Public Release: 

July/August 2015 Annals of Family Medicine tip sheet

American Academy of Family Physicians

Erectile Dysfunction a Marker for Undiagnosed Diabetes

Researchers in Canada find that erectile dysfunction, already known to be a marker for future cardiovascular disease, doubles the odds of having undiagnosed diabetes. Analyzing cross-sectional data on U.S. men aged 20 years and older who participated in the National Health and Nutrition Examination Survey during 2001-2004, they found for an average man aged 40 to 59 years, the probability of undiagnosed diabetes jumps from one in 50 to one in 10 in men with erectile dysfunction. They found no association for erectile dysfunction and undiagnosed hypertension or hypercholesterolemia. The authors conclude these findings underscore the importance of erectile dysfunction as a marker for undiagnosed diabetes. They call for physicians to be vigilant in obtaining sexual histories in middle-aged men and screening those with erectile dysfunction for diabetes.

Erectile Dysfunction and Undiagnosed Diabetes, Hypertension and Hypercholesterolemia

By Sean C. Skeldon, MD, et al

The University of British Columbia Center for Health Services and Policy Research , Vancouver

Oregon Medicaid Experiment Offers Insight Into How Demand for Primary Care Services May Increase Following Affordable Care Act Insurance Expansions

To better predict how utilization of community health center services might change in the wake of Affordable Care Act Medicaid expansions, researchers studied primary care use over a three-year period among a population of low-income adult CHC patients who gained coverage after Oregon expanded its Medicaid program in 2008. Their findings suggest that use of primary care services in CHCs will increase when patients gain Medicaid through ACA insurance expansions. Analysis of data on 34,849 patients (13,219 who were selected to apply for coverage through the Oregon Experiment and 21,630 who applied but were not selected to receive coverage) showed that Medicaid coverage significantly increased the rate of primary care visits, laboratory tests, referrals and imaging. Specifically, they found the number of primary care office visits per month was 282 per 1,000 Medicaid-covered patients, compared with 201 for patients without such coverage. Moreover in the 3-year follow-up period, Medicaid coverage led to a 58 percent higher rate of referrals, 27 percent higher rate of orders for laboratory tests and a 33 percent higher imaging rate. The authors conclude that these findings suggest that ACA insurance expansions could lead to increased demand for services from CHCs and other primary care settings. To maximize access to critical health services, they assert that it will be important to ensure that the health care system can support increasing demands by providing more resources to CHCs and other primary care settings.

Community Health Center Use After Oregon's Randomized Medicaid Experiment

By Steffani R. Bailey, PhD, et al

Oregon Health and Science University, Portland

Sleep Apnea May Increase Risk of Developing Panic Disorder

Analyzing data from a nationwide database, researchers in Taiwan discover that sleep apnea more than doubles the risk of subsequently developing panic disorder. Analysis of data from 8,704 sleep apnea patients and 34,792 control patients from the Taiwan National Health Insurance Research Database revealed that of the 43,496 patients, 263 (0.60 percent) suffered from panic disorder during a nearly 4-year follow-up period, including 117 (1.34 percent) from the sleep apnea cohort and 146 (0.42 percent) from the control group. The adjusted hazard ration for subsequent panic disorder among the sleep apnea patients was 2.17 (95 percent confidence interval, 1.68-2.81; P <.001).The authors posit several explanations for the link between sleep apnea and panic disorder, and they advise clinicians to be aware of panic disorder as a potential comorbid condition in sleep apnea patients.

