Public Release: 

March/April 2016 Annals of Family Medicine tip sheet

American Academy of Family Physicians

Electronic Consultations Improve Access to Cardiac Specialty Care

Electronic consultations appear to improve access to and timeliness of referrals to cardiac care for underserved populations, as well as reduce overall specialty utilization and streamline specialty referrals without an increase in adverse cardiovascular outcomes. A randomized controlled trial of 36 primary care physicians at a multi-site health clinic who referred 590 patients to cardiologists found that for the patients in the intervention group who were referred to a cardiologist by the e-consultation pathway (about half were not sent by e-consultation because of urgency or the existence of an established relationship between the patient and a cardiologist), approximately two-thirds never required a face-to-face visit. Moreover, the researchers found e-consultations were completed, on average, almost a month sooner than those sent for a face-to face consultation (five days versus 24 days, respectively), even for those deemed urgent by the referring physician. A review of six-month follow-up data found fewer cardiac-related emergency department visits for the intervention group. The authors conclude these results show that a substantial number of consultations can be safely and more efficiently managed through a secure electronic exchange of information without compromising the quality of care and with improved convenience for the patient. Moreover, they assert that e-consultations show great promise in advancing integration of the patient-centered medical home into the larger medical neighborhood and potentially mitigating health disparities in access and treatment.

Electronic Consultations to Improve the Primary Care-Specialty Care Interface for Cardiology in the Medically Underserved: A Cluster-Randomized Controlled Trial
By J. Nwando Olayiwola, MD, MPH, et al
University of California, San Francisco and San Francisco General Hospital

Researchers Propose Framework for Integrating Social Determinants of Health into Primary Care

Researchers offer a conceptual framework and path for integrating social determinants of health -- the nonclinical factors such as socioeconomic conditions and neighborhood resources that influence patients' health outcomes -- into primary care practice. Amid mounting evidence that SDH influence health outcomes more than medical care, they call for innovative solutions to systematically address them in the primary care setting. They offer specific ideas for integrating SDH, including 1) collecting and organizing community-level and individual-level data in a systematic way 2) making the data available and useful in ways that enhance care (the right data, at the right time, in the right place), and 3) developing automated systems that harness SDH data to prompt action. Recognizing that simply documenting SDH data in electronic health records may not be enough to create meaningful change, they call on stakeholders to identify evidence-based workflows that enable care teams to use SDH data purposefully in clinical care.

Perspectives in Primary Care: A Conceptual Framework and Path for Integrating Social Determinants of Health Into Primary Care
By Jennifer E. DeVoe, MD, DPhil, et al
Oregon Health & Science University and OCHIN, Inc., Portland

Point/Counterpoint Asks Whether Primary Care Should Take on Social Determinants of Health

Arthur Kaufman, MD, and Leif Solberg, MD, address the boundaries of medical practice in a point/counterpoint that asks the question: "Should primary care practice take on social determinants of health now?"

Kaufman argues that with appropriate transformation, primary care practices are well-suited to address the social determinants of health. Primary care, he asserts, has not only the evidence to justify investments in addressing social determinants of health, but also a growing, supportive health care climate that provides funding strategies to address those needs by expanding the clinical care team. He points to several developments that support primary care embracing this new responsibility: incentives that have emerged in recent years to invest in prevention, expansion of primary care health teams to include community health workers and others who can help in addressing social determinants, incentives from payers for primary care clinicians who address social determinants, and mandates that residency programs address health disparities through quality improvement activities.

On the other side of the argument, Solberg contends that such an additional expectation on primary care is likely to have serious unintended consequences and is unlikely to produce the hoped-for benefits. Noting that primary care clinicians already feel overworked, stressed and discouraged, largely due to a growing list of expectations that have been added to their plates over the years, he asserts that it seems unlikely clinicians can address social determinants without diverting energy from existing responsibilities. Moreover, he argues, there is no reason to believe primary care physicians can have much impact on the social determinants of their patients because they have no expertise or resources for the work -- work that even social service agencies created for this purpose find to be difficult, frustrating and of limited success.

