Public Release: 

November/December 2015 Annals of Family Medicine tip sheet

American Academy of Family Physicians

Intervention Lowers Potentially Inappropriate Prescribing in Older Patients

Potentially inappropriate prescribing is a common and growing public health concern that can result in increased morbidity, adverse drug events, hospitalizations and expenditures. With previous research in Ireland showing 36 percent of those aged 70 years or older received at least one potentially inappropriate prescription in 2007 with an associated expenditure of more than €45 million, researchers in Ireland tested the effectiveness of an intensive multifaceted intervention for reducing PIP in primary care. They found the intervention was effective in reducing PIP, particularly in modifying prescribing of proton pump inhibitors, the drugs most commonly associated with PIP in Ireland. Specifically, the cluster-randomized controlled trial of 196 patients aged 70 or older at 21 Irish primary care practices tested a year-long intervention that included face-to-face academic detailing with a pharmacist, medicine review with web-based pharmaceutical treatment algorithms that provided alternative treatment options, and tailored patient information leaflets. At intervention completion, they found the percentage of patients having PIP was 52 percent in the intervention group compared with 77 percent in the control group. The mean number of PIP drugs per patient in the intervention group was 0.70 compared with 1.18 in the control group. Proton pump inhibitor PIP, which was highly prevalent at baseline (60 percent), was greatly improved through the intervention. At the end of the study, patients in the intervention group had significantly lower odds of receiving potentially inappropriate proton pump inhibitors compared to those in the control group (adjusted OR = 0.30, 95 percent CI, 0.14-0.68, P=.04). The authors write that the effectiveness of this intervention likely hinged on its intensive and multifaceted nature. Face-to-face, patient-specific detailing encouraged immediate action rather than simply providing educational support or information. The authors call for future research to examine tailoring of this intervention to influence different cases of PIP.

Effectiveness of a Multifaceted Intervention for Potentially Inappropriate Prescribing in Older Patients in Primary Care: A Cluster-Randomized Controlled Trial (OPTI-SCRIPT Study)
By Barbara Clyne, PhD, et al
Royal College of Surgeons in Ireland, Dublin

Systematic Review: Providing Transitional Care Interventions to Congestive Heart Failure Patients Reduces Readmission and Emergency Room Visits

Noting that after discharge 25 percent of patients with congestive heart failure are readmitted within 30 days and 50 percent within six months, researchers at McGill University conducted a systematic review and meta-analysis of 41 randomized controlled trials to determine the impact of transitional care interventions on the rate of all-cause readmission and emergency department visits by CHF patients and identify the most effective interventions and their optimal duration. The TCIs evaluated comprised a broad range of time-limited health services including patient and caregiver education on self-management, discharge planning, and structured follow-up and coordination among health professionals involved in the transition, including primary care physicians. They found that providing TCIs to congestive heart failure patients reduced readmission and emergency department visits by 8 percent and 29 percent, respectively. Furthermore, they found that high-intensity interventions that combined home visits with telephone follow up and/or clinic visits reduced readmission risk regardless of the duration of follow-up. Moderate-intensity TCIs were also efficacious but only if implemented for a longer duration (at least six months). In contrast, low-intensity interventions, which only entailed follow-up in outpatient clinics or telephone follow-up, were not efficacious. The authors conclude clinicians and managers who implement TCIs in primary care can incorporate these results within the health care context to determine the optimal balance between intensity and duration of TCIs.

Transitional Care for Patients With Congestive Heart Failure: A Systematic Review and Meta-Analysis
By Isabelle Vedel, MD, PhD and Vladimir Khanassov, MD, MSc
McGill University, Montréal, Canada

Meta-Analysis Finds Mindfulness-Based Interventions Promising for the Mental Health and Quality of Life of Primary Care Patients

