in counties without access to buprenorphine treatment. Psychiatrists represented the largest group of physicians who had obtained waivers (42 percent), and most of them practiced in urban areas. The relative paucity of rural physicians trained to provide office-based treatment of opioid use disorder, the authors conclude, is a major barrier to office-based outpatient treatment for opioid use disorder.

Geographic and Specialty Distribution of US Physicians Trained to Treat Opioid Use Disorder

By C. Holly A. Andrilla, MS, et al

University of Washington School of Medicine, Seattle

Two Systematic Reviews Summarize Efficacy of Different Pharmacotherapy and Psychotherapy Treatment Options for Depression in Primary Care

A systematic review of randomized trials investigating the efficacy and acceptability of different pharmacological treatments for depression in primary care finds that tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs) have the most solid evidence base for being effective in the primary care setting, but with a small effect size compared with placebo. Analyzing data from 66 studies involving 15,161 patients, researchers found that TCAs and SSRIs, as well as serotonin-noradrenaline reuptake inhibitors (SNRI), low-dose serotonin antagonist and reuptake inhibitors (SARI) and hypericum extracts are effective for the treatment of acute depression, with estimated odds ratios between 1.69 and 2.03. They found no statistically significant differences between the drug classes. While hypericum, reversible inhibitors of monominoxidate A (rMAO-A), nor-adrenaline reuptake inhibitors (NRI), noradrenergic and specific serotonergic antidepressive agents (NaSSA), SNRI and SARI showed some positive results, the authors emphasize that limitations of the currently available evidence make difficult a clear recommendation on their place in clinical practice. Compared with other agents, rMAO-A and hypericum extracts were associated with significantly fewer dropouts because of adverse effects. The authors call for future research prioritizing large, long-term, pragmatic trials and observational studies addressing clinically relevant questions, such as the best management of mild-to-moderate depression and comparison of pharmacological and psychological treatments under conditions of routine care and stepped-care strategies.

A companion systematic review of randomized trials investigating the efficacy of different psychological treatments for depression in primary care finds that overall, psychological treatments, including cognitive behavioral therapy, are superior to usual care alone, with small to moderate effect sizes. Of particular note for time- and resource-strapped primary care practices, the researchers found the differences between different types of psychological treatments are minor, with remote therapist-led, guided self-help and minimal-contact approaches appearing to yield effects similar to more intensive, personalized face-to-face therapies. Specifically, analyzing data from 30 studies involving 5,159 patients, the researchers found that compared with control, the effect (standardized average difference) at completion of treatment was -0.30 for face-to-face CBT, -0.14 for face-to-face problem-solving therapy, -0.24 for face-to-face interpersonal psychotherapy, -0.28 for other face-to-face psychological interventions, -0.43 for remote therapist-led CBT, -0.56 for remote therapist-led problem solving therapy, -0.40 for guided self-help CBT and -0.27 for no or minimal contact CBT. Given the limited number and moderate size of the identified studies, the authors advise caution when interpreting their finding that remote, reduced or minimal-contact CBT-based interventions and intense, face-to-face treatments seem to be similarly effective. For patients and clinicians wishing to pursue nonpharmacological options, the authors conclude these findings are reassuring, and they call for an eclectic rather than dogmatic approach given the lack of major differences in the effectiveness between the different types of psychological therapies. Although the available evidence for nonpharmacological treatment of depression in primary care is promising, they conclude that it is still insufficient to guide practice and health policy, and they call for large pragmatic trials comparing long-term outcomes and acceptability of different psychological treatment strategies in depressed primary care patients.

In an accompanying editorial, Frank deGruy, MD, chair of the department of family medicine at the University of Colorado School of Medicine, extends the conversation by addressing the challenge of implementing the pharmacotherapy and psychotherapy treatments summarized by Linde et al. He asserts that the meta-analyses not only summarize and clarify what we know about depression treatment in primary care, but set the stage for the intensive implementation work that must inevitably follow before successful clinical improvement occurs in primary care. He explains it is one thing to know that a treatment is effective in primary care when applied under research conditions and using study resources to assure that limitations and barriers can be overcome. It is quite another thing, he asserts, for a primary care practice to implement such an evidence-based intervention using existing practice resources, working within the constraints of existing practice workflows, and pressing against the ubiquitous pressing demands in these settings. Successful implementation, he concludes, starts with an effective intervention--which is where the two meta-analyses leave off--then must take into consideration the factors associated with the patient, clinician, clinical setting, health plans and regulators.