Sleep Apnea and Risk of Panic Disorder By Kun-Ta Chou, MD, et al

Taipei Veterans General Hospital, Taiwan

Changes to Cervical Cancer Screening Guidelines Accompanied By Decrease in Chlamydia Screening Among Young Women

Following a 2009 cervical cancer screening guideline change that postponed cervical cancer screening to age 21 (previously, the American College of Obstetrics and Gynecologists had recommended beginning screening three years after first sexual intercourse or by age 21, whichever occurred first), researchers found a dramatic, concurrent decrease in chlamydia screening among 15-21 year old females in primary care clinics, suggesting an unintended consequence of the guideline change. Analyzing data on 3,472 female patients visiting family medicine clinics at the University of Michigan before and after the guideline change, researchers found women had higher odds of being screened for chlamydia before versus after the guideline change (odds ratio -= 13.97; 95 percent confidence interval, 9.17-21.29; P <.001). The was no corresponding decrease in office visits, which could explain the reduced screening rates. The authors note that the American College of Physicians recently recommended against performing screening pelvic examinations in nonpregnant, asymptomatic women. This recommendation, the authors warn, may affect chlamydia screening rates in a way similar to that of the change in cervical cancer guidelines. They conclude that chlamydia, pelvic examinations and cervical cancer screening need to be uncoupled and new screening opportunities should be identified.

Impact of Cervical Cancer Screening Guidelines on Screening for Chlamydia

By Allison Ursu, MD, et al

University of Michigan, Ann Arbor

Findings Suggest Growing Misuse of Antidepressant Bupropion in Ontario, Canada

Amid increasing reports of misuse of bupropion, a widely prescribed drug for the treatment of depression that can create a cocaine-like high when crushed, snorted or injected, researchers explored prescribing trends for bupropion in Ontario, Canada and replicated the analysis for citalopram and sertraline, antidepressants not known to be prone to abuse. They found that although no marked differences were seen for early refills of bupropion relative to its comparators, potentially duplicitous prescriptions have increased dramatically in Ontario, suggesting growing misuse of the drug. Specifically, researchers evaluated 1,780,802 prescriptions for bupropion, 3,402,462 prescriptions for citalopram, and 1,775,285 prescriptions for sertraline between 2000 and 2013. While they found no differences in early refills between the three drugs, they did find potentially duplicitous prescriptions for bupropion increased from less than 0.05 percent in early 2000 to 0.47 percent in early 2013. In contrast, potentially duplicitous refills for citalopram decreased from 0.25 percent to 0.11 percent, and potentially duplicitous refills for sertraline decreased from 0.15 percent to 0.12 percent over the same period. The authors conclude that these findings suggest a troubling phenomenon that bupropion prescriptions are being used recreationally at an increasing rate. They advise physicians and pharmacists to be aware of the potential for bupropion misuse, particularly in patients prone to substance use disorders or those who display unusual drug-seeking behaviors.

Rates of Anomalous Bupropion Prescriptions in Ontario, Canada

By Leah S. Steele, MD, PhD, et al

University of Toronto, Ontario, Canada

Many Women Maintain Satisfying Sex Life Into Middle Age and Beyond

A considerable proportion of midlife and older women remain sexually active if they have a partner available, according to a nationally representative study of women aged 28 to 84 years. Moreover, findings suggest among older women who are sexually active, sexual satisfaction is related not to age or menopausal status, but to higher relationship satisfaction, better communication and higher importance placed on sex. Analyzing data from 2,116 women who answered questions regarding sexuality in the Survey of Midlife Development in the United States, researchers found that 62 percent of respondents reported being sexually active in the previous six months. Among women aged 60 and older who had a romantic partner, 59 percent were sexually active. Women who were romantically partnered had approximately eight times higher odds of being sexually active; about 13 percent of sexually active women surveyed did not have a romantic partner. The authors conclude that many women maintain or want to maintain a satisfying sex life into middle age and beyond. Given these findings, they advise clinicians to ask women about sexual activity and sexual satisfaction and work with them to maintain a satisfying sex life with aging, including ways to improve relationship satisfaction and communication.

