News Release 

March/April 2020 Annals of Family Medicine tip sheet

American Academy of Family Physicians

Facilitating Safe Intermittent Fasting for Muslims With Diabetes During Ramadan

Most Muslims who have diabetes engage in intermittent fasting during Ramadan, yet there are concerns regarding how to safely manage diabetes while fasting. A study of fasting adults with type 2 diabetes found that those who managed their condition in collaboration with their health care provider using an empowerment-based approach, saw greater improvements in glycemic control.

Health researchers from the University of California, Irvine and the National University of Singapore developed a collaborative diabetes management tool tailored for fasting Muslims and their doctors called FAST, or "Fasting Algorithm for Singaporeans with Type 2 Diabetes." The FAST tool sought to empower diabetic patients who fast with Ramadan-specific educational materials, dosing modification information for patients and their doctors, and encouragement of active self-monitoring of blood glucose before, during and after fasting.

The tool was evaluated for safety and effectiveness in a prospective, multi-center, randomized controlled trial with 111 fasting adults with type two diabetes in Singapore. Additionally, the FAST protocol did not increase the risk of hypoglycemic events. On average, those in the FAST intervention group showed four times the reduction in hemoglobin A1c compared to the control group (-0.4% vs -0.1%, 95% CI: -0.605 to - 0.001, p = 0.049), in measures taken before and after the fasting period. There were no major hypoglycemic events in either group, and no increase in minor hypoglycemic events in the FAST group. The researchers conclude that the use of empowerment-based, tailored tools for diabetes management like FAST can help observant Muslims with diabetes fast safely.

In an accompanying editorial, University of Michigan family physician Jonathan Gabison, MD, argues for the broader clinical implications of protocols like FAST that enable people with medical conditions to fast safely. To avoid hypoglycemic events, Gabison recommends physician supervision for diabetic patients considering fasting as well as another trending practice: low carbohydrate diets. Gabison concludes, "While more research is needed, a protocol to manage diabetes medications safely with intermittent fasting may help keep patients safe while we learn more about the use of these strategies to help combat obesity and diabetes."

Efficacy and Safety of Use of the Fasting Algorithm for Singaporeans With Type 2 Diabetes (FAST) During Ramadan: A Prospective, Multicenter, Randomized Controlled Trial
Joyce Yu-Chia Lee, PharmD, FCCP, BCPS, BCACP, et al
University of California, Irvine, Susan & Henry Samueli College of Health Sciences, Department of Clinical Pharmacy Practice, Irvine, California

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Implications of the FAST Protocol Beyond Spirituality
Jonathan G. Gabison, MD
University of Michigan, Department of Family Medicine, Ann Arbor, Michigan

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Comparing the Safety and Efficacy of Two Types of Blood Thinners in a Primary Care Setting

Adults taking blood thinners, such as an anticoagulant Vitamin K antagonist medication like warfarin, were shown to have a lower incidence of overall bleeding events compared to those taking direct oral anticoagulants. However, the study also showed two times higher incidence of death in the VKA group. Researchers tracked 1,882 adult primary care patients treated with either VKA or DOAC in their usual primary care. Their doctors recorded incidences of significant bleeding events, blood clots and death over the course of one year. Researchers then compared health outcomes for the two drug groups using a matched propensity score model. The two groups had similar rates of serious adverse events, like blood clots and major bleeding, however the VKA group had a lower incidence of minor and non-major clinically significant bleeding. The two times higher incidence of death among patients taking VKAs aligns with prior analysis from health insurance data. The authors call for further research to explain the excess mortality with VKA.

Anticoagulants' Safety and Effectiveness in General Practice: A Nationwide Prospective Cohort Study
Paul Frappe?, MD, PhD, et al
Jean Monnet University, Medicine Jacques Lisfranc, Department of General Practice, Saint-Etienne, France

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Anticholinergic Burden is Associated With Adverse Outcomes in a Middle-Aged Population

Many common prescription medications for urinary problems and muscle spasms, as well over- the-counter medications for cold, cough and allergies, share an anticholinergic property. The use of multiple medications in this class can lead to negative cumulative effects referred to as anticholinergic burden. ACB is known to increase the risk for future adverse events like falls, dementia, heart attack, stroke, and death. Guidelines recommend against using anticholinergic medications for geriatric patients, but little is known about their effect on middle-aged patients.