Theory vs Practice: Should Primary Care Practice Take on Social Determinants of Health Now? Yes.
By Arthur Kaufman, MD
University of New Mexico, Albuquerque

Theory vs Practice: Should Primary Care Practice Take on Social Determinants of Health Now? No.
By Leif I. Solberg, MD
Minneapolis, Minnesota

Practical Opportunities for Diet and Activity Shape Intentions and Achieved Behaviors

Effectively responding to the epidemic of obesity and chronic disease requires interventions that account for important drivers of diet and physical activity patterns. Clinical management often focuses on motivating patients to eat better or exercise more without evaluating what it is practical for them to do. This study demonstrates that practical opportunities for healthy diet and physical activity are measurable and predict behavioral intentions, diet quality, activity minutes and body mass index. In a sample of 746 adults visiting eight large primary care practices in Texas, researchers at the University of Texas Health Science Center in San Antonio find a relatively large effect size of practical opportunity measures for predicting physical activity minutes, diet quality and BMI. The authors assert these findings underline the need to understand the complexity of people's lives because achieving goals depends on the interaction between what people intend to do and what is feasible for them to do. Assessing opportunities as part of health behavior management, they conclude, could lead to more effective, efficient and respectful interventions.

Practical Opportunities for Healthy Diet and Physical Activity: Relationship to Intentions, Behaviors, and Body Mass Index
By Robert L. Ferrer, MD, MPH, et al
University of Texas Health Science Center at San Antonio

Five Key Strategies Employed by Top-Performing Clinicians to Support Patients' Behavior Change

Seeking to elucidate the clinician behaviors that are effective in supporting patient self-management of chronic conditions, researchers identify five key strategies employed by exemplar physicians to support patient behavior change. The authors identified and interviewed 10 clinicians whose patients had relatively large changes in patient activation, defined as having the knowledge, confidence and skills to take care of one's health and health care. They also interviewed 10 clinicians whose patients had small changes in activation. The authors found those clinicians with high patient activation reported using the following five strategies (mean = 3.9): 1) emphasizing patient ownership; 2) partnering with patients; 3) identifying small steps; 4) scheduling frequent follow-up visits to cheer successes, problem solve, or both; and 5) showing care and concern for patients. Clinicians whose patients had smaller changes in activation were far less likely to describe using these approaches (mean = 1.3 strategies). The authors conclude that given the key role patients play in determining health outcomes, it is critical that all primary care physicians support patient self-management and activation. They call for more systematic professional and organizational approaches to help clinicians adopt evidence-based strategies to support patients and increase activation levels.

Supporting Patient Behavior Change: Approaches Used by Primary Care Clinicians Whose Patients Have an Increase in Activation Levels
By Jessica Greene, PhD, et al
George Washington University, Washington, DC

Disclosure of Sexual Identity Associated With Increased HIV Testing and Hepatitis Vaccines Among Rural Men Who Have Sex With Men

Full disclosure of sexual orientation to their primary care clinician sharply increases the probability that rural men who have sex with men receive recommended HIV testing and hepatitis A and B vaccinations. Analyzing data from a national survey of rural men who have sex with men (N = 319), researchers find that disclosure of sexual identity to clinicians is significantly associated (odds ratio = 1.26; 95 percent confidence interval, 1.08-1.47) with uptake of routine HIV testing and hepatitis vaccination. The authors assert this finding reinforces the need for safe, nonjudgmental spaces for patients to freely discuss their sexual identities with their clinicians. Being fully out to their clinician and talking opening about their sexuality, they conclude, is a fundamental gateway to receiving appropriate sexual health services.

Disclosure of Sexual Orientation and Uptake of HIV Testing and Hepatitis Vaccinations for Rural Men Who Have Sex With Men
By Nicholas Metheny, MPH, RN and Rob Stephenson, PhD
University of Michigan, Ann Arbor

Clinician Communication Reinforces Parents' Antibiotic Expectations for Children With Respiratory Tract Infections

Clinicians' communication and prescribing behavior around antibiotic use for respiratory tract infections in children appears to reinforce parents' beliefs that antibiotics are indicated when children's symptoms are more severe. Examining communication within 60 primary care consultations for respiratory tract infections, researchers found a mutually-reinforcing cycle of explanation and discussion in which clinicians accompanied viral diagnoses with problem-minimizing language and antibiotic prescriptions with more problem-oriented language confirming parents' existing beliefs about what indicated illness severity. Interestingly, while most parents had a poor understanding of antibiotic resistance, most supported reduced antibiotic prescribing. The authors conclude that communication aimed at reducing antibiotic expectations would be more effective if it acknowledged that viral illness can be severe (e.g., in bronchitis or viral pneumonia) and that bacterial infections can be self-limiting. The findings also suggest that clearer explanations of the symptoms and signs of a child's illness that indicate when antibiotics are and are not warranted would help reduce misconceptions. Interventions to reduce antibiotic prescribing, they assert, need to address within-consultation communication, prescribing behavior and lay beliefs simultaneously to avoid having one undermine the other.

