News From The Annals Of Family Medicine: March/April 2013
False-positive results are a common unintended harmful effect of breast cancer screening mammography - the cumulative risk in Europe and the United States of false positives in 10 screening rounds ranges from 20 to 60 percent - and they have long-term psychosocial consequences. In a longitudinal cohort study of 1,310 women, 454 of whom had abnormal findings on screening mammography, researchers found even three years after being declared free of suspected cancer, women who had a false-positive result consistently reported greater negative psychosocial consequences compared with women with normal test findings. Specifically, they found six months after final diagnosis, women with false-positive findings reported changes in existential values and inner calmness as great as those reported by women with a true diagnosis of breast cancer (∆=1.15; P=.0145 and ∆=0.13; P=.4232, respectively). Three years after being declared free of cancer, women with false-positive results reported more negative psychosocial consequences compared with women who had normal findings in all 12 psychosocial outcomes (∆>0 for 12 of 12 outcomes; P<.01 for of outcomes the pattern psychosocial was consistent at time screening and one six months after final diagnosis: women with breast cancer experienced more negative consequences than false-positive findings these normal findings. that false positives reported changes just as great in existential values inner calmness first half-year diagnosis indicates significant psychological harm caused by diagnoses. long-term mammography>
By John Brodersen, PhD and Volkert Dirk Siersma, PhD
University of Copenhagen, Denmark
Researchers Propose Annual Blood Pressure Screening Instead of Checking at Every Visit
Checking blood pressure annually instead of at every outpatient office visit may improve the screening test's ability to correctly identify those without hypertension (specificity) without sacrificing its ability to identify those with hypertension (sensitivity). Comparing the usual screening practice of checking blood pressure at every visit with a second strategy that used only annual blood pressure measurements in a group of 440 adults over a five year study period, researchers found the reduced frequency of screening produced a significant decrease in the false-positive rate from 30 percent to 18 percent of nonhypertensive patients. They found no statistically significant difference in sensitivity between the two methods. In their analysis, the authors point out that when applied to the roughly 2,000 healthy adults cared for by a typical family physician, the annual screening strategy results in 232 fewer patients needing further workup over five years. They conclude that in addition to improving the false-positive rate, reducing the number of unnecessary blood pressure screenings in healthy adults provides other benefits, including increasing clinic efficiency, reducing clerical burdens, and allowing sufficient clinical staff time to more accurately measure blood pressures. Screening For Hypertension Annually Compared With Current Practice
By Gregory M. Garrison, MD, MS and Sara Oberhelman, MD
Mayo Clinic, Rochester, Minn.
Largest Study of Osteopathic Manual Treatment Shows Regimen Offers Short-Term Relief of Chronic Low Back Pain But Ultrasound Therapy Does Not
With low back pain responsible for more than 20 million office visits and $100 billion dollars in health care costs annually in the United States, researchers examine the efficacy of osteopathic manual treatment and ultrasound therapy in the largest such trial ever conducted. The randomized controlled trial involving 455 patients with chronic low back pain found OMT offered effective short-term pain relief; by contrast, ultrasound therapy was not effective in relieving patients' chronic low back pain. Randomizing patients to receive OMT (n=230), sham OMT (n=225), UST (n=233) or sham UST (n=222) for six treatment sessions over eight weeks, the researchers found 145 (63 percent) OMT patients vs. 103 (46 percent) sham OMT patients reported moderate improvement at week 12. Similarly, 114 (50 percent) OMT patients vs. 79 (35 percent) sham OMT patients reported substantial improvement. By contrast, moderate improvement was observed in 128 (55 percent) UST patients vs. 120 (54 percent) sham