Efficacy and Acceptability of Pharmacological Treatments for Depressive Disorders in Primary Care: Systematic Review and Network Meta-analysis

Effectiveness of Psychological Treatments for Depressive Disorders in Primary Care: Systematic Review and Meta-analysis

By Klaus Linde, MD, et al
Technische Universität München, Germany
Treatment of Depression in Primary Care

By Frank deGruy, MD
University of Colorado School of Medicine, Denver

Substantial Decline in the Rate of Uninsured Safety Net Clinic Visits Since Affordable Care Act-related Medicaid Expansions

Affordable Care Act-related Medicaid expansions appear to have successfully decreased the number of uninsured safety net visits in the United States. Researchers analyzed health records data from 333,655 nonpregnant adult patients and their 1,276,298 in-person billed encounters at 156 community health centers in nine states (five expanded Medicaid coverage and four did not) from 12 months before Medicaid expansion (January 1, 2013 to December 31, 2013) through six months after expansion (January 1, 2014 to June 30, 2014). They found that overall, clinics in the expansion states had a 40 percent decrease in the rate of uninsured visits in the postexpansion period and a 36 percent increase in the rate of Medicaid-covered visits. In contrast, clinics in the nonexpansion states had a significant 16 percent decline in the rate of uninsured visits but no change in the rate of Medicaid-covered visits. The findings of this study, the first to use electronic health record data to measure changes in community health center encounter coverage rates after Affordable Care Act Medicaid expansions, confirm other reports showing increased health insurance coverage rates subsequent to state Medicaid expansion and add new information demonstrating a measurable effect on community health center visits in expansion states.

An Early Look at Rates of Uninsured Safety Net Clinic Visits After the Affordable Care Act

By Heather Angier, MPH, et al

Oregon Health & Science University, Portland

Researchers Highlight Potential Unmet Palliative Care Needs for Many Older Patients in the Year Before Death

Researchers identify five clinically distinct functional trajectories of older patients in the year before hospice, representing worsening cumulative burden of disability, a finding that has implications for better meeting the palliative care needs of people in the year before death. Evaluating data on 213 community-dwelling persons aged 70 years or older who were subsequently enrolled in hospice, researchers find the course of disability differs greatly among older persons, but is particularly poor among those with neurodegenerative disease. Specifically, participants with neurodegenerative disease (21 percent) had the worst functional trajectory, whereas those with a cancer diagnosis (35 percent) had the most favorable. Nearly 60 percent of the study sample had progressively or persistently severe disability during the year before hospice. The median survival in hospice was only 14 days and did not differ significantly by functional trajectory. The authors conclude that late admission to hospice (as shown by the short survival), coupled with high levels of severe disability before hospice indicate there are potential unmet palliative care needs for many at the end of life.

Functional Trajectories in the Year Before Hospice

By Thomas M. Gill, MD, et al
Yale School of Medicine, New Haven, Connecticut

Researchers Identify Special Challenges Faced by Low-Resource Primary Care Practices in Sustaining "Meaningful Use" of Electronic Health Records

Primary care practices with limited financial, technical and organizational resources, especially those in rural areas, are at high risk for falling on the wrong side of a "digital divide" as payers and regulators enact increasing expectations for EHR use and information management. While previous research has largely addressed the challenges of health information technology implementation, it has not clearly addressed the unique challenges associated with maintaining use of health IT, especially in low-resource practices. Through interviews and direct observation of health IT implementation in Michigan, researchers identified deficiencies and barriers to maintenance of meaningful use of EHRs in priority primary care practices. They assert that maintaining EHR technology will require ongoing expert technical support indefinitely beyond implementation to address upgrades and security needs. Moreover, maintaining meaningful use of quality improvement will require ongoing support for leadership and change management. Rural priority practices, they note, are particularly challenged because expertise is often not available locally. The authors warn that absent long-term support solutions, the multifaceted challenge of health information technology maintenance will almost inevitably overwhelm low-resource practices, and the operational and financial consequences of falling behind in maintenance will mean lower quality of care for the patients in areas these practices serve - or quite possibly no care at all.

