News from Annals of Family Medicine: May/June 2014
Despite Benefits, Many Patients at High Risk for Cardiovascular Events Not on Statins
Many people at high risk for cardiovascular events, including those with coronary artery disease, diabetes or both, are not receiving statins despite evidence that these agents reduce adverse events. Following the 2013 release of guidelines by the American College of Cardiology and the American Heart Association that substantially broadened the number of individuals for whom statins are recommended, researchers analyzed nationally representative data and found an estimated 9 million people with diabetes aged older than 40 years and 5.6 million people with coronary artery disease - populations that have clearly been shown to benefit from the drugs - are not on statins. Specifically, analysis of data from the 2010 Medical Expenditure Panel Survey found that overall, 58 percent of individuals with coronary artery disease and 52 percent of individuals with diabetes aged older than 40 years are statin users. Further analysis revealed that those with high cholesterol but without diabetes or heart disease are more likely to be on statins than those without high cholesterol but who have diabetes or heart disease. Given that individuals with heart disease or diabetes are at considerably higher cardiovascular risk, the authors assert this pattern strongly supports the notion that statin use is being driven by high cholesterol instead of by overall cardiovascular risk, a concerning finding. The authors cite previous research showing that these patient populations benefit from statin use regardless of cholesterol levels - patients with coronary artery disease have an approximate 16 percent reduction in overall mortality, while those aged older than 40 years with diabetes have a more than 30 percent reduction in cardiovascular disease outcomes and likely a reduced risk of death. The authors conclude that the recently released ACC-AHA guidelines offer an opportunity to reframe statins as medications that reduce cardiovascular risk rather than as medications that lower cholesterol.
Cardiovascular Risk and Statin Use in the United States
By Michael Edward Johansen, MD, MS, et al
The Ohio State University, Columbus
Researchers Explore Why Many Patients with Coronary Artery Disease Discontinue Medications
Despite compelling evidence supporting cardiovascular medications in the secondary prevention of coronary artery disease, many patients discontinue treatment. A systematic review of 17 studies involving 391 patients teases out the extent to which clinicians, patient self-perceptions and disease understanding influence patients' decisions to either continue or stop taking their medications. Analyses suggest that some patients hold fatalistic beliefs about their disease, whereas others feel they have been cured by interventional procedures, both leading to a failure to take medication. In contrast, the researchers found that patients who adapt to being a "heart patient" are positive about medication taking. Notably, they found that relationships with prescribing clinicians are of critical importance to patients, with inaccessibility and insensitive terminology negatively affecting patients' perceptions about treatments. By adopting a more open approach, clinicians can engage patients in a discourse about what they think about their medications. Moreover, they assert that providing medication-specific information when initiating therapy, improving the transition between secondary and primary care, and explaining the risk of disease recurrence may all help to modify patient attitudes toward drugs to prevent further cardiovascular disease. The authors conclude that strategies to promote higher persistence of secondary prevention medications in patients with coronary artery disease need to recognize the key role of the prescribing clinician.
Medication Taking in Coronary Artery Disease: A Systematic Review and Qualitative Synthesis
By Mohammed A. Rashid, MSc, et al
University of Cambridge, United Kingdom
Defining the Future Role of the Family Physician in the United States
Recognizing that clarification of the family physician's role is critical to the discipline's future success and possibly even to its future existence amid the strong shifts happening in health care, representatives from seven family medicine organizations propose a statement defining the role to which family physicians aspire. "Family physicians are personal doctors for people of all ages and health conditions. They are a reliable first contact for health concerns and directly address most health care needs. Through enduring partnerships, family physicians help patients prevent, understand and manage illness, navigate the health system and set health goals. Family physicians and their staff adapt their care to the unique needs of their patients and communities. They use data to monitor and manage their patient population, and use the best science to prioritize services most likely to benefit health. They are ideal leaders of health care systems and partners for public health." In addition to the accepted definition, they offer a "foil" definition of what family medicine could become absent any change. The authors conclude that embracing a new definition and, perhaps more importantly, rejecting the foil, are important steps as family medicine negotiates with government, payers, health systems, patients and communities and works to build the future of the specialty.
The Future Role of the Family Physician in the United States: A Rigorous Exercise in Definition
By Robert L. Phillips, Jr., MD, MSPH, et al
The American Board of Family Medicine, Lexington, Ky.
