News From The Annals Of Family Medicine, May/June
A meta-analysis of previous research into an unintended effect of acid suppression medications - some of the most widely used medications in the world - finds evidence that long-term use of proton pump inhibitors, but not H2-receptor antagonists, is associated with increased risk of fracture. The meta-analysis of 11 studies finds that PPIs are associated with a 29 percent increase of fracture, including 31 percent increased risk of hip fracture and a 54 percent increased risk of vertebral fractures. Long-term H2RA use, by contrast, was not significantly associated with fracture risk. With acid-suppressive drugs representing the second leading medication worldwide, these findings are of great importance to public health. The authors conclude clinicians should carefully consider their decision to prescribe PPIs for patients, especially those who already have an elevated risk of fracture because of age or other factors.
An accompanying editorial puts the study findings into context. The editorialists conclude the study findings reinforce the need for balancing risks and benefits of any therapy physicians prescribe. Because long-term PPI exposure may lead to other unwanted effects, they should be reserved for patients likely to benefit from them and should be prescribed at the lowest effective maintenance dose.
Use of Acid-Suppressive Drugs and Risk of Fracture: A Meta-Analysis of Observational Studies
By Chun-Sick Eom, M.D., M.P.H., et al
Seoul National University Hospital, Republic of Korea
Balancing the Risks and Benefits of Proton Pump Inhibitors
By James M. Gill, M.D., M.P.H., et al
Delaware Valley Outcomes Research, Wilmington
CME Saves Lives, Study Finds Decreased Mortality in Heart Disease Patients
In one of the few studies to evaluate the impact of physician continuing medical education on patient outcomes, researchers in Sweden found that patients of physicians who participated in case-based training promoting evidence-based care for coronary heart disease had a 10-year mortality rate - half that of patients whose physicians who didn't take the training. In addition to a standard lecture and mailing of new evidence-based treatment guidelines received by physicians in the study region, the 26 physicians in the intervention group participated in several small-group seminars, facilitated by a well-known cardiologist, which encouraged the discussion of cases and active problem solving. After 10 years, 22 percent of the 45 patients in the intervention group had died as compared with 44 percent of the 43 patients in the control group, a difference mainly attributed to reduced cardiovascular mortality. The 22 percent mortality rate in the intervention group was comparable to the rate of 23 percent seen in patients treated by a comparison group of cardiology and internal medicine specialists. In light of these very compelling findings, the authors call for case-based training to be tested in other areas of clinical practice.
In an accompanying editorial, David Davis, M.D., C.C.F.P., with the Association of American Medical Colleges, asserts these convincing findings make it clear that CME has an important and necessary role to play in health care delivery. He calls on the medical community to broaden its definition of CME to include nontraditional approaches that are anchored in the new health system in order to translate new knowledge and clinical findings into practice and ultimately to improved patient outcomes.
Case-Based Training of Evidence-Based Clinical Practice in Primary Care and Decreased Mortality in Patients with Coronary Heart Disease
By Anna Kiessling, M.D., Ph.D., et al
Karolinska Institutet, Stockholm, Sweden
Can CME Save Lives? The Results of a Swedish, Evidence-Based Continuing Education Intervention
By Dave Davis, M.D., C.C.F.P.
Association of American Medical Colleges, Washington, D.C.
Large Majority of Family Physicians Participating In Voluntary Maintenance of Certification
The great majority of family physicians in the United States have current board certification and are actively engaged in the voluntary Maintenance of Certification process instituted by the American Board of Family Medicine in 2003 as a means to improve quality of care and continually assess clinical performance. Even so, this analysis into the geographic, demographic and practice characteristics associated with variations in MOC participation also reveals that family physicians practicing in poorer and underserved areas are more likely to have lapsed board certification and to have missed initial MOC certification requirements. Researchers found that 85 percent of the 70,323 family physicians studied had current board certification, and 91 percent of all active board-certified family physicians eligible for MOC were participating in MOC. Physicians who worked in poorer neighborhoods (OR=1.105), were U.S.-born (OR=1.444) or foreign-born international medical graduates (OR=1.4441), or were solo practitioners (OR=1.460) were more likely to have missed initial MOC requirements. Moreover, they found that family physicians over the age of 55 were almost twice as likely as their younger colleagues to have allowed their certification to lapse and were less likely to participate in MOC. The authors conclude that the widespread penetrance of MOC means it is a viable mechanism for the dissemination of information and has the potential to make a meaningful, national impact on health care quality. The authors note that as more studies link quality of medical care to board certification, it is troubling that physicians who have not maintained certification tend to be practicing in underserved areas or caring for underserved populations. High levels of health care disparities and the need for high-quality care in those areas, they assert, make it even more pressing to understand the barriers to participation in MOC by these physicians.
In an accompanying editorial, American Board of Pediatrics' Senior Vice President for Quality and Maintenance of Certification, Paul V. Miles, M.D., points out there are few other examples of voluntary programs that require investments of physician time and money that can match the documented levels of MOC compliance. At a time when there is widespread interest in how to change physician practice, MOC appears to be a strong potential driver for change, he asserts. He notes, however, that there is considerable room for improvement and calls for medical boards to identify and test focused interventions to improve participation, particularly among older physicians as well as those in solo practice and in underserved areas. Moreover, he calls for future research to determine whether physician participation in MOC is improving patient outcomes and closing gaps in quality of care.
Family Physician Participation in Maintenance of Certification
By Imam M. Xierali, Ph.D., et al
The Robert Graham Center for Policy Studies in Family Medicine and Primary Care, Washington, D.C.
Maintenance of Certification: The Profession's Response to Physician Quality
By Paul V. Miles, M.D.
