Public Release: 

March/April 2015 Annals of Family Medicine tip sheet

American Academy of Family Physicians

Residency Expansion Required to Avoid Projected Primary Care Physician Shortages

More than 44,000 additional primary care physicians will be needed by 2035 to meet the demands of a growing, aging and increasingly insured population, assuming maintenance of the current ratio of primary care physicians to population and current physician retirement rates, researchers find. To eliminate projected shortages, they call for a 21 percent increase in the current primary care residency production. Analyzing data from the 2010 National Ambulatory Medical Care Survey and 2010 US Census, researchers find that at current rates of physician production, there will be a shortage of more than 33,000 primary care physicians over the next 20 years. Specifically, they project that demographic changes and insurance expansion will require an additional 44,340 primary care physicians by 2035, with population growth accounting for most of the increase. They report that from 2015 to 2035, at current production rates (8,049 each year), allopathic and osteopathic graduate medical education will produce 169,029 new primary care physicians. Because of retiring primary care physicians, however, this production cannot match need, resulting in a shortage of 33,283 primary care physicians by 2035. The authors assert that this deficit could be eliminated by adding nearly 2,200 first-year residency positions by 2020, a 27 percent increase. The authors also note that changing care models toward smaller panel sizes would substantially increase the projected shortage.

Estimating the Residency Expansion Required to Avoid Projected Primary Care Physician Shortages by 2035

By Winstow Liaw, MD, MPH, et al

Virginia Commonwealth University, Richmond

Health Coaching By Medical Assistants Improves Glycemic and Cardiovascular Health Indicators

With primary care clinicians in increasingly short supply and overwhelmed by the expanding preventive and chronic care needs of their growing patient populations, researchers find that health coaching by medical assistants is a promising way to improve control of clinical indicators for the nation's most prevalent chronic conditions, including type 2 diabetes, hypertension and high cholesterol. In a 12-month randomized controlled trial of 441 patients at two safety net primary care clinics in San Francisco, California, researchers found participants who receive coaching from full-time medical assistants trained as coaches were more likely to reach their goal for one or more of the conditions (hemoglobin A1c, systolic blood pressure and low-density lipoprotein cholesterol) uncontrolled at the time of enrollment compared with those receiving usual care (46 percent vs. 34 percent). Patients who received coaching were also more likely than the control group to achieve control of all conditions (34 percent vs. 25 percent). Almost twice the proportion of people in the health-coaching arm achieved goals for glycemic control compared with the usual care group (49 percent vs. 27 percent), and at the larger study site, coached patients were more likely to achieve the LDL cholesterol goal (42 percent vs. 25 percent). These findings, the authors conclude, demonstrate that medical assistants can successfully serve as in-clinic health coaches to improve glycemic and cardiovascular health indicators. Moreover, the authors add that the medical assistant health-coaching model may provide an important answer to the barriers of time, resources and cultural concordance faced by many primary care practices seeking to implement self-management support.

Health Coaching by Medical Assistants to Improve Control of Diabetes, Hypertension, and Hyperlipidemia in Low-Income Patients: A Randomized Controlled Trial

By Rachel Willard-Grace, MPH, et al

University of California, San Francisco

While Most Patients Do Not Benefit From Early Follow-up After Hospital Discharge, Researchers Identify a High-Risk Group That May

Although timely outpatient follow-up has been promoted as a key strategy to reduce hospital readmissions, researchers in North Carolina find that most patients do not meaningfully benefit from early outpatient follow-up. Rather, the findings of their study suggest transitional care resources are best allocated toward ensuring high-risk patients receive timely follow-up. Analyzing North Carolina Medicaid claims data for 44,473 patients with 65,085 qualifying discharges between April 2012 and March 2013, they found that although follow-up within seven days was associated with substantially lower readmission rates among patients with highest clinical complexity and highest underlying risk of readmission, most patients did not appear to benefit from very early follow-up. Among patients with no or just one chronic or acute condition (representing 38 percent of the discharges in the study population), readmissions were uncommon and negligibly affected by the timing of outpatient follow-up for up to 30 days. However, among those whose readmission risk exceeds 20 percent -- patients who have three or more chronic conditions, often including advanced coronary artery disease, chronic obstructive pulmonary disease, chronic renal failure, congestive heart failure, diabetes, ischemic vascular disease, or a history of organ transplant, dialysis or total parenteral nutrition -- one readmission may be prevented for every five patients who receive outpatient follow-up within 14 days. Notably, in this statewide Medicaid population, only 51 percent of patients in high-risk categories received follow-up within 14 days, and for every high-risk patient who did not receive follow-up, there was a low-risk patient who did. The authors write that while healthier patients and those with greater social support or self-management skills may be better equipped to secure and attend an earlier follow-up appointment, it is potentially at the cost of delaying care for those with more complex needs. Based on these findings, they call for risk segmentation to inform the timing of follow-up appointments.

