Index by author
The Issue in Brief
Martin C. Gulliford , and colleagues
Background While widespread unnecessary use of antibiotics can diminish their effectiveness, reducing antibiotic prescribing may increase the risk of serious bacterial infections.
What This Study Found This study quantifies the benefits of prescribing antibiotics for respiratory tract infections in terms of reduction in risk of peritonsillar abscess. Researchers used a large sample of 11,000 anonymized electronic health records in the United Kingdom from 2002 through 2017 to estimate the probability of peritonsillar abscess within 30 days of a consultation for a respiratory tract infection, and compared rates between people prescribed or not prescribed antibiotics. Overall, the risk of peritonsillar abscess was low, and in two-thirds of cases, patients did not consult their primary care physician prior to developing an abscess.
Implications
- Antibiotic prescriptions were protective against PTA across all age groups studied, although the absolute risk of PTA was very low.
- The study concludes that antibiotics may only prevent one case of peritonsillar abscess for every 1,000 antibiotic prescriptions, and authors suggest that reducing antibiotic prescribing may not have a significant impact on incidence of peritonsillar abscess, although the authors caution that lack of randomization and data standardization in the study may bias estimates.
David A. Katz , and colleagues
Background Patient engagement is a relationship-based approach that builds trust and promotes patient autonomy by actively involving and supporting patients in health care and treatment decisions-making. The Veterans Health Administration launched the Patient Aligned Care Team (PACT) Initiative in 2010, which aims to provide continuous, comprehensive, and coordinated team-based care to veterans while improving first-contact care. Previous research found that patients who are actively engaged in their own care are more likely to adhere to treatment, perform regular self-monitoring, have better intermediate health outcomes, and report better mental health and physical functioning.
What This Study Found In a cross-sectional analysis of data from the 2016 PACT national survey of direct care providers, researchers found that high performing clinics were more likely to have fully-staffed primary care teams, clearly defined roles for team members, leadership responsible for implementing team-based care, and team meetings to discuss performance improvement, compared to clinics that performed poorly with regard to use of patient engagement processes. Strategies for engaging patients in self-management include involving patients in long-term planning and goal setting, training providers in motivational interviewing, and promoting the use of shared medical appointments, group visits, peer support, and home telehealth.
Implications
- Improving organizational functioning of primary care teams, including the promotion of full staffing of primary care teams, clearly defining roles of team members, utilizing effective leadership, and practicing a culture of performance improvement, may enhance patient engagement in care.
Aaron Jones , and colleagues
Background Home nursing patients in Ontario, Canada, have an increased risk of visiting the emergency room after normal clinic hours on the same day they receive a home nursing visit. These ER visits may be linked to the visiting nurse identifying a health issue they are unable to appropriately address during the visit. This population-based, case-crossover study analyzed almost 12,000 home care patients who visited the ER after 5 p.m. to determine whether access to after-hours primary care modified the association between patients' ER visits following a home nursing visit.
What This Study Found The authors found that patients with after-hours primary care access had a smaller increased risk of an ER visit on the day a nurse came to their home compared to patients with no after-hours primary care access.
Implications
- These findings suggest increasing access to after-hours primary care could prevent some less-urgent ER visits.
Wendy V. Norman , and colleagues
Background Canada is the first country to facilitate provision of medical abortion in primary care settings through evidence-based deregulation of mifepristone, which is considered the �gold standard� for medical abortion. Despite the deregulation, Health Canada put in place certain restrictions on the drug. Researchers, hypothesizing that these restrictions would impede implementation of mifepristone in primary care, investigated the factors that influence successful initiation and ongoing provision of medical abortion services among Canadian health professionals. They also looked at how these factors relate to abortion policies, systems, and service access throughout the country.
What This Study Found Researchers identified four barriers to utilizing/prescribing the drug. Those barriers include the initial federal restrictions, which made mifepristone "more complicated than it needs to be"; navigating the "huge bureaucratic process" of organizational implementation; challenges with diffusion and dissemination of policy information; and adoption by physicians as "a process rather than an event."
Implications
- This study is relevant to other nations experiencing challenges to accessing family planning services. For example, U.S. policies restricting access to mifepristone have reached the Supreme Court after a federal district court judge temporarily suspended strict FDA regulations that require patients to visit a hospital or clinic in-person to obtain mifepristone during the COVID-19 pandemic.
Assessing the Longitudinal Impact of Physician-Patient Relationship on Functional Health
R. Henry Olaisen , and colleagues
Background Having access to primary care has ben associated with better health, improved health care quality, improved access and lower health care costs. Prior studies have not clarified how changes in the relationship between primary care doctor and patient impacts functional health outcomes over time. Authors of this article accessed information from the Medical Expenditure Panel Survey to conduct an observational study to investigate the longitudinal impact of changes in the physician-patient relationship on functional health.
What This Study Found There is an association between improved physician-patient relationships and improved patient-reported functional health status. The researchers found over a one-year period that while consistent access to a provider is important, the quality of each clinical encounter is equally as important in shaping a patient�s reported overall health outcomes, as measured by the Short Form Survey (SF-12) quality of life questionnaire.
Implications
- The study findings can potentially inform health care strategies and health policy aimed at improving patient-centered health outcomes, particularly because relationship-centered care may be especially important among adults with a disproportionate burden of chronic diseases. These patients represent a growing subpopulation in the United States.