With previous research demonstrating positive effects from mindfulness-based interventions in diverse clinical and nonclinical populations, researchers conducted the first meta-analysis addressing the efficacy of mindfulness-based interventions specifically in primary care patients. The researchers analyzed six randomized controlled trials of MBIs conducted in primary care settings and found mindfulness interventions were efficacious for improving general health with moderate heterogeneity. MBIs were also efficacious for improving mental health with a high heterogeneity and for improving quality of life with a low heterogeneity. The authors note that the effect size observed in primary care was similar to that observed across general clinical populations and other settings, and similar to those found for pharmacologic and psychological therapies in primary care for complex disorders. While the results of this review suggest that MBIs are promising for the mental health and quality of life of primary care patients, the researchers point out that the number of randomized controlled trials applying MBIs in primary care is still limited and there is insufficient evidence to draw firm conclusions about the effects of MBIs in this setting. They offer innovative approaches for implementing MBIs and call for more well-designed randomized controlled trials and translational studies to address unanswered questions about the use of MBIs in primary care.

The Efficacy of Mindfulness-Based Interventions in Primary care: A Meta-Analytic Review
By Javier Garcia-Campayo, et al
University of Zaragoza, Spain

Health Records Data Shows White Children, Adolescents and Children Seen in Non-Pediatric Clinics at Increased Risk of Receiving Antibiotics for Upper Respiratory Infections

In the first study to use electronic health record and community data to evaluate the patient, clinician and community factors affecting the management of pediatric upper respiratory infections, researchers find that white children, adolescents and children seen at non-pediatric clinics are at increased risk of receiving antibiotics for URIs, the majority of which are attributed to viral processes. Linking EHR data from 42 University of Wisconsin Clinics with community statistics, researchers identified patients aged three months to 18 years in whom URI was diagnosed between 2007 and 2012 and applied the Healthcare Effectiveness Data and Information Set protocol to estimate the frequency of appropriate management of children with URI. Of the 20,581 patients reviewed, the overall rate for appropriate management for URI was 94 percent, higher than the national HEDIS rate, which ranged from 84 percent in 2007 to 87 percent in 2010. The researchers found that family medicine clinicians, urgent care clinicians, patients aged 12 to 18 years, and patients of white race were independently predictive of antibiotic prescription. Specifically, patients seen in family medicine and urgent care clinics were 1.5 and 2.23 times as likely to be prescribed antibiotics as those seen in pediatric clinics, respectively. After controlling for other factors, adolescents and white patients were 1.4 and 1.8 times as likely to be prescribed antibiotics, respectively. No community factors were independently predictive of antibiotic prescription. The authors point out that their findings correlate with prior studies in which non-pediatric clinicians and white race were predictive of antibiotic prescription, illustrating the promise of linking electronic health records with community data to evaluate antibiotic prescription in children as well as health care disparities.

Role of Clinician, Patient and Community Characteristics in the Management of Pediatric Upper Respiratory Tract Infections
By Jeffrey P. Yaeger, MD, MPH, et al
Drexel University College of Medicine, Philadelphia, Pennsylvania

Report Calls for Increased Vigilance for Obstructive Sleep Apnea in Patients Who Work in Jobs Where Impairment Could Result in Serious Public Harm

A special report by the chief medical officer for the National Transportation Safety Board describes the findings of the investigation into the probable cause of the derailment of a Metro-North passenger train in the Bronx, New York, on December 1, 2013 that resulted in four deaths and injuries to 59 additional people. A key finding of the medical investigation was the engineer's post-accident diagnosis of severe, obstructive sleep apnea, which led investigators to determine the probable cause of the accident was the engineer having fallen asleep while operating the train. The report concludes the accident highlights the importance of screening, evaluating and ensuring adequate treatment of obstructive sleep apnea, especially among patients working in positions where impairment of physical or cognitive function or sudden incapacitation may result in serious harm to the public.