Timeliness of Outpatient Follow-up: An Evidence-Based Approach for Planning After Hospital Discharge

By C. Annette DuBard, MD, MPH, et al

Community Care of North Carolina, Raleigh

Population Screening for Diabetes Has Limited Effect on Cardiovascular Morbidity, Self-Rated Health and Health Behavior

Researchers at the University of Cambridge find that screening high-risk individuals for type 2 diabetes appears to have a limited impact on population levels of cardiovascular morbidity, self-rated health status and health behavior after seven years of follow-up. In the cluster-randomized controlled trial of 18,875 individuals aged 40 to 69 years at high risk of diabetes in 32 general practices in eastern England, researchers found 466 (2.9 percent) of those eligible for screening were diagnosed with diabetes. Seven years after randomization, patient questionnaires surveyed a random sample of the participants to examine the effect of the screening program on their cardiovascular morbidity, self-rated health and health-related behavior. Data analysis revealed no significant differences between the screening and control groups in the proportion of participants reporting heart attack or stroke, self-rated health status, physical activity, smoking status or alcohol consumption. Additionally, they found that diabetes screening did not adversely affect self-rated functional status or health utility. The findings also suggested that screening did not lead to the adoption of unhealthy behaviors through false reassurance or to an increase in subsequent health service use. Based on the data, the authors see no long-term beneficial effect of screening for type 2 diabetes at the population level. They conclude that a single round of screening may be associated with benefits among the minority whose previously undiagnosed diabetes is detected, but it appears unlikely to affect the health of the population as a whole.

Long-Term Effect on Population Screening for Diabetes on Cardiovascular Morbidity, Self-Rated Health, and Health Behavior

By Simon Griffin, DM, et al

University of Cambridge School of Clinical Medicine, United Kingdom

Continuity with Primary Care and Specialty Physicians Associated with Fewer Hospitalizations and Emergency Room Visits

In an integrated delivery system with high informational continuity through shared electronic records, continuity of care with primary care and specialist clinicians is associated with decreased risk of emergency room visits or hospitalizations for seniors with multiple chronic medical conditions. In the study of 12,200 members of Kaiser Permanente Colorado aged 65 years or older with three or more chronic conditions, researchers found that greater primary care and specialty care continuity were each associated with lower inpatient admission (respective hazard ratios = 0.97 and 0.95) and lower risk of emergency department visits (respective hazard ratios = 0.97 and 0.98). For the subgroup of patients with three or more primary care and three or more specialty care visits, specialty care continuity, but not primary care continuity was associated with a decreased risk of inpatient admissions (hazard ratio = 0.94), and primary care continuity, but not specialty care continuity was associated with a decreased risk of emergency department visits (hazard ratio = 0.98). Based on these findings, the authors conclude that different subgroups of patients will benefit from continuity with primary care and specialty care clinicians depending on their care needs. They add that the study findings also suggest that interpersonal continuity has a beneficial effect on utilization independent of the informational continuity provided by electronic medical records.

Effect of Continuity of Care on Hospitalization Utilization for Seniors With Multiple Medical Conditions in an Integrated Health Care System

By Elizabeth A. Bayliss, MD, MSPH, et al

Kaiser Permanente Colorado, University of Colorado, Denver

Interconnected Primary Care Teams Deliver High-Quality Cardiovascular Disease Care

Primary care teams that are more interconnected, less centralized and have a shared team vision are better positioned to deliver high-quality cardiovascular disease care at a lower cost. Analysis of survey data from 155 health professionals at six primary care clinics and outcome data from their patients with a cardiovascular disease diagnosis, revealed that teams with more members reporting daily interactions with a greater number of team members showed better quality of care as measured by a 38 percent reduction in hospital days and $556 less spent on average per patient in the previous 12 months. Additionally, the findings suggested that teams with more daily face-to-face interactions had a 66 percent reduction in urgent care visits, a 73 percent reduction in emergency department visits and $594 less spent in medical costs per patient in the previous 12 months. A team's shared vision about goals and expectations, they note, mediated the relationship between social network structures and patient quality of care outcomes.

