September/October 2016 Annals of Family Medicine tip sheet

Oral Probiotics Not Effective in Reducing Winter Antibiotic Prescriptions in People with Asthma

Although previous studies have shown that orally administered probiotics may prevent respiratory tract infections and associated antibiotic use, a new study in the current issue of Annals finds no evidence to support those earlier findings. In a randomized trial involving 1,302 asthmatic patients aged five years and older, researchers assessed whether advice to take probiotic treatment implemented as part of routine winter infection advice could reduce antibiotic prescription rates and respiratory tract infections. Participants in the intervention group received a leaflet that recommended taking a probiotic capsule daily, as well as free access to the supplements. Outcomes were similar between the probiotic and control groups. Specifically, they found 28 percent of the intervention group received antibiotics within the six month period for which probiotics were recommended, and 27 percent of the control group received antibiotics during that same window. These findings differ from those of a 2011 Cochrane review that analyzed the effects in predominantly younger children, casting doubt on the reproducibility of those findings in older children and adults with asthma. The authors conclude these data suggest that real-world use of probiotics to prevent winter infections and reduce antibiotic use cannot yet be recommended despite earlier positive findings -- at least not in older children and adults with asthma.

Recommending Oral Probiotics to Reduce Winter Antibiotic Prescriptions in People With Asthma: A Pragmatic Randomized Controlled Trial
By Robert J. Boyle, MBBCh, et al
Imperial College London, United Kingdom

One-Fifth of Drug Prescriptions Deemed Important By Physicians Not Taken Correctly By Patients

Researchers find substantial discordance between patient-reported drug adherence and physicians' assessment of drug importance with nearly 20 percent of drugs deemed important by physicians not correctly taken by patients. Researchers recruited 128 patients taking 498 drugs from both hospital and outpatient practices in France. Comparing drug adherence reported by patients and drug importance assessed by physicians, they found patients reported good adherence for 339 drugs (68 percent) evaluated as important by physicians, but for 94 drugs (19 percent), patients reported poor adherence even though their physicians evaluated them as important. Poor adherence involved mainly heart drugs, namely antihypertensive medications, platelet aggregation inhibitors, and other cardiac agents (18 percent); oral blood glucose-lowering drugs and insulin (14 percent); and drugs for airway diseases (13 percent). Patients intentionally did not adhere to 26 (48 percent) of the drugs for which they reported reasons for non-adherence. Notably, physicians rated 65 drugs (13 percent) as less important to patient health, raising questions about overtreatment and drug appropriateness. The authors conclude these findings highlight the need for better patient-physician collaboration in drug treatment, especially for patients having the poorest understanding of their medications and fewer beliefs in the need for medications.

Discordance Between Drug Adherence as Reported by Patients and Drug Importance as Assessed by Physicians
By Viet-Thi Tran,MD, PhD, et al
Sorbonne Paris Cité Research Centre and Paris Diderot University, France

Systematic Review: Psychological Interventions Are Effective Treatment Options for Postnatal Depression Managed in Primary Care

With approximately 13 percent of mothers experiencing postnatal depression during the first year after delivery and 90 percent of cases managed in primary care, researchers conducted a systematic review to assess the efficacy of psychological therapies for postnatal depression in primary care. They point out that while antidepressant medication is commonly used as a first-line treatment for postnatal depression, potential medication adverse effects are worrisome to both mothers and clinicians, making it important to evaluate the efficacy of nonpharmacologic therapies. The review, which included 10 clinical trials involving 1,324 depressed new mothers, found that psychological interventions delivered in community settings are effective treatment for postnatal depression. Compared with treatment as usual or a wait-list control, psychological interventions resulted in lower levels of depressive symptomatology and higher levels of remission immediately after treatment. Improvements in symptoms at four to six months of follow up were still significant but less robust. No particular type of therapy emerged as the most effective, but interpersonal therapy and cognitive behavioral therapy showed promising results. Statistically significant improvements were also found in anxiety and stress, marital relationships, adjustment to parenthood and perceived social support. The authors note that the small number of studies available means that caution is required when interpreting the secondary results and longer-term follow up. That said, these findings suggest primary care clinicians need to ensure that psychological therapies are as available as medication to their patients.