Fatal Consequences: Obstructive Sleep Apnea in a Train Engineer
By Mary Pat McKay, MD, MPH
National Transportation Safety Board, Washington, DC

Improving the Patient-Centeredness of Primary Care Consultations for Osteoarthritis

With patients and physicians both reporting dissatisfaction with primary care consultation experiences relating to osteoarthritis, the most common cause of musculoskeletal pain in older adults, researchers in the United Kingdom investigated the language, explanations and exchanges that occur in these consultations in order to identify how to improve care delivery for OA. Observations of 19 real-life OA consultations and subsequent physician and patient interviews using video-stimulated recall identified three key themes: complexity, dissonance and prioritization. The researchers found the topic of OA often arises in the consultation in complex contexts of multimorbidity and multiple, often not explicit, patient agendas. Dissonance between patient and doctor was frequently observed and reported, occurring when physicians normalized symptoms of OA as part of life, reassured patients who were not seeking reassurance and failed to meet patients' information needs. Moreover, the researchers found physicians subconsciously made assumptions that patients did not consider OA a priority and that symptoms raised late in the consultation were not troublesome. The authors conclude that these findings highlight generic communication issues regarding the potential negative consequences of failure to validate concerns and elicit patient expectations - difficulties likely to be influenced by the complexity that multimorbidity introduces in the modern-day consultation. The findings also raise new arguments for tackling OA's identity crisis by developing a clearer medical language with which to explain the condition in primary care consultations.

The Identity Crisis of Osteoarthritis in General Practice: A Qualitative Study Using Video-Stimulated Recall
By Zoe Paskins, MRCP, MMedEd, PhD, et al
Keele University, Staffordshire, United Kingdom

Patients Report Positive Experience with Case Management

With case management increasingly being used to improve patient satisfaction and quality of life and reduce costs associated with frequent users of health care services, researchers in Canada examine the experience of patients, frequent users with chronic diseases, and their family members with care integration as part of a primary care case management intervention. They found the experience of patients and family members was overall very positive regarding care integration, and participants confirmed that, as their preferred contact with primary care, their case management nurse could inform, educate, support, and help them navigate the health care system as well as advocate for them. Through qualitative interviews with 25 patients and focus groups with eight family members, participants revealed improved access, communication, coordination and involvement in decision-making, as well as better health care transitions. Participants also proposed several ways to improve case management interventions, including ensuring patients fully understand the purpose of case management and have ample opportunity to ask questions during the process, finding ways to reduce travel costs and multiple visits, and offering home visits for patients who have severe functional disabilities. The authors conclude these findings demonstrate that case management by a primary care nurse effectively responds to the complex needs of a very vulnerable clientele and appears to successfully promote self-management support and better integration of health care services.

Case Management in Primary Care for Frequent Users of Health Care Services With Chronic Diseases: A Qualitative Study of Patients and Family Experience
By Catherine Hudon, MD, PhD, CFPC, et al
Université de Sherbrook, Québec, Canada

Concordant-discordant Model Only Partially Explains the Quality of Diabetes Care in English Family Medicine Practices

In an attempt to explain the quality of diabetes care in family practices, researchers in England assessed the potential impact of the practice-level prevalence of diabetes-concordant conditions (such as obesity, hypertension, coronary heart disease, chronic kidney disease, stroke, atrial fibrillation and heart failure that have the same pathophysiologic risk profile and are therefore more likely to be part of the same management plan) and diabetes-discordant conditions (such as asthma, cancer, chronic obstructive pulmonary disease, dementia, depression, epilepsy, hypothyroidism and severe mental disorders, which are not directly related to each other in their pathogenesis or management). They hypothesized that family practices that have a higher proportion of patients with diseases in the cardiometabolic cluster may prioritize and more efficiently allocate resources for the management of these conditions, potentially improving the quality of health care for patients with diabetes. Conversely, those practices with a higher proportion of patients with diabetes-discordant conditions could be impaired in their ability to deliver high-quality diabetes care as a result of competition for resources and attention. Analyzing data from 7,884 English family practices, the researchers found that although the quality of diabetes care provided in practices was associated with the prevalence of other major chronic conditions, the nature and direction of the associations could not be explained by the concordant-discordant model. Specifically, they found that prevalence rates for four of seven concordant conditions examined (obesity, chronic kidney disease, atrial fibrillation and heart failure) were positively associated with quality of diabetes care. Similarly, negative associations were observed as predicted for two of eight discordant conditions examined (epilepsy and mental health). Observations for other concordant and discordant conditions, however, did not match predictions in the hypothesized model. The prevalence of hypertension and coronary heart failure, for example, were negatively associated with both processes and intermediate outcomes of diabetes, and the authors found strong positive associations for diabetes quality of care and cancer and COPD. The authors conclude that while the concordant-discordant model does not explain the patterns of association between the prevalence of chronic conditions and the quality of diabetes care provided by practices in England, the prevalence of a number of chronic conditions can be a predictor of quality of care for diabetes. Incentive programs, they assert, should consider the prevalence of other chronic conditions when assessing performance of practices in providing healthcare to people with diabetes.