Effects of Primary Care Team Social Networks on Quality of Care and Costs for Patients with Cardiovascular Disease

By Marlon P. Mundt, PhD, et al

University of Wisconsin School of Medicine and Public Health, Madison

Predictors of Persistent Abdominal Pain in Children

Researchers in the Netherlands find that more than one in three children coming to a family practice with abdominal pain have persistent pain affecting quality of life after one year, and they identify four practical predictors of persistent pain. The study of 283 children aged 4 to 17 years seen for abdominal pain by their family physician found that the risk of having chronic abdominal pain at one-year follow up was 37 percent overall. Increased age, waking up at night with pain, high levels of other somatic complaints and chronic abdominal pain at baseline independently predicted chronic pain at one year. The probability of having chronic abdominal pain after one year ranged from 19 percent in children with none of the predictors to 66 percent among those having three or four.

However, researchers found the predictors had a poor discriminative ability -- collectively explaining only 14 percent of variance in the development of chronic abdominal pain. Based on these findings, the authors assert that on the basis of simple medical evaluation alone, the family physician is unable to accurately predict the prognosis of a child presenting with abdominal pain. They conclude that other yet to be identified psychosocial, environmental or family stressors may play a role, necessitating a more time consuming evaluation of these factors in order to identify children with a poor prognosis who might benefit from more intensive management.

Predictors of Chronic Abdominal Pain Affecting the Well-Being of Children in Primary Care

By Leo A. A. Spee, MD, et al

Erasmus MC University Medical Center, Rotterdam, The Netherlands

The Relationship Between Multimorbidity, Income and Hospital Admission in Three Different National Health Care Systems

Multimorbidity is strongly associated with hospitalization across three widely different national health care systems, but the impact of income on this relationship varies across the systems. Investigating population samples from Scotland (n=36,921), a country with a well-established health care system providing universal coverage, China (n=162,464), a country that does not provide universal health coverage, and Hong Kong (n=29,187), which has a dual-track system including both a public and private health care sector, researchers found that multimorbidity increased odds of admission in all three settings. Looking at the impact of income on hospitalizations, the researchers found in Scotland, lower household income per head was associated with increased odds of hospitalization (adjusted odds ratio = 1.62; 95 percent CI, 1.41-1.86 for the lowest income group vs. the highest), whereas in China the opposite was found -- those with lower incomes had reduced odds of hospitalization (adjusted odds ratio = 0.58; 95 percent CI, 0.56-0.60). After subanalysis by health care sector, the researchers found in Hong Kong, poorer people were more likely to be admitted to public hospitals (adjusted odds ratio = 1.68; 95 percent CI, 1.36-2.07), but less likely to be admitted to private ones (adjusted odds ratio = 0.18; 95 percent CI, 0.13-0.25). These findings, the authors conclude, offer insights into how the health care systems might be made more equitable and effective. They assert that strategies to improve equitable health care should consider the impact of socioeconomic deprivation on the use of health care resources, particularly among populations with prevalent multimorbidity.

Relationships of Multimorbidity and Income With Hospital Admissions in 3 Health Care Systems

By Stewart W. Mercer, MBChB, PhD, FRCGP, et al

University of Glasgow, United Kingdom

Researchers Propose Multi-Component Approach for Evaluating Practice Transformation Toward the Patient-Centered Medical Home

Researchers report on a mixed qualitative-quantitative methodology for evaluating how transformation to the patient-centered medical home occurs in different practice settings. The methods and measures in the proposed set are intended to be used together and include survey instruments, PCMH meta-measures, patient outcomes, quality measures, qualitative interviews, participant observation and process evaluation. The authors assert that PCMH evaluation must be sufficiently comprehensive to assess and explain the context of transformation in different primary care practices and the experiences of diverse stakeholders. The approach, the authors conclude, can foster insights about how transformation affects critical outcomes to achieve meaningful, patient-centered, high-quality and cost-effective sustainable change among diverse primary care practices. These insights, in turn, can inform recommendations for practice facilitation that can most effectively achieve the goals of the PCMH model.