Effectiveness of Psychological Interventions for Postnatal Depression in Primary Care: A Meta-Analysis
By Elizabeth Ford, PhD, et al
Brighton and Sussex Medical School, United Kingdom

Given the tenuous financial sustainability of many primary care practices, the decision to make investments in the patient-centered medical home is influenced by financial outcomes as well as the benefits to patient care. With this in mind, researchers used a novel microsimulation model to test the effects of new payment strategies on patient-centered medical home practices' net annual revenue and service delivery. Evaluating three different funding initiatives -- increased fee-for-service payments, traditional fee-for-service with additional per-member-per-month payments and traditional fee-for-service with per-member-per-month and pay-for-performance payments -- they found that practices gained substantial additional revenue under per-member-per-month or per-member-per-month with pay-for-performance payments ($104,000 and $113,000 per full-time physician per year, respectively) but not under increased fee-for-service payments (-$53,500) after accounting for the costs of meeting PCMH funding requirements. Notably, expanding services beyond minimum levels required for PCMH requirements decreased net revenue because of lost traditional fee-for-service revenues. The authors conclude that achieving goals of the PCMH will likely require more radical payment reforms, including more robust non-visit-based payment mechanisms specifically targeting funding toward the delivery of desired services.

In an accompanying editorial, Michael K. Magill, MD, asserts that these robust and convincing study findings provide ample evidence that it is time to end fee-for-service payment for primary care. Writing that the study "puts a very large nail in the coffin for failed models of payment based on fee-for-service," he calls for comprehensive payment reform. Simply tweaking fee-for-service payment, as payers have been doing since the collapse of many health maintenance organizations in the 1990s, he writes, will only perpetuate the structural disadvantages for primary care. He contends that achieving the benefits of overall care redesign will require comprehensive payment that rewards primary care physicians and their colleagues not just for providing "desired services," but for achieving the Quadruple Aim of better care, lower cost, better health and clinician satisfaction.

Effects of New Funding Models for Patient-Centered Medical Homes on Primary Care Practice Finances and Services: Results of a Microsimulation Model
By Sanjay Basu, MD, PhD, et al
Stanford University, Palo Alto, California

Time to Do the Right Thing: End Fee-for-Service for Primary Care
By Michael K. Magill, MD
University of Utah School of Medicine, Salt Lake City

Four Articles Address the Importance of Treating Mental Illness in the Context of Families and Communities

Three insightful essays and a cross-cutting editorial reflect on the effects of mental illness in individuals, families and clinicians. Collectively, the authors assert that family physicians should practice in the context of family and community and treat mental illness not as a patient illness but as a family illness.

A Daughter's Experience With Bipolar Disorder Reveals the Need for Family Physicians to Treat Not Just the Patient, But the Family as a Whole

Khare describes her experience as the daughter of a father with bipolar disorder and the enormous strain his illness placed on their relationship. She relates the destructive cycling of mania, rage and depression, as well as her emotions that resulted from the experience. She explains how her experience led her to understand that mental illness is not a patient illness but rather a family illness -- one that requires a whole family approach to treatment. She writes that while she was equally affected by her father's mental disorder, she received no treatment from the family physician who saw all of the members of her immediate family. Despite numerous routine check-ups, the author's family physician never asked how she was coping with her father's bipolar disorder. Consequently, she managed her feelings in isolation, never truly learned how to effectively cope and struggled with feelings of sadness, confusion, anger and injustice, all of which culminated in intense guilt.