UST patients. Substantial improvement was observed in 103 (44 percent) UST patients vs. 90 (41 percent) sham UST patients. The OMT treatment effects met or exceeded the Cochrane Back Review Group criterion for a medium size effect for both moderate and substantial improvements in low back pain, making the findings clinically relevant. The authors add that the less frequent use of drugs for low back pain reported by OMT patients further corroborates the clinical relevance of the findings. They assert these results may begin to explain why one-third of ambulatory, chronic problem visits for low back pain in the United States are provided by osteopathic physicians and why they less frequently prescribe medications, such as nonsteroidal anti-inflammatory drugs, than allopathic physicians during such visits. Because the OMT regimen was found to be effective, safe, parsimonious and well accepted by patients, the authors call for a larger trial to assess the efficacy and cost-effectiveness of OMT at long-term endpoints. Osteopathic Manual Treatment and Ultrasound Therapy for Chronic Low Back Pain: A Randomized Controlled Trial
By John C. Licciardone, DO, MS, MBA, et al
The Osteopathic Research Center, University of North Texas Health Science Center, Fort Worth, Texas
Researchers Find Small Benefit from Antibiotics for Patients with Respiratory Infections
Assessing the risks and benefits of antibiotic use in a large cohort of patients consulting their physicians for respiratory infections, researchers find a small reduction in subsequent hospitalization for pneumonia and no increase in severe adverse drug reactions for those prescribed antibiotics. Analyzing data on more than 1.5 million patient visits for nonspecific respiratory infections, researchers found antibiotics were prescribed in 65 percent of cases. The adjusted risk difference for treated versus untreated patients per 100,000 visits was 1.07 fewer adverse events and 8.16 fewer pneumonia hospitalizations within 15 days following the visit. The number needed to treat was 12,255 patients to prevent one hospitalization. The authors conclude this small benefit from antibiotics for a common ambulatory diagnosis creates a persistent tension; at the societal level, physicians are compelled to reduce antibiotic prescribing, thus minimizing future resistance, whereas at the encounter level, they are compelled to optimize the benefit-risk balance for that patient. Risks and Benefits Associated With Antibiotic Use for Acute Respiratory Infections: A Cohort Study
By Sharon B. Meropol, MD, PhD, et al
Case Western Reserve University School of Medicine, Rainbow Babies and Children's Hospital, Cleveland, Ohio
Redesigned Diabetes Care Using a Care Management Team Improves Glycemic Control Among Rural African-American Patients
Redesigning diabetes care to incorporate interprofessional care management results in significantly improved glycemic control among rural, low-income African-American patients, a group traditionally found to have poorer clinical outcomes. Analyzing data on 727 diabetic patients at three rural primary care practices, researchers found patients in the intervention group who received point-of-care education, coaching and medication intensification from a care management team comprised of a nurse, pharmacist and dietician had significantly greater reduction in mean hemoglobin A1c levels than those receiving usual care at the 18-month (-0.5 percent vs. -0.2 percent) and 36-month follow-ups (-0.5 percent vs. -0.1 percent). Moreover, a significantly greater percentage of patients in the intervention practices achieved a hemoglobin A1c value near 7 percent at the final assessments (68 percent vs. 59 percent), and the proportion achieving a systolic blood pressure of less than 140 mm Hg was also substantially greater in the intervention group (69 percent vs. 57 percent). The authors conclude their findings suggest that a portion of chronic diabetes management can be accomplished with an interprofessional team operating as a patient-centered medical home, potentially making physicians and extenders more available for acute problems. Using an interprofessional team, they add, may help to address the primary care provider shortage in rural areas.
Improved Outcomes in Diabetes Care for Rural African Americans
By Paul Bray, MA, LMFT, et al
Vidant Health, Greenville, N.C.