Recommendations for a Mixed-Methods Approach for Evaluating the Patient-Centered Medical Home

By Roberta E. Goldman, PhD, et al

The Warren Alpert Medical School of Brown University, Providence, Rhode Island

Point-Counterpoint: Is Exposure to Secondhand Smoke Child Abuse?

A pair of point-counterpoint articles argue the question: is exposure to secondhand smoke child abuse? In the first article, Adam O. Goldstein, director of tobacco intervention programs at the University of North Carolina School of Medicine, asserts that purposefully and recurrently exposing children to secondhand smoke -- a known human carcinogen -- despite repeated warnings is child abuse. Goldstein recounts a case in which parents refused to take adequate safeguards to prevent their 5- and 7-year-old children's recurrent exposure to cigarette smoke. After frequent visits for ear infections, coughing, bronchitis, asthma and ultimately admission to the emergency room for a recurrence of pneumonia and severe asthma, the team realized there was a role for Social Services. He concludes that as our understanding of the harms of secondhand smoke increases, so does our responsibility to advocate for those involuntarily placed in harm's way. He calls for medical associations to endorse policies classifying purposeful and recurrent exposure of children to secondhand smoke as child abuse.

Offering an opposing viewpoint, Taryn Lindhorst, PhD, LCSW, asserts that expanding definitions of child abuse to include environmental tobacco smoke is not the answer because it reinforces a punishment orientation toward addiction that harms both child and family. Making environmental tobacco smoke exposure a form of child abuse, she adds, is a policy recommendation that would fall primarily on low-income populations and would disproportionately affect the children of people of color, reinforcing disparities in both child welfare and health care. Instead, she argues that more needs to be done to ensure that all people who need treatment for smoking cessation get access to this help. Until we know that parents have received adequate collaborative treatment, she concludes, we should not resort to further sanctions by treating their behavior as a form of child abuse.

Is Exposure to Secondhand Smoke Child Abuse? Yes.

By Adam O. Goldstein, MD, MPH

University of North Carolina at Chapel Hill School of Medicine

Is Exposure to Secondhand Smoke Child Abuse? No.

By Taryn Lindhorst, PhD, LCSW

University of Washington, Seattle

Essay: Why Medical Schools Tolerate Unethical Behavior

In a thought-provoking essay, physicians in Sao Paulo, Brazil, tackle the question: "Why is unethical behavior tolerated in medical schools?" They assert that unethical and unprofessional behavior in medical schools and health organizations are associated with medical errors, increased costs and preventable harm to patients, students, residents, nurses and other physicians. They posit several reasons why medical schools are tolerant of unethical behavior of faculty, including barriers to reporting, the reluctance of deans and directors to look for unethical behavior in their colleagues, the fact that people have become accustomed to a disrespectful health care environment, and the fact that accreditation of medical schools does not usually cover the processes or outcomes associated with fostering ethical behavior in students. The authors note a few examples of promising efforts of several health care institutions aimed at preventing, reducing and mitigating unethical/unprofessional behaviors in medical schools. They call for changes to the organization and underlying culture of health care institutions.

Why Medical Schools Are Tolerant of Unethical Behavior

By Edison Iglesias de Oliveira Vidal, MD, PhD, et al

Universidade Estadual Paulista, Botucatu, Sao Paulo, Brazil

Family Physician Explores How Witnessing a Suicide Changed Her Both Personally and Professionally

A family physician reflects on her struggle to reconcile the experience of witnessing a man commit suicide during her residency, and how it shaped her personally and professionally. She describes the powerlessness she felt in the face of inevitability, the questions of professional boundaries the experience elicited, and how the experience challenged her sense of capability to fulfill the very calling that brought her into medicine -- to help patients fix important problems in their lives.

You Can't Hide the Bridges

By Lauren S. Hughes, MD, MPH, et al

University of Michigan, Ann Arbor

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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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