A variety of assessment scales are available for doctors and researchers to calculate a patient's risk of ACB. A study of more than 500,000 middle-aged adults, aged 37 to 73 years in the United Kingdom, compared 10 of those scales to assess their accuracy in predicting risk for future adverse events. Researchers found that all 10 ACB scales identified individuals at higher risk for heart attack, stroke and death, after adjusting for sociodemographic and baseline health factors. Each scale also had significant predictive accuracy for falls and dementia.

While the study showed consistent association between ACB and adverse outcomes, regardless of which scale was used, the populations identified as being at risk varied considerably depending on which scale was used. Less than one in four people detected to be at risk by one scale were also detected by the other three most frequently used scales. This variation across scales has implications for clinical practice and research interventions to target ACB.

Assessing Risks of Polypharmacy Involving Medications With Anticholinergic Properties
Frances S. Mair, MD, et al
University of Glasgow, Institute of Health and Wellbeing, Department of General Practice and Primary Care, Glasgow, Scotland, United Kingdom

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http://www.annfammed.org/site/misc/TEMPORARY_LINK_EXPIRES_MARCH_9_2020/148.pdf

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Optimizing Opioid Prescribing After Cesarean Delivery: A Study of Pre- and Post-Discharge Use

Women who take less opioid pain medication in the 24-hour period before being discharged from the hospital after a cesarean delivery also use less opioid medication during the four weeks following discharge. Thus, quantifying the amount of opioids taken during the last day of hospitalization may help better inform prescribing practices for the continuation of pain medication during recovery. While doctors prescribe opioids to most C-section patients, the total milligram morphine equivalents they prescribe vary widely. While persistent opioid use after C-section is rare, overprescribing creates a pool of uncontrolled opioids in the community, which poses a potential risk for non-medical use.

A team of researchers at the University of Colorado who conducted a prospective cohort study of 203 C-section patients found that those reporting low opioid intake after discharge took on average 44% less opioids in the 24-hours prior to discharge compared with those reporting higher usage. Researchers also learned that most of the patients in the study did not properly dispose of leftover opioids. The researchers recommend further study to evaluate strategies for reducing overprescribing pain medications following C-section surgery.

Predicting Opioid Use Following Discharge After Cesarean Delivery
Karsten Bartels, MD, PhD, et al
University of Colorado, Anschutz Medical Campus, Department of Anesthesiology, Aurora, Colorado

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More Family Medicine Residencies Must Train Their Residents to Treat Substance Use Disorder Among Pregnant Women

Early-career family physicians who both provide maternity care and prescribe buprenorphine--a medication used to treat opioid use disorder--primarily completed their training in a small number of residency programs. Using data from the 2016, 2017 and 2018 National Family Medicine Graduate Survey, administered annually by the American Board of Family Medicine, the research team behind this study asked clinicians who graduated from family medicine residency programs within the past three years whether "maternity care" or "buprenorphine treatment" were part of their practice and whether they were currently delivering babies. Of the 5,103 respondents in their sample, 153 both deliver babies and prescribe buprenorphine. A further 108 respondents provide maternity care and prescribe buprenorphine but do not perform deliveries. The researchers note that it is not clear whether the surveyed physicians are necessarily providing pregnancy care and prescribing buprenorphine to the same patients.

Of 614 total family medicine residencies represented in the survey, only 15 of them, mostly in urban areas on the East and West Coasts, trained 25% of the respondents who provide this care. As data about the risks of maternal mortality from substance use disorder emerges, it will be important to increase training opportunities in family medicine residencies to meet the needs of pregnant women with substance use disorder.

Maternity Care and Buprenorphine Prescribing in New Family Physicians
Josh St. Louis, MD, MPH, et al
Greater Lawrence Family Health Center, Lawrence, Massachusetts

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Caring for Rohingya Refugees Amidst an Outbreak: A Doctor's Story

A Doctors Without Borders/Médecins Sans Frontières field doctor reveals the personal toll it takes to establish medical services during a humanitarian health crisis. In 2017, Rohingya refugees fleeing Myanmar arrived in Bangladesh, where Ramin Asgary, MD, an MSF medical advisor and professor of global health, was helping to establish medical services. The refugee camps were ravaged by a dual outbreak of measles and diphtheria--two diseases that, under less complex circumstances, were easily preventable with inexpensive vaccines. In his essay, Asgary invites readers to join him on his medical rounds as he treats patients in makeshift medical tents. Intimately, he reveals the thought process of a humanitarian physician responding to an environment of perpetual desperation.