Peer Health Coaches Improve Diabetes Control in Low-Income Patients Clinic-based peer health coaching improves the glycemic control of patients with poorly controlled diabetes seen in urban public health clinics. A randomized controlled trial involving almost 300 low-income patients with poorly controlled type 2 diabetes found patients who receive one-on-one coaching and self-management support from volunteer peer coaches (trained patient volunteers who themselves have diabetes) saw a greater reduction in HbA1c levels than those in the usual care arm at 6 months follow-up (1.07 percent reduction vs. 0.3 percent reduction - a 0.77 percent difference in favor of coaching). HbA1c levels decreased 1 percent or more in 50 percent of coached patients versus 32 percent of usual care patients, and levels at six months were less than 7.5 percent for 22 percent of coached versus 15 percent of usual care patients. The authors note that because peer coaches experience similar challenges of living with the same chronic condition as the patients they assist, they are uniquely poised to engage and motivate them in self-management. Peer coaches, they conclude, represent a potential resource to increase primary care capacity and remove some of the burdens of patient-self-management support from primary care clinicians and staff. Impact of Peer Health Coaching on Glycemic Control in Low-Income Patients With Diabetes: A Randomized Controlled Trial
By David H. Thom, MD, PhD, et al
University of California, San Francisco
Telenephrology Improves Care for Patients With Chronic Kidney Disease
A Web-based consultation system between family physicians and nephrologists has the potential to reduce the number of referrals and appears to improve treatment appropriateness among patients with chronic kidney disease. Analyzing 122 telenephrology consultations involving 116 patients, researchers found that in the absence of telenephrology, 43 patients (35 percent) would have been referred by their family physicians, whereas the nephrologist considered referral necessary in only 17 patients (14 percent) - an 84 percent reduction. The opposite was seen in 10 patients, who according to clinicians could be treated in primary care but for whom the nephrologist deemed referral necessary. The researchers note the time investment per consultation, most of which were performed during office hours, amounted to less than 10 minutes, and nephrologists' average response time was 1.6 days. The authors assert these findings support the introduction of telenephrology in primary care as a means of delivering higher quality, more convenient care at a lower cost. They conclude that on a broader scale, e-consultation has the potential to break down walls between primary and specialty care.
Initial Implementation of a Web-Based Consultation Process for Patients With Chronic Kidney Disease
By Nynke Scherpbier-de Haan, MD, et al
Radboud University Nijmegen Medical Centre, The Netherlands
Numerous Barriers to Prescribing of IUDs and Implantable Contraception to Adolescents
Despite their safety and efficacy, only 3 percent of adolescents who use contraceptives have an IUD, and far fewer use implantable contraception. Through in-depth interviews with 28 New York City-based family physicians, pediatricians and obstetrician-gynecologists, researchers identify multiple factors affecting their likelihood of prescribing long-acting reversible contraception to adolescents, and they find numerous barriers, including financial concerns, the clinical environment, and physicians' knowledge, attitudes and beliefs. In short, the authors found physicians rarely counsel about implantable contraception because of knowledge gaps (capability) and limited access to the devices (opportunity). Notably, many physicians, in particular pediatricians, did not know that girls who have not previously given birth can be appropriate candidates for IUDs and consequently never counsel about this option. The authors found specific enablers to counseling included the availability of the device in the clinic, a "culture" within the clinic supportive of adolescent contraception provision, and the ability to insert IUDs or easy access to someone able to insert the device. Factors enabling motivation included a belief in the positive consequences of IUD use, which was particularly influenced by physicians' perception of adolescents' risk of pregnancy and sexually transmitted disease. Asserting that a concrete step to addressing the persistent public health issue of adolescent pregnancy is optimizing access to reliable, forgettable forms of reversible contraception, the researchers call for future research to explore strategies to increase adolescents' LARC access in primary care.