Tailored Intervention to Improve Colorectal Cancer Screening Rates No More Effective Than Nontailored Control
An interactive multimedia computer program tailored to patient sociopsychological factors associated with colorectal cancer screening was no more effective than a nontailored informational program in improving colorectal cancer screening rates despite its salutary effects on sociopsychological factors and visit behaviors predictive of screening. Although the tailored interactive multimedia program improved colorectal cancer screening knowledge, self-efficacy, readiness, test preference specificity, discussion and recommendation in a multiethnic sample of 1,164 patients, researchers found 132 (23 percent) intervention patients and 123 (22 percent) control patients received screening in the subsequent year, a statistically insignificant difference. The authors point out that many of the factors that were enhanced by the tailored screening have previously been shown to be associated with screening. The authors conclude the greater simplicity and lower cost of the nontailored control compared with the IMCP intervention, coupled with its similar behavior effects, suggests that wider use of one-time computer-delivered sociopsychological tailoring may not be cost-effective.
Sociopsychological Tailoring to Address Colorectal Cancer Screening Disparities: A Randomized Controlled Trial
By Anthony Jerant, MD, et al
University of California - Davis School of Medicine, Sacramento, Calif.
Researchers Explore How to Bring Context Into Research Efforts to Improve the Health of The Growing Number of People With Multiple Chronic Conditions
Despite the growing prevalence and cost of multiple chronic health conditions - more than one in four Americans lives with the burden of more than one ongoing health condition, and more than 90 percent of the Medicare spending on older adults is devoted to persons suffering from multiple chronic conditions - much of current health care and research approaches are focused on single diseases. In light of this mismatch, researchers explore how to bring context into research efforts to improve the health of persons living with multiple chronic conditions. They synthesize insights from 45 experts, including people with multiple chronic conditions, family and friend caregivers, researchers, policy makers and funders and elucidate an approach for moving from the well-establish reductionist thinking that asks, "What is the matter?" to a research community that values context and asks, "What matters?" They conclude that in order to generate the new knowledge needed to improve the health of persons with multiple chronic conditions, a paradigm shift that focuses consistent attention on contextual factors is necessary. Efforts must consider complementary perspectives across multiple levels, including public policy, community, health care systems, family and person as well as the cellular and molecular levels where most research is currently focused. This shift also will require new partnerships between researchers, clinicians, patients, caregivers, policy makers and other stakeholders, as well as dynamic research methods that are participatory, flexible, multilevel, longitudinal and mixed-method.
Understanding the Context of Health for Persons With Multiple Chronic Conditions: Moving From What is the Matter to What Matters
By Kurt C. Stange, MD, PhD, et al
Case Western Reserve University, Cleveland, Ohio
Report Details Outcomes of National Policy Meeting to Improve Applicability of Guidelines for Patients with Multiple Chronic Conditions
A special report summarizes recent policy work by the U.S. Department of Health and Human Services and the Institute of Medicine addressing the challenges of guidelines for people with multiple chronic conditions. The authors detail the outcomes of a meeting convened in May 2012, which identified principles and action items for government, guideline developers and others to use in strengthening the applicability of clinical practice guidelines to the growing population of people with multiple chronic conditions. The participants identified 11 principles to improve guidelines' attentiveness to patients with comorbidities. These principles are grouped into three interrelated categories based on their aims: 1) principles intended to improve the stakeholder technical process for developing guidelines; 2) those intended to strengthen the content of guidelines in terms of multiple chronic conditions; and 3) those intended to increase focus on patient-centered care. The authors hope these suggested actions will amplify the use of previous recommendations and catalyze new efforts to improve guidelines' attentiveness to the population with multiple chronic conditions.
IOM and DHHS Meeting on Making Clinical Practice Guidelines Appropriate for Patients with Multiple Chronic Conditions
By Richard A. Goodman, MD, MPH, et al
U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Atlanta
Practice Facilitation Most Effective Intervention for Improving Primary Care Practices' Adherence to Asthma Guidelines
Practice facilitation appears to be better than education, practical tools and performance feedback alone in helping primary care practices implement asthma guidelines. In a cluster-randomized trial across 43 practices involving 1,016 patients, researchers sought to tease out the individual and conjoint effects of practice facilitation and learning collaboratives added to performance feedback and academic detailing on practices' success in implementing the National Heart, Lung and Blood Institute's Asthma Guidelines. In unadjusted analyses, researchers found the intensity of the intervention appeared to correlate with effectiveness. Initial examination showed that practices in the control group significantly improved adherence to two of the six recommendations, whereas practices in the practice facilitation group improved in three, practices in the learning collaborative group improved in four, and practices in the practice facilitation plus learning collaborative group improved in five. After controlling for covariates, however, researchers found that only practice facilitation proved more effective than the control for two of the guideline recommendations - assessments of asthma severity and level of control. For these outcomes, practice facilitation was even more effective than practice facilitation plus learning collaborative, which was statistically no better than the control condition. These findings may help efforts to improve guideline implementation in primary care practices.