Impact of the Prevalence of Concordant and Discordant Conditions on the Quality of Diabetes Care in Family Practices in England
By Ignacio Ricci-Cabello, PhD, et al
University of Oxford, United Kingdom

Joint Displays a Powerful Visual Tool for Describing Complex Mixed Methods Research Findings

Mixed methods research has emerged as an important research methodology for investigating complex, nuanced health-related topics, but the meaningful integration of qualitative and quantitative data in ways that allow researchers and readers to understand the insights gleaned remains elusive. Researchers in Michigan examined 19 previously published joint displays that visually bring mixed methods data together, creatively conveying summary statistics and stories, sometimes joined by theory and recommendations. They identify several different display types and discuss exemplars for each of the designs. They conclude that joint displays provide an effective structure for discussion of integrated analyses and call for increased application of joint displays to represent mixed methods analysis.

Integrating Quantitative and Qualitative Results in Health Science Mixed Methods Research Through Joint Displays
By Timothy C. Guetterman, PhD, et al
University of Michigan, Ann Arbor

Editorial: Values-Driven Leadership Essential for Health Care Change

Carol P. Herbert, MD, CCFP, FCFP, FCAHS, professor of family medicine at Western University in London, Ontario, calls for values-driven, principled leadership in order to bring about the transformative change needed to address the problems confronting health care today. She asserts that because of their training and experience as generalists who deal with undifferentiated illness, family physicians are particularly suited to leadership in current health care environments where evidence is often incomplete and the way forward is uncertain. She calls on her colleagues to demonstrate value-driven principled leadership in order to inspire others, including future family physicians, to invest their time and energy into leading change. Change is possible, she concludes, if enough leaders emerge who have a sophisticated appreciation of how the system operates, optimism that change is possible, and an unshakeable belief that evidence-informed change with measurement of outcomes is the only sensible way to deal with the health care problems that confront us.

Perspectives in Primary Care: Values-Driven Leadership is Essential in Health Care
By Carol P. Herbert, MD, CCFP, FCFP, FCAHS
Western University, London, Ontario

Family Physician Reflects on the Final Lessons Learned From Her Mentor, Colleague and Friend

An essay by a family physician about her fellow physician, friend and mentor who died from a rare type of cancer addresses the many unexpected lessons learned from the experience of her colleague's illness and passing. She reflects on her frustration and deep disappointment with her friend's final choices that prevented them from processing and sharing their feelings and deepest thoughts. She writes that while we may never fully comprehend the complex fabric of culture, personality, conditions, community, family and other factors that converge to ultimately determine a patient's decisions, this experience helped her to better understand and accept the preferences of patients and others close to her.

The Untaught Lesson
By Ruth Kannai, MD
Hebrew University, Jerusalem, Israel

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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.

Annals of Family Medicine continues to be rated among the most influential journals in general and internal medicine. According to the recently released Thomson Reuters' 2015 Journal Citation Report, the journal's impact factor of 5.434, which measures the average number of citations to recent articles published in the journal, places it number one out of 19 journals in the primary healthcare category and number 16 among 153 journals in the larger category of general and internal medicine. Moreover, Annals' immediacy index rating, which measures the number of times an article is cited in the year it is published, places it at number seven of 153 in the general and internal medicine category. We are proud of these extremely high rankings, which suggest that Annals continues to address timely topics and is publishing articles that are highly relevant to the discipline and to a broad research community.

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