Correlates of Sexual Activity and Satisfaction in Midlife and Older Women

By Holly N. Thomas, MD, MS, et al

University of Pittsburgh, Pennsylvania

Compensation for Physicians Participating in Accountable Care Organizations May Not Sufficiently Incentivize Better Quality and Lower Costs

Analyzing data from a nationally representative sample of physician practices, researchers find compensation arrangements for primary care physicians inside accountable care organizations are similar to those in practices that are not part of accountable care organizations. Measuring physicians' compensation as the percentage of compensation based on salary, productivity, clinical quality or patient experience and other factors, the researchers found that primary care physicians in ACO practices on average received 49 percent of their compensation from salary, 46 percent from productivity, 3 percent from quality and 2 percent from other factors. Physicians not in ACOs but with substantial risk for primary care costs received two-thirds of their compensation from salary, nearly one-third from productivity and slightly more than 1 percent from quality and other factors. The authors write that although ACO practices provide higher compensation for quality compared with practices at large, they provide a similar mix of compensation based on productivity and salary. They conclude that incentives for ACOs may not be sufficiently strong to encourage practices to change physician compensation policies for better patient experience improved population health and lower per capita costs.

Salary and Quality Compensation for Physician Practices Participating in Accountable Care Organizations

By Andrew M. Ryan, PhD, et al

University of Michigan School of Public Health, Ann Arbor

Researchers: Accountable Communities for Health Have Greater Potential to Improve Health Than Traditional Accountable Care Organizations

Tipirneni and colleagues propose using lessons from community-oriented primary care to move from the current narrowly health care-focused accountable care organizations toward "accountable communities for health" that address health from a community perspective integrating medical care, public health and social services. The authors assert this approach is more inclusive of the diverse determinants of health and thus has much greater potential to improve population health than do current accountable health organizations. They share case studies of early examples of exemplary ACH models, including one in Minneapolis, MN and Akron, Ohio.

Accountable Communities for Health: Moving From Providing Accountable Care to Creating Health

By Renuka Tipirneni, MD, MSc

Robert Wood Johnson Foundation Clinical Scholars Program, University of Michigan, Ann Arbor

Roadmap for Integrating Genomic Medicine into Primary Care Practice

Synthesizing insights gained from the Institute of Medicine (recently renamed the National Academy of Medicine) Roundtable on Genomic-Based Research for Health, researchers propose a model for implementing genomic medicine into the patient-centered medical home. They assert that genomic medicine may have the greatest impact on health care if it is integrated in primary care, where most health care is received and where evidence supports the value of personalized medicine grounded in continuous healing relationships. Yet, implementation of clinical genomics into primary care and clinical practice has been limited because of critical evidence gaps, especially those related to clinical utility and applicability to diverse populations. The authors propose a roadmap for integration that includes three components: 1) evidence analysis and gap filling, 2) clinical implementation science, and 3) clinical implementation within a continuous improvement loop whereby clinical observations inform translational science and dissemination.

Making Personalized Health Care Even More Personalized: Insights from Activities of the IOM Genomics Roundtable

By Sean P. David, MD, DPhil, et al

Stanford University School of Medicine, California

Areas of Agreement and Tension Between the Needs and Preferences of Vulnerable Patients and Staff in Primary Care

In the first qualitative study to concurrently assess the experience of low income, chronically ill patients and the clinic staff who care for them throughout each step of the primary care process, researchers identified two major challenges that frequently got in the way of an effective visit: 1) information flow, despite systems that are intended to improve communication and 2) misaligned goals and expectations among patients, clinicians and staff members. Interviews with 21 patients and 30 staff members at three primary care practices in Philadelphia also revealed that personal relationships are highly valued by patients and staff. The authors conclude that when considering how to improve the care of vulnerable patients, it will be important to focus efforts on improving information flow, aligning goals and expectations and developing personal relationships.