New York City Physicians' Views of Providing Long-Acting Reversible Contraception to Adolescents
By Susan E. Rubin, MD, MPH, et al
Albert Einstein College of Medicine, Bronx, New York
To Speed Health Reform, Policy Leaders Must Fund the Primary Care Extension Program Authorized by the Affordable Care Act
Researchers explain how critical the Primary Care Extension Program, which was authorized but not funded by the 2010 Affordable Care Act, is to enhancing primary care effectiveness, to the integration of primary care and public health and to translating research into practice. They contend that much like the Cooperative Extension Program of the U.S. Department of Agriculture sped the modernization of farming a century ago, the PCEP could speed the transformation of primary care through local deployment of community-based Health Extension Agents. The authors call for $120 million in annual federal funding for the PCEP, with a target of $500 million for future appropriations. They conclude that the rapid pace of change in health care demands that a PCEP be viewed as an essential, not optional, ingredient for transformation of primary care and improvement of population health.
The Primary Care Extension Program: A Catalyst For Change
By Robert L. Phillips Jr., MD, MSPH, et al
The American Board of Family Medicine, Washington, D.C.
Enhanced Communication Skills Training Associated with Reduced Antibiotic Prescribing for Respiratory Tract Infections
Assessing the long-term effects of family physicians' use of C-reactive protein point-of-care testing, a widely used and acknowledged means of diagnosing and monitoring infections, and their training in enhanced communication skills, on office visit rates and antibiotic prescribing for patients with respiratory tract infections, researchers found mixed results. While neither intervention had an effect on the rate of office visits for respiratory tract infection episodes during the subsequent 3.5 years, patients managed by a physician trained in enhanced communication skills were less likely to be prescribed antibiotics for episodes of respiratory tract infection for which they consulted during the 3.5 year follow-up. Specifically, family physicians trained in communication skills treated 26 percent of all episodes of respiratory tract infection with antibiotics compared with 39 percent treated by family physicians without training in communication skills. The cluster-randomized controlled trial included 379 patients at 20 family practices in the Netherlands. The authors call for implementation of both interventions on a larger scale, noting that training physicians on the use of enhanced communication skills may have a wider longer-term effect on the treatment of respiratory tract infections beyond acute cough to include reduced antibiotic prescribing.
Enhanced Communication Skills and C-reactive Protein Point-of-Care Testing in the Management of Respiratory Tract Infection: 3.5-year Follow-up of a Cluster Randomized Controlled Trial
By Jochen W. L. Cals, MD, PhD, et al
Maastricht University, The Netherlands
Improving the Peer-Review Process in Medical Publishing
Researchers propose streamlining the review process for rejected manuscripts by including the initial reviews when submitting the revised manuscript to another journal, reasoning this would expedite the decision process and decrease the burden on peer reviewers. In their analysis of the practices of 51 general medical journals surveyed online, researchers find that a quarter of journals at least occasionally receive previous peer-review reports from authors submitting manuscripts, and about one-half indicated an interest in the idea. Editors reported both pros and cons. They reasoned that including pervious reviews may reduce reviewers' workload, improve transparency, prevent duplication of efforts, and shorten the decision process; however, they expressed concerns about the introduction of bias and reluctance of authors to submit unfavorable reviews. They also expressed concerns that the practice of using previous peer reports could create lazy reviewers and editors and prohibit the manuscript from receiving an objective fresh start.
In an accompanying editorial, two associate editors of Annals of Family Medicine discuss the growing challenges of reviewers and journal editors whose essential behind-the-scenes work often goes unrecognized and unpaid, but who now serve larger and broader audiences. The choice of what to publish in medical research publishing, they assert, has higher stakes and is faster paced than ever and has economic and political effects that extend far beyond the laboratory and examination room. They acknowledge the importance of the fresh perspective reviewers bring to the marketplace of medical publishing, and they call on journals to find ways to reward them for their valuable contribution.
Should Authors Submit Previous Peer-Review Reports When Submitting Research Papers? Views of General Medical Journal Editors
By Jochen W. L. Cals, MD, PhD, et al
Maastricht University, The Netherlands
Publishing Medical Research: A Marketplace on the Commons
By John J. Frey III, MD, and William R. Phillips, MD, MPH
University of Wisconsin - Madison and University of Washington, Seattle