Influence of Clinical Communication on Parents' Antibiotic Expectations for Children With Respiratory Tract Infections
By Christie Cabral, PhD, et al
University of Bristol, England

Group Visit Model Effectively Facilitates Advance Planning Conversations

Group visits offer a feasible approach for facilitating discussions about advance care planning. Researchers describe a pilot demonstration of an advance care planning group visit in a geriatrics clinic involving 32 patients aged 65 years and older. Most participants evaluated the group visit as better than usual clinic visits for discussing advance care planning. After two 90 minute sessions, patients reported increases in detailed advance planning conversations after participating (19 percent to 41 percent). Qualitative analysis of the group visits found that participants were willing to share personal values and challenges related to advance care planning and that they initiated discussions about a broad range of topics related to advance care planning. The authors conclude the model warrants further evaluation for effectiveness in improving advance care planning outcomes for patients, clinicians and the system.

Advance Care Planning Meets Group Medical Visits: The Feasibility of Promoting Conversations
By Hillary D. Lum, MD, PhD, et al
University of Colorado School of Medicine, Aurora

Researchers: More Patient-Centric View of Value Should Guide Primary Care Evaluation

Asserting that existing metrics for evaluating the impact of patient-centered medical homes do not adequately reflect what patients value, researchers propose a framework for defining patient-centric value and a model to guide primary care practices in delivering such value. The proposed framework is based on five domains that are important to patients: health, cure, healing, preconditions of health and experience of care. The proposed primary care value model is characterized by three tiers of additive and complementary activities: 1) foundational activities providing organizational infrastructure, 2) direct care activities providing medical and complementary services, and 3) care coordination activities providing coordination and support for direct care activities. The authors advocate for use of the model when measuring the impact of primary care transformation, recognition, and performance-based payment; for financial support and research; and to support primary care organizations in transformation.

Achieving Value in Primary Care: The Primary Care Value Model
By William Rollow, MD, MPH and Peter Cucchiara, BSMIS, MBA
University of Maryland School of Medicine, Baltimore and Primary Care Development Corporation, New York, New York

Patients in Areas of High Deprivation in Scotland Have Poorer Outcomes From Primary Care Consultations

Reporting a comparison on general practitioner consultations in areas of high and low deprivation in Scotland and analyzing the factors predicting poorer or better outcomes in both low and high socioeconomic groups, researchers find in both settings patients' perceptions of the physicians' empathy predicts outcomes. They also find a persistence of the "inverse care law" which holds that the availability of good medical care tends to vary inversely with the need for it in the population served. Specifically, assessing patient (N = 659) expectations and experiences before and after consultations with their GP (N = 47) and analyzing video recordings of the consultations, researchers found that compared with affluent areas, patients in the deprived areas had higher rates of ill health, psychosocial problems, and multimorbidity; more problems to discuss within the same consultation time yet less desire for shared decision making; perceived their GPs as less empathetic; and had outcomes that were worse at one month. Analysis of the videotaped consultations showed physicians in the deprived areas displayed verbal and nonverbal behaviors that were less patient centered. Perceived physician empathy was the only consultation factor that predicted better outcomes in patient symptoms and wellbeing in both high- and low-deprivation groups. The authors point out that despite the higher levels of unmet need in deprived areas, the distribution of GPs in Scotland is flat across deprivation deciles and the ability of physicians to more fully respond to the needs of patients in deprived areas is limited. To improve health in deprived areas, they call for policies that address the wider social determinants of health and that improve consultation quality by reversing the inverse care law.

General Practitioners' Empathy and Outcomes: Prospective Observational Study of Consultations in Areas of High and Low Deprivation
By Stewart W. Mercer, et al
Institute of Health and WellBeing, Glasgow, Scotland

Systematic Review: Case Management Addresses Majority of Needs of Dementia Patients and Their Caregivers

Researchers conducted a systematic mixed studies review to determine whether the collaboration of family physicians with case managers adequately responds to the needs of patients with dementia and their caregivers in the community. The analysis of 54 studies first identified needs from the perspectives of patients and their caregivers and then evaluated whether case management targeted those needs and led to the desired outcomes. The researchers found that although case management addressed the majority of the identified needs, some very common needs like early diagnosis are overlooked while other needs like education on the disease are well addressed. The authors call for future studies to evaluate the effects of case management on the needs that are overlooked, specifically early diagnosis of dementia, legal issues, and financial issues. They suggest that the integration of social workers into primary care to assist with financial and legal issues of the dyad may be an avenue for future studies.

Family Physician--Case Manager Collaboration and Needs of Patients With Dementia and Their Caregivers: A Systematic Mixed Studies Review
By Vladimir Khanassov, MD, MSc, and Isabelle Vedel, MD, PhD
McGill University, Montréal, Québec

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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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