Bipolar Disorder: A Daughter's Experience
By Satya Rashi Khare, MScN, MBA
McGill University, Montreal, Quebec, Canada

Family Physician Relates Her Patient's Struggles to Keep Her Sanity After Her Siblings are Diagnosed With Schizophrenia

A family physician tells the story of a young female patient, Hope, who had four siblings diagnosed with full-blown schizophrenia and the woman's all-consuming fear that the mental illness that afflicted her siblings would touch her as well. The author writes that although her patient's family seemed like any other family from all external appearances, Hope was keenly aware that the statistics were against her, and she worked tirelessly to create a fortress of sorts for her own family to protect them from her past and her fears of the future. She describes the unsettling anxiety that consumed Hope whenever she or her children experienced any difficulties -- shyness, provocative behavior, hostility or isolation. In closing, the author reflects on how she feels she isn't able to do much for Hope other than to hold close her darkest, most painful secrets and offer reassurance and a safe, nonjudgemental and accepting environment. As a family physician practicing in a small community, the author concludes that psychiatric, social and family issues are family medicine concerns.

Hope
By Ruth Kannai, MD and Aya Alon, MA
Hebrew University, Jerusalem, Israel

Family Physicians Uniquely Qualified to Support Mentally Ill Patients and Their Families

A mental health professional and educator asserts that family physicians are positioned to intervene in powerful ways to support mentally ill patients and their families because of the specialty's family systems orientation. He writes that even though family physicians do not manage severe mental illness per se, they may manage the physical care of the patient and family members and play a major role in their psychological support, helping them to access available resources and offering them compassion and coping strategies.

Family Physician Support for a Family With a Mentally Ill Member
By J. LeBron McBride, PhD, MPH
Floyd Medical Center, Rome, Georgia

Editorial Calls on Family Physicians to Practice in the Context of Families and Communities

In an accompanying editorial, two family physicians from the University of Colorado, Denver, write that the three essays on mental health in the current issue of Annals serve as reminders that family physicians, when at their best, practice in the context of family and community. They assert that despite specific and compelling evidence that family factors can be overwhelmingly important in health and illness, family physicians sometimes forget the family in the press of demands for productivity, documentation requirements, exclusion of family information in modern electronic health records, pressure to narrow the scope of practice and individual privacy considerations. The authors assert emphatically that this must end, and they call on family physicians to pay attention to those others bound to patients by history, commitment, attachment or other commonalities -- the hidden patients who may be suffering outside the light of urgent clinical attention.

Return, For Good This Time, to Practicing in the Context of Families and Communities
By Frank V. deGruy III, MD, MSFM and Larry A. Green, MD
University of Colorado, Denver

Co-prescribing Naxolone With Opioids Is Acceptable Among Primary Care Safety-Net Patients

Drug overdose, driven by opioids, is the leading cause of accidental death in the United States, but distribution of the opioid antagonist naloxone has been associated with a reduction in opioid overdose mortality. In the first study to evaluate patients' experiences receiving a co-prescription of naloxone with opioids, researchers found patients overwhelmingly responded positively to being offered a naloxone prescription and that having naloxone was associated with beneficial changes in their opioid use behaviors. Specifically, interviews with 60 patients who received naloxone prescriptions across six safety-net primary care clinics revealed that 90 percent of patients had never previously received a naloxone prescription, 82 percent successfully filled the prescription, 97 percent believed patients prescribed opioids should be offered naloxone, 79 percent had a positive or neutral response to being offered naloxone, and 37 percent reported positive behavior change after receiving the prescription (safer dosing, safer timing and increased knowledge around opioids and overdose). Notably, although 37 percent of patients described having previously overdosed, 17 percent of those patients described the events as "bad reactions," and 77 percent estimated their risk of overdose as low. Given this low perceived overdose risk despite a history of prior overdose, the authors call for improved terminology to describe opioid poisonings as patients may not interpret "overdose" to imply unintentional opioid poisoning. Moreover, given that 90 percent of patients in this study had never previously received a naloxone prescription, the authors conclude that primary care prescribing appears to be reaching a population not served by community distribution. They call for future studies to investigate strategies to maximize the positive effects on behavior change and to integrate naloxone prescribing with broader opioid stewardship efforts.