Exploring the Patient and Staff Experience With the Process of Primary Care

By Elizabeth J. Brown, MD, MSHP, et al

University of Pennsylvania, Philadelphia

Improving HPV Vaccination Coverage: Researchers Identify Opportunities for Interventions to Enhance Uptake and Shared Decision Making

Given lower-than-anticipated uptake of the human papillomavirus vaccine in the eight years since its introduction, researchers investigated a broad range of health care delivery, health policy and attitudinal factors influencing vaccination and identify opportunities for strategic interventions to enhance uptake and shared decision making. Interview and survey data from primary care clinicians, health policy makers and immunization experts revealed health service delivery challenges as the greatest barrier to HPV vaccination, specifically the lack of capacity to track and distribute reminders to eligible patients. Clinicians also reported variations in counseling approaches attributable to both age and emphasis on the cancer prevention benefits of the vaccine. They did not find any evidence of sociocultural influences on vaccine decision making, nor did concerns about perceived overprotection emerge. Finding that patients' attributes and health system delivery are most influential in HPV vaccination coverage challenges, the authors call for interventions targeting innovation communication techniques, as well as health system changes that build on efforts toward coordinated care and utilization of other venues to promote vaccination.

Catching Up With the HPV Vaccine: Challenges and Opportunities in Primary Care

By Andrew L. Sussman, PhD, MCRP, et al

University of New Mexico, Albuquerque

Editorial: The Urgent Importance of Establishing a Shared Primary Care Data Model

Researchers make a renewed call for primary care leaders, communities and health information technology experts to establish a conceptual primary care data model that will guide the development of health IT standards to support robust primary care within a transformed US health care system. The authors assert that in large part because of primary care's complex nature, there is not yet a shared understanding of what particular data, from which diverse sources, should be collected, organized, linked and used to enable excellent primary care. They call on stakeholders to provide health IT developers a sufficient primary care data model that describes structures and standardizes the content necessary to support the higher-order, primary care functions of integrating, personalizing and prioritizing care to foster healing and health. They propose a new starting point and way forward for realizing this ambitious and intimidating goal.

The Foundational and Urgent Importance of a Shared Primary Care Data Model

By Larry A. Green, MD and Michael Klinkman, MD, MS

University of Colorado, Denver and University of Michigan, Ann Arbor

New Search Filters More Effectively and Efficiently Identify Family Medicine Articles in Online Medical Databases

Researchers in The Netherlands created and validated one highly sensitive and one highly specific search filter for family medicine that should aid researchers and clinicians using online medical databases to obtain biomedical information. The new specific search filter, which has a specificity of 97 percent and a sensitivity of 90 percent was developed to help family physicians find answers to clinical questions at the point of care when time is limited, providing the physician with references that are relevant, but with a small risk of missing articles. In contrast, the sensitive search filter, which has a sensitivity of 97 percent and a specificity of 75 percent, provides considerable efficiency while avoiding missing relevant articles and may be helpful to researchers conducting systematic reviews.

Development and Validation of Search Filters to Identify Articles on Family Medicine in Online Medical Databases

By David H.J. Pols, MD, MSc, et al

Erasmus MC, University Medical Center, Rotterdam, The Netherlands

Reflection: How a Broken Healthcare System Adversely Affects Patients Who Can't Afford Care

A family physician reflects on the unexpected passing of one of his uninsured patients, with whom he made financial arrangements that allowed him to become a continuity patient. He asserts that his patient died in part as a result of a health care system that has a messy patchwork of regulations mixed with politics, and he reflects on how a lack of access to affordable health care profoundly affects patients and their clinicians. Affordable Care?

By Adam O. Goldstein, MD, MPH

University of North Carolina at Chapel Hill

Family Physician Reflects on Finding a Profound Opening During a Routine Encounter

A family physician in the Bronx, NY, reflects on the history of a single mother with HIV for whom he has been caring for almost ten years. He describes how what starts out as a routine visit with her turns into a unique opening for communication and connection. He describes how a chance glimpse out of the window of the exam room following the visit inspired a deeper meditation on parenthood, survival and healing both for him and his patient.

Openings

By Peter A. Selwyn, MD, MPH

Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York

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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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