Sustaining "Meaningful Use" of Health Information Technology in Low-Resource Practices

By Lee A. Green, MD, MPH, et al
University of Alberta, Canada

Study: Current Guidelines for Diagnosing COPD Using Spirometry Should Be Amended to Reduce Overdiagnosis Currently, there is no consensus on the best spirometric diagnostic criteria to be used for the clinical diagnosis of chronic obstructive pulmonary disease, and the failure to resolve the controversy has resulted in inappropriate treatments for many patients. Researchers aim to shed light on the debate by analyzing data 4,882 adults aged 40 years and older participating in the Canadian Cohort of Obstructive Lung Disease study, a large, population-based study of lung health. Comparing the clinical relevance of differing cutoffs of forced expiratory volume in one second/forced vital capacity (FEV1/FVC) for airflow limitation in COPD, they found that airflow limitation defined solely by the fixed ratio was inadequate and may misdiagnosis patients with COPD, in particular those with cardiovascular complaints, leaving them at risk for inappropriate or unnecessary treatments. Conversely, a diagnosis of COPD established by low FEV1/FVC by fixed ratio and/or by lower limit of normal, coupled with a low FEV1 (<80 percent from predicted) was strongly associated with adverse clinical outcomes. The authors conclude that guidelines should be reconsidered to require both spirometry abnormalities so as to reduce overdiagnosis of COPD.

Clinical Relevance of Fixed Ratio vs Lower Limit of Normal FEV1/FVC in COPD: Patient-Reported Outcomes From the CanCOLD Cohort

By Jean Bourbeau, MD, et al
Montreal Chest Institute, Quebec, Canada

Using Laryngeal Height and a Lung Function Questionnaire to Diagnose COPD

Researchers in Spain find that the combination of laryngeal height measurement and a lung function questionnaire are useful for diagnosing chronic obstructive pulmonary disease. The study involving 233 people aged between 40 and 75 years finds that combining a maximum laryngeal height of less than 4 cm with Lung Function Questionnaire findings of less than 18 yielded a sensitivity of 76 percent, specificity of 97 percent, a positive likelihood ratio of 29.06 and a negative likelihood ratio of 0.26. These findings, the authors conclude suggest that combining Lung Function Questionnaire and laryngeal height can help to confirm or rule out COPD.

Laryngeal Measurements and Diagnostic Tools for Diagnosis of Chronic Obstructive Pulmonary Disease

By Verónica Casado, MD, PhD, et al
Centro de Salud Universitario Parquesol, Valladolid, Spain

American Academy of Family Physicians Issues Guidelines for Labor and Vaginal Birth After Cesarean

A clinical practice guideline summary from the American Academy of Family Physicians offers evidence-based recommendations to help guide clinicians in planning for labor and planned vaginal birth after a prior Cesarean delivery. Basing recommendations on a systematic review by the Agency for Healthcare Research and Quality, the multidisciplinary panel recommends that clinicians counsel, encourage and facilitate planned vaginal birth after cesarean, and offer pregnant women referrals to facilities or clinicians who can offer the service if PVBAC is not locally available. Additionally, the panel strongly recommends that clinicians inform women who have had a prior vaginal birth that they have a high likelihood of vaginal birth after cesarean. Absent specific contraindications to a vaginal birth, they assert these women should be encouraged to plan LAC/VBAC. Lastly, the panel recommends that induction of labor after cesarean is appropriate for women who have a medical indication for induction of labor and who are planning an LAC/VBAC. They call for increased access to providers and facilities capable of managing LAC/VBAC in order to reduce the U.S. cesarean rate and associated maternal morbidity while increasing choice for childbearing women and their families. Clinical Practice Guideline Executive Summary: Labor After Cesarean/Planned Vaginal Birth After Cesarean By Bellinda Schoof, MHA, CPHQ, et al American Academy of Family Physicians, Leawood, Kansas

Point-Counterpoint: Should Health Transformation Efforts Focus on Super-Utilizers?

A pair of point-counterpoint articles argue the question: is a strategy focused on super-utilizers - patients with high medical costs from recurring, preventable inpatient or emergency department visits - equal to the task of health care system transformation?

In the first article, Uchenna Emeche, MD, asserts that a strategy based on these patients, who represent 5 percent of the population but account for 50 percent of health care expenditures, has the potential to transform overall health care delivery. She posits that because the development of a delivery model for this specific population segment employs a multifaceted strategy that includes data, stakeholder engagement and clinical redesign, it provides a framework for changing the entire system. Offering an opposing viewpoint, a pair of researchers at the University of North Carolina School of Medicine caution against focusing on super-utilizers as a sole strategy for health transformation. They warm that targeting a population on cost alone may in fact distract from the real opportunities of health care reform and possibly harm the evolution of primary care. Instead, they call for continued evolution of the patient-centered medical home and improvement of the medical neighborhood. The key, they assert, will be building super-utilizer interventions into office systems that can truly support patient populations with their varying levels of care by using an engaged and appropriately resourced care team.