Primary Care Patient Experience with Naloxone Prescription
By Emily Behar, MS, et al
San Francisco Department of Public Health, California

Nifedipine, Commonly Prescribed for Treatment of Chilblains, Not Effective and May Cause Harm

The vascularly active drug nifedipine is commonly prescribed for the treatment of chilblains, the painful inflammation of small blood vessels in response to exposure to cold; however, this randomized controlled trial found the drug was no more effective than placebo for treating chronic chilblains and may even cause harm. Researchers randomized 32 patients with chronic chilblains to receive either nifedipine (30 mg controlled release twice a day) or placebo and found after six weeks of treatment, the nonsignificant difference in patient-reported complaints (symptoms) tended to favor nifedipine (1.84 mm, P=.44), while the nonsignificant difference in patient-reported disability tended to favor placebo (0.56 mm, P=.75). Notably, nifedipine was associated with a lower systolic blood pressure and a higher incidence of edema. These findings contrast that of previous studies, only one of which was also randomized but involved only 10 patients. The authors conclude that these findings underscore the importance of rigorous evaluation of treatments with adequate numbers of patients and control for potential cofounders before widespread adoption.

Nifedipine vs Placebo for Treatment of Chronic Chilblains: A Randomized Controlled Trial
By Ibo H. Souwer, MD, et al
Radboud University Medical Center
Nijmegen, The Netherlands

Fecal Calprotectin Effective in Ruling Out Pediatric Inflammatory Bowel Disease in Primary Care

Guidelines recommend primary care physicians refer children with chronic diarrhea, recurrent abdominal pain, or both for specialist care if red flags are present, however the red flags are nonspecific and discriminate poorly between functional and organic gastrointestinal diseases, often leading to referral and extensive diagnostic testing. Fecal calprotectin is a simple, noninvasive diagnostic test commonly used in specialist care for ruling out inflammatory bowel disease in children with chronic gastrointestinal symptoms. In the first study to evaluate the use of FCal for IBD in symptomatic children in primary care, researchers in the Netherlands find the test has satisfactory discriminatory power between children with and without IBD. Studying two prospective cohorts of symptomatic children (114 children initially seen in primary care and 90 children referred to specialist care), the researchers find that none of the 114 children in the primary care cohort ultimately received a diagnosis of IBD. The specificity of fecal calprotectin in the primary care cohort was 0.87, higher than the specificity reported in previous studies performed in specialist care. Among the 90 children in the cohort referred by a primary care physician to specialist care, 17 (19 percent) ultimately received a diagnosis of IBD. The sensitivity of fecal calprotectin in the referred cohort was 0.99, comparable to the sensitivity reported in other studies performed in primary care. While FCal showed good sensitivity and specificity, the researchers question, however, whether it can add to the diagnostic information that is already readily available for a thorough history and physical examination. They call for further research to determine the cost-effectiveness of FCal and whether it should be incorporated in to the routine diagnostic evaluation of pediatric patients with chronic gastrointestinal symptoms and red flags in primary care. Based on their research, they suggest a pragmatic approach may be to monitor children with an initial calprotectin value between 50 μg/g and 250 μg/g feces, and later refer children whose symptoms persist and whose calprotectin values remain high.

Diagnostic Accuracy of Fecal Calprotectin for Pediatric Inflammatory Bowel Disease in Primary Care: Prospective Cohort Study
By Marjolein Y. Berger, MD, PhD, et al
University of Groningen, the Netherlands

Hostility Toward Primary Care Embedded in the Culture and Structure of Medical Training

In light of the growing shortage of primary care physicians, a researcher at the University of Kansas School of Medicine illuminates the historical roots of primary care disparagement by analyzing primary care physician oral histories. Examining 52 oral histories, she finds 64 percent of respondents reported experiencing discouragement and disparagement about primary care across five decades. Analysis revealed that hostility toward primary care was embedded in the culture and structure of medical training, creating barriers to the portrayal of primary care as appealing and important. While some respondents reported support for primary care choice, it was uncommon. The author concludes that for policy responses to be most effective in meeting the primary care workforce shortage, they must address the presence and power of persistent and deeply rooted hostility against primary care during training.

Hostility During Training: Historical Roots of Primary Care Disparagement
By Joanna Veazey Brooks, PhD, MBE
University of Kansas School of Medicine, Kansas City

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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.