Caring for Rohingya Refugees With Diphtheria and Measles: On the Ethics of Humanity
Ramin Asgary, MD
Weill Cornell Medicine, New York, New York; George Washington University, Milken Institute School of Public Health, Washington, D.C.; Médecins Sans Frontières/Doctors Without Borders, Paris, France

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What I Wish My Doctor Really Knew: The Voices of Patients With Obesity

"Obese--what a cruel word," opens an essay written by a coalition of patients involved in a weight reduction medical trial. The essay channels the collective voice of a group of patients who were organized to advise the study. The authors share the doubt, dread and anxiety they experience at doctors appointments--fearing judgement, prejudice and insensitivity--and in conversations with doctors around weight management and their health. They identify key limitations in how obesity is addressed in primary care visits and describe the components of more effective treatment plans. Finally, the patient advisory panel describes the competencies they would like to see from medical professionals: "If we had to summarize what we want providers to know...it is this: we want you to know how to look at us, to see each of us as a person."

What I Wish My Doctor Really Knew: The Voices of Patients With Obesity
Christie Befort, PhD, et al
University of Kansas Medical Center, Department of Population Health, Kansas City, Kansas

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Medical Professionals and Community Members Work Together to Improve Well-Being Close to Home

A landscape looks much different from a mountaintop or even a treetop than it does from a canoe on the river. Like those on higher ground, medical researchers and clinicians see a broader picture filled with statistics and analyses, while community members, like the person fishing, see the up-close details of everyday life. Both perspectives offer essential information for a more comprehensive view.

In 2016, Dr. Tana Fishman, a family physician from New Zealand, joined with Ms. Rose Lamont, a Samoan teacher, to become the first non-North American patient-clinician dyad to participate in North American Primary Care Research Group's Patient and Clinician Engagement Program. The PaCE workshop's emphasis on co-design, which values the role of community engagement in health care research, inspired them to adopt a Samoan research framework to address questions aimed at decreasing health disparities among Pacific people in South Auckland. Rose recruited members of the Pacific Island community to form the Pacific People's Health Advisory Group, while Tana worked with health care professionals to create a Pacific practice-based research network. In partnership with researchers at the University of Auckland, they are working to identify and address key health issues affecting their community.

View From the Canoe: Co-Designing Research Pacific Style
Felicity Goodyear-Smith, MB, ChB, MD, FRNZCGP, et al
University of Auckland, Department of General Practice and
Primary Health Care, Auckland, New Zealand

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An Online Tool to Aid in the Advance Care Planning Process Shows Promise

A team of Canadian researchers tested an online program that guides patients through the process of advance care planning in a "real-world" setting with two groups: adult cancer patients and older adults. The program PREPARE was developed by clinicians at the University of California San Francisco and the Veterans Affairs Medical Center, San Francisco, to increase engagement in advance care planning. One hundred thirty-six participants from across multiple outpatient clinic sites in Canada completed the self-paced program and a before-and-after survey. Researchers found they were better equipped to handle advance care planning after completing the online program, with improvements in their knowledge, decision making, confidence and readiness for the planning process. Additionally, participants took modest action to begin advance care planning. Researchers conclude that the results "suggest that self-directed tools could support advance care planning initiatives in outpatient health care settings and among the public."

Effect of an Interactive Website to Engage Patients in Advance Care Planning in Outpatient Settings
Michelle Howard, PhD, et al
McMaster University, Department of Family Medicine, Hamilton, Ontario, Canada

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Prognosis and Survival of Older Dizzy Patients in Primary Care: A 10-Year Prospective Cohort Study

Older patients evaluated by a physician for dizziness were classified into three subtypes: presyncope, vertigo or disequilibrium. They were further classified by causes of dizziness, with cardiovascular disease and peripheral vestibular disease being the most common causes. Those classified in the vertigo subtype had significantly lower mortality rates than the other subtypes after 10 years. Patients with dizziness caused by peripheral vestibular disease had a lower mortality rate than that of patients with cardiovascular disease. The study included 417 adults from 2006 to 2008. During the 10-year follow-up, 169 of the patients (40.5%) died. Many of the patients still alive at follow-up reported experiencing substantial dizziness-related impairment (47.7%). There was no significant difference in substantial impairment between different subtypes or primary causes of dizziness.