Is a Strategy Focused on Super-Utilizers Equal to the Task of Health Care System Transformation? Yes.

By Uchenna Emeche, MD
Franklin Square Medical Center, Baltimore, Maryland

Is a Strategy Focused on Super-Utilizers Equal to the Task of Health Care System Transformation? No.

By Warren Polk Newton, MD, MPH and Ann Lefebvre, MSW, CPHQ
University of North Carolina School of Medicine, Chapel Hill

Ultrasound Imaging Useful for Guiding Treatment for Patients With Shoulder Pain in Primary Care

Ultrasound imaging appears to be useful in diagnosing acute shoulder pain and potentially for providing tailored treatment for patients seen in primary care. The study of 129 patients aged 18 to 65 years with acute shoulder pain who underwent ultrasound imaging, found 81 percent of patients had rotator cuff disorders, and 50 percent had multiple disorders. Researchers found that age of 40 years and older was a strong predictor of RCD in patients complaining of acute should pain. Full thickness tears were found in only 3 percent of patients. These findings, the authors conclude, demonstrate that ultrasound imaging can help guide treatment, especially in patients who are aged 40 years and older, with acute shoulder pain. They add that given the low prevalence of tears, ultrasound imaging can also help prevent unnecessary referrals to secondary care.

Ultrasound Imaging for Tailored Treatment of Patients With Acute Shoulder Pain

By Ramon P.G. Ottenheijm, MD, et al
Maastricht University, The Netherlands

Increasing the Transparency of Direct-to-Consumer Pharmaceutical Marketing in the Digital Age

In light of pharmaceutical marketing's emergence in direct-to consumer advertising on the Internet, in social media and through mobile applications, and new federal "sunshine" regulations implemented under the Affordable Care Act requiring disclosure of certain marketing and industry payments to physicians, health policy researchers call for greater DTCA transparency, especially in the emerging digital forms of DTCA, to complement forthcoming pharmaceutical marketing transparency data. To get a clearer picture of the overall impact of pharmaceutical promotion in the changing digital health landscape, the authors propose some initial DTCA disclosure requirements. This data, they assert, could lead to more targeted state and federal policy interventions leveraging existing federal transparency regulations to ensure appropriate marketing, spending and consumption of pharmaceutical products.

It's Time to Shine the Light on Direct-to-Consumer Advertising

By Tim K. Mackey, MAS, PhD and Bryan A. Liang, PhD, MD, JD
Global Health Policy Institute, San Diego, California

Study Examining Identification of Alcohol Dependence in European Primary Care Calls into Question Validity of Current Reference Standard

Across six European countries, a large study examines the rate of identification of patients with alcohol dependence by general practitioners versus a semistructured interview using the Composite International Diagnostic Interview reference standard for assessing alcohol use disorders, and finds the two methods discover about the same number of alcohol dependent people, but there is little overlap between the people identified. Analyzing data from physicians' assessments of 13,003 patients and 9,098 CIDI interviews, researchers found the 12-month prevalence of alcohol dependence was 5.1 percent when assessed by the physician and 5.5 percent when assessed by the CIDI interview. Although the physician assessment and the CIDI yielded a similar prevalence, they identified different patient populations, with fewer than one-fifth of the cases being identified by both methods. Overall, a physician or the CIDI identified alcohol dependence in 8.7 percent of patients, confirming that in Europe, alcohol dependence is common and disabling among primary car patients. Further analysis revealed that compared with the CIDI, general practitioners identified more patients with severe alcohol dependence (same level of drinking and mental problems but higher level of physical problems and social disintegration). Moreover, analysis showed the CIDI was not as successful as a physician in identifying cases of alcohol dependence in older patents. These significant differences, they conclude, raise questions about the validity of the CIDI and its status as a reference standard for assessing alcohol use disorders.

General Practitioners Recognizing Alcohol Dependence: A Large Cross-sectional Study in 6 European Countries

By Jakob Manthey, MS, et al
Technische Universität Dresden, Germany


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,

Disclaimer: AAAS and EurekAlert! are not responsible for the accuracy of news releases posted to EurekAlert! by contributing institutions or for the use of any information through the EurekAlert system.