Implementing Asthma Guidelines Using Practice Facilitation and Local Learning Collaboratives: A Randomized Controlled Trial
By James W. Mold, MD, MPH, et al
University of Oklahoma Health Sciences Center, Oklahoma City
The Future of Clinical Practice Guidelines - Are They Worthwhile?
In new a point/counterpoint feature, two researchers examine the question of whether clinical guidelines still make sense. Considering the four articles in the current issue of Annals that examine various aspects of clinical guidelines, Harold C. Sox, MD, and Ross E.G. Upshur provide insights into how and when guidelines may be relevant to improving patient care and outcomes. While Sox contends that practice guidelines have a bright future, Upshur is skeptical, questioning whether clinical practice guidelines have achieved any meaningful goals in advancing health care.
Do Clinical Guidelines Still Make Sense? Yes.
Harold C. Sox, MD
The Dartmouth Institute for Health Policy and Clinical Practice, New Hampshire
Do Clinical Guidelines Still Make Sense? No.
Ross E.G. Upshur, MD
University of Toronto, Ontario
Brief Family History Screening Tool Accurately Identifies Primary Care Patients at Increased Disease Risk
Researchers in Australia validate a family history screening questionnaire that identifies patients at increased risk for seven common, potentially preventable serious conditions, including breast, ovarian, colorectal, and prostate cancer; melanoma, ischemic heart disease and type 2 diabetes. They tested the nine-question instrument with 526 patients at six primary care practices in Australia and found the combination of questions had sensitivity of 92 percent and 96 percent for the five and six conditions applicable only to men and women, respectively. The specificity was 63 percent for men and 49 percent for women. The positive predictive values were 67 percent and 68 percent, and the false-positive rates were 9 percent for both men and women. With the instrument showing good performance for identifying primary care patients at increased disease risk because of family history, the authors call for future research to understand the feasibility of implementing the screening into routine practice.
Development and Validation of a Family History Screening Questionnaire in Australian Primary Care
By Jon D. Emery, MA, MBBCh, MRCGP, FRACGP, DPhil, et al
University of Melbourne and Western Health, Australia
Researchers Explore the Appropriate Application of Shared Decision Making and Motivational Interviewing
In order to provide patient-centered care, clinicians must recognize that different clinical situations require different communications approaches, and they must be skilled enough to determine which method is most appropriate, and where necessary, integrate methods. Researchers explore two specific approaches - shared decision making and motivational interviewing - and provide guidance for identifying the appropriate application of these patient-centered methods across a range of clinical problems. They write that shared decision making, in which the clinicians' role is to help patients understand what the reasonable options are, then elicit, inform and integrate patients' informed preferences as they relate to the available options, is effective in situations when patients face tough treatment decisions. Motivational interviewing, by contrast, is most often applied in situations that usually require some degree of behavior change about which a patient feels ambivalent such as lifestyle choices or adherence to medications. Using motivational interviewing, clinicians typically help patients identify and resolve ambivalence by exploring their personal perspectives as well as perceived barriers. The authors suggest that although these methods have traditionally been applicable in distinct and non-overlapping situations, practitioners may benefit from drawing on both approaches to maintain a patient-centered orientation in real-world clinical situations when behavior change and choosing between competing options are relevant. For example, they suggest the complementary processes can be integrated in providing counsel for long-term conditions like diabetes as well as for behavioral changes, such as weight loss. They acknowledge the considerable challenge of implementing these approaches into routine practice but conclude that unless they are valued as core elements of good practice, we will see little progress in patient-centered care. They call for these methods to be taught, assessed, integrated into practice, and then appropriately measured and rewarded.
Shared Decision Making and Motivational Interviewing: Achieving Patient-Centered Care Across the Spectrum of Health Care Problems
By Glyn Elwyn, PhD, et al
The Dartmouth Center for Health Care Delivery Science, New Hampshire
Reflection: How One Family Physician Continues to Derive Sustenance From a Patient Experience in His Early Years of Practice
A family physician reflects on how he continues to draw meaning from having cared for a dying woman and her family over several home visits in his earliest years of private practice. He describes how his memories of these house calls continue to reinforce his love for medicine. At a time when physicians are overburdened with countless numbers of interruptions, requirements and measures, he reminds readers that one of the things that can sustain physicians' passion for medicine is realizing that caring for others is the focus of their sacred vocation.
I Remember...It Was December
By Richard Colgan, MD
University of Maryland, Baltimore