Prognosis and Survival of Older Patients With Dizziness in Primary Care: A 10-Year Prospective Cohort Study
Vincent A. van Vugt, MD, et al
Amsterdam University Medical Center UMC, Department of General Practice and Elderly Care Medicine, Amsterdam, The Netherlands

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Study Outlines Significant Differences Between Self-Identified General Practitioners and Board-Certified Family Practitioners

Physicians who identify as "general practitioners" are a group distinct from board-certified "family physicians," according to a new study that was supported, in part, by the American Board of Family Medicine Foundation. Family medicine researchers from the University of Washington, University of Wisconsin, University of Kentucky and the American Board of Family Medicine analyzed national data on physicians in direct patient care, linking records from the American Medical Association to American Board of Family Medicine board certification status, as well as to Centers for Medicare and Medicaid Services and US Department of Health and Human Services data. In their analysis of all 102,604 MD and DO physicians in the United States, the authors of this study describe the personal, professional and practice characteristics of self-identified general practitioners as compared with American Board of Family Medicine certified family physicians.

GPs are more likely to be older (average age 64.6 years for GPs compared with 49.4 for FPs), male (77% of GPs vs. 58% of FPs), DOs (28% vs. 10%), and graduates of non-US medical schools (41% vs. 23%). Few GPs have family medicine residency training (9%); less than half have any residency training directly relevant to primary care (48%). GPs and board-certified FPs practice in similar geographic locations, but GPs are less likely to participate in Medicare (53% vs. 76%) or work in hospitals (13% vs. 22%). GPs are slightly more likely to provide nursing home services (13% vs. 11%) and to make home visits (3% vs. 1%). The authors recommend that GPs and FPs be considered separate groups for research, workforce and policy purposes.

The American Board of Family Medicine is among the Annals of Family Medicine's seven sponsoring organizations.

General Practitioners in US Medical Practice Compared With Family Physicians
William R. Phillips, MD, MPH, et al
University of Washington, Department of Family Medicine, Seattle, Washington

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Tracing How Operational Failures Affect the Work of Primary Care Physicians

In this literature review, researchers synthesized information about operational failures in primary care and found that such failures led to differences between "work as imagined" and "work as done." As a result, physicians compensated for suboptimal systems by undertaking additional work. Operational failures were defined as system-level errors in the supply of information, equipment and materials to health care personnel. This study synthesized results from 95 papers that aligned with the author's general definition of "operational failures," although none of the papers expressly used that term. From this, a gap was shown between what physicians perceived they should be doing and what they were doing because of operational failures. The most common failures were related to information technology and focused on the failures of the electronic medical record. These failures were tied into the extra work required to deliver the goals of care.

Impacts of Operational Failures on Primary Care Physicians' Work: A Critical Interpretive Synthesis of the Literature
Carol Sinnott, MB, BAO, BCh, MMedSci, PhD, MICGP, MRCPI, et al
University of Cambridge, UK Imperial College, The Healthcare Improvement Studies Institute, Cambridge, United Kingdom

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Innovations in Primary Care

Innovations in Primary Care are brief 1-page articles that describe novel innovations from health care's front lines. In this issue:

  • Reinventing the Medical Assistant Staffing Model at No Cost in a Large Medical Group - Citing burnout and negativity caused by increasing non-medical burden, declining staff ratios and rotating staff in large medical groups, primary care physicians are matched with one medical assistant to help reduce burdens and increase effectiveness and job satisfaction.

  • Body Surface Examination Facilitated by Digital Microscopy - By using a digital microscopy camera to examine small areas of a patient's skin, doctors can spot--and share with their patients during consultation--otherwise imperceptible clinical details that may lead to more definitive diagnoses.

  • Connecting General Practitioners Through a Peer-Facilitated Community of Practice for Chronic Disease Care - Structured, peer-led, "community of practice" meetings were organized to bring together general practitioners from a culturally diverse region of Australia in an effort to combat professional isolation and to generate local relationship-building and continuing professional development around shared interests.

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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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