American Board of Pediatrics, Chapel Hill, North Carolina
Cortisone Injections Offer Early Pain Relief for Hip Bursitis
For patients suffering from bursitis of the hip, or greater trochanteric pain syndrome, corticosteroid injections offer better short-term pain relief than pain medicines. Evaluating the effect of corticosteroid injections compared with usual care consisting of analgesics as needed in 120 patients with symptoms of GTPS, researchers found 34 percent of patients in the usual care group had recovered compared with 55 percent in the injection group at the 3-month follow up. At three months, pain severity at rest and on activity decreased in both groups, but the decrease was greater in the injection group, for an adjusted difference in pain at rest of 1.18 and in pain with activity of 1.30. At the 12-month follow-up visit, the differences in outcomes were no longer present. Although local corticosteroid injections are frequently given for GTPS, this study is the first to document the additional value of injection therapy, providing physicians with a more evidence-based rationale for offering it to patients.
Corticosteroid Injections for Greater Trochanteric Pain Syndrome: A Randomized Controlled Trial in Primary Care
By Aaltien Brinks, M.D., et al
Erasmus Medical Center, Rotterdam, The Netherlands
Black Patients More Likely Than Whites to Receive Recommended Opioid Risk Reduction Strategies
Compared with white patients, black patients are significantly more likely to receive recommended opioid risk reduction strategies designed to minimize misuse of prescription pain medications, despite the fact that previous studies have found whites are more likely than blacks to misuse these drugs. Analyzing health records for 1,612 patients prescribed opioid analgesics for chronic non-cancer pain, researchers found black patients were more likely than white patients to receive urine drug testing (10 percent vs. 4 percent), regular office visits (56 percent vs. 39 percent) and restricted early refills (80 percent vs. 72 percent). After adjustment for patient and health care factors, the odds of urine drug testing for blacks was still higher, but no longer significantly so, while the odds of regular office visits and restricted refills remained significantly higher in black patients. The authors point out the use of risk reduction strategies was very limited overall, raising concern that physicians are inappropriately lax in monitoring patients, especially white patients, taking opioids long term. The racial differences, they point out, contradict evidence that the risk of prescription drug abuse is greater in whites than in other racial/ethnic groups. They conclude that the poor performance of long-term opioid treatment monitoring supports widespread calls for improved quality of care to promote safe prescribing of these potentially dangerous medications.
Racial Differences in Primary Care Opioid Risk Reduction Strategies
By William C. Becker, M.D., et al
Yale University School of Medicine, New Haven, Connecticut
Substantial Treatment Burden Borne by Heart Disease Patients
An examination of the experiences of 47 patients living with heart failure reveals a wide range and substantial burden of "work" - or treatment burden - these patients need to undertake to manage their disease. Using the Normalization Process Theory framework, the authors identify numerous components of treatment burden that are separate and distinct from illness burden, including the work of developing an understanding of treatments, interacting with others to organize care, attending appointments, taking medications, enacting lifestyle measures, and appraising treatments. Patients also reported several factors that increased this burden, including too many medications and appointments, barriers to accessing services, fragmented and poorly organized care, lack of continuity and inadequate communication between health professionals. The authors conclude these findings lay the foundation for a new target for treatment and quality improvement efforts toward patient-centered care. The findings, they say, also suggest that NPT is a useful framework for understanding patients' experiences of illness and health care services, and their active contributions to their overall care and self-care.
Understanding Patients' Experiences of Treatment Burden in Chronic Heart Failure Using Normalization Process Theory
By Katie Gallacher, M.B.Ch.B., B.Sc., et al
University of Glasgow, Scotland
Preventing Life-Sustaining Treatment by Default
Researchers propose an ethically justified strategy to prevent life-sustaining treatment by default, in which seriously ill patients receive life-sustaining treatment because they either did not make decisions or did not, orally or in writing, clearly communicate their end-of-life decisions effectively to others. Informed by qualitative focus group research, the authors' strategy emphasizes supporting and encouraging patients to make clearly expressed decisions based on their values and goals, and to communicate these decisions to their surrogates or physicians.
Preventing Life-Sustaining Treatment by Default
By Ursula K. Braun, M.D., M.P.H. and Laurence B. McCullough
Baylor College of Medicine, Texas
Building Strong Patient-Physician Relationships with Women Who Use Illicit Drugs
Exploring 10 family physicians' experiences building patient-physician relationships with women who use illicit drugs, researchers identify a two-phase process of relationship development. The authors describe an initial engagement phase that attempts to build relationships from a tenuous starting point of patients' difficult past experiences. This phase, they conclude, requires trust and presence. When successful, the engagement phase leads to a maintenance phase, which requires continuity and finding common ground, or "meeting people where they're at." Improving physicians' ability to engage these women in a patient-physician relationship has implications for improving their overall health. Strong patient-physician relationships, the authors assert, are especially important for marginalized women, such as those who use illicit drugs.
'Meeting People Where They're At': Experiences of Family Physicians Engaging Women Who Use Illicit Drugs
By Susan Woolhouse, M.D., M.C.I.Sc., et al
South Riverdale Community Health Centre, Ontario
Looking Beyond the Standard Algorithms of Care to Find Healing
Relating the story of one of his patients and his inability to control her chronic problems using the standard algorithms of care, a family physician shows that the cause of illness can sometimes be found outside the usual biomedical framework of explanation, and healing can be fostered in ways that transcend clinical guidelines and algorithms.
Nasruddin and the Coin
By Peter de Schweinitz, M.D., et al
Family and Preventive Medicine, Salt Lake City, Utah
American Academy of Family Physicians