Michael E. Johansen , and colleagues
Background Previous research has not characterized changes over time in out-of-pocket expenditures and total expenditures for primary care physician visits among different insurance types in the United States. However, research in inpatient setting has shown that total expenditures for inpatient visits are greater for private insurance than for public insurance, and this gap is expected to widen over time. This study looks at trends in out-of-pocket and total visit expenditures for visits to primary care physicians.
What This Study Found Using the 2002-2017 Medical Expenditure Panel Survey (MEPS), the authors described changes in out-of-pocket and total visit expenditures for primary care visits for Medicare, Medicaid and private insurance. Between 2002 and 2017, the proportion of primary care visits associated with private insurance or no insurance decreased, while Medicare- and Medicaid-associated visits increased. Total expenditure per visit increased for private insurance and Medicare visits. Out-of-pocket expenditures rose primarily from increases in private insurance visits with higher out-of-pocket expenditures, while Medicare and Medicaid changed minimally.
Implications
- If these current trends continue, the authors would expect increasing difficulty with primary care physician access, particularly for Medicaid patients.
Telepsychiatric Consultation as a Training and Workforce Development Strategy for Rural Primary Care
Morhaf Al Achkar , and colleagues
Background There is a shortage of rural primary care personnel with expertise in team care for patients with common mental disorders, such as depression. Traditionally, primary care clinics connect patients who have mental health care needs to specialists like psychiatrists in a collaborative care model. However, rural clinics often lack the workforce capacity to provide collaborative behavioral health services. In a new qualitative study, researchers investigated whether regular systematic case reviews through telepsychiatric consultation with collaborative care for depression functions as a continuous training and workforce development strategy in rural clinics. Three rural Washington primary care clinics adopted telehealth methods to connect remotely with specialists. Study authors interviewed 17 clinical, support and administrative staff members of those three rural primary care clinics.
What This Study Found Telepsychiatric collaboration prepared primary care physicians and rural clinic staff to deliver high quality mental health care in underserved areas. Telepsychiatric consultation also helped all members of the clinic learn to better serve the needs of mental health patients. Primary care doctors learned to work proficiently with these patients. Care managers learned to appreciate how medical issues affect mental health and how to diagnose and assess mental health issues, and consulting psychiatrists learned how to coach a primary care team, serve as educators and lead program implementation.
Implications
- The collaborative care model provides important benefits that other rural primary care clinics should consider adopting to help meet the needs of patients with mental health disorders.
Catherine Riggs , and colleagues
Background Hypothyroidism is a common endocrine disorder that affects approximately 5% of the population. Both synthetic and desiccated thyroid are used in the treatment of hypothyroidism. Although there are a few small trials reporting greater symptom and quality-of-life improvements with desiccated thyroid compared with levothyroxine, there is a lack of data comparing objective measures of hypothyroidism management between the two modalities over an extended period.
What This Study Found A study by researchers at Kaiser Permanente in Denver, Colorado evaluated the stability of thyroid stimulating hormone (TSH) in patients using synthetic medication vs those using desiccated thyroid products to treat hypothyroidism. The results showed no difference in TSH stability over a three-year period between patients taking desiccated thyroid products and those on synthetic levothyroxine.
Implications
- Desiccated thyroid is prescribed much less frequently partly due to concerns about variability among batches. than synthetic levothyroxine. This study adds to the limited body of evidence showing the stability of both levothyroxine and desiccated thyroid.
Use of Chronic Care Management Among Primary Care Clinicians
Ashok Reddy , and colleagues
Background To address the problem of care fragmentation for Medicare recipients with multiple chronic conditions, Medicare introduced Chronic Care Management (CCM) in 2015 to reimburse clinicians for care management and coordination.
What This Study Found The authors of this study analyzed publicly available Medicare data on all CCM claims submitted nationwide from 2015 through 2018. They compared CCM code usage and paid and denied services across a broad range of medical specialties. The study showed that CCM use increased over this four-year period, driven largely by primary care physicians. Most claims were billed to the original general CCM code, with newer codes for more complex services accounting for a small portion of overall code usage. The percentage of denied services remained consistent at around 5 percent during this period. The authors note that a limited number of clinicians currently deliver CCM services and that future work evaluating facilitators and barriers to patients' and providers' usage of CCM will be needed.
Implications
- That 5% of chronic care management was denied by Medicare underscores the need for future work evaluating facilitators and barriers to use. Such insight is especially vital given the large number of eligible beneficiaries that have not received chronic care management to date, as well as the limited number of clinicians who currently deliver these services.
Immigrant Health and Changes to the Public-Charge Rule: Family Physicians' Response
Cynthia Haq , and colleagues
Background As the U.S. federal government pursues immigration reform, changes to the federal public charge rule have triggered confusion and concerns among patients who are immigrants. Although federal judges temporarily blocked implementation, a decision by the U.S. Supreme Court in January 2020 allowed the proposed changes to take effect. These policy changes have resulted in many legal immigrants and their family members becoming more reluctant to apply for health insurance, food, housing and other benefits for which they are qualified.
What This Study Found Physicians from the University of California, Irvine School of Medicine summarize current knowledge on the public benefits included in the "public charge" rule and offer suggestions for family physicians to support the health of their immigrant patients and families.
Implications
- The authors conclude that "family physicians can effectively respond to patient and immigrant community concerns about these changes by providing outreach education, access to primary health care, and referrals to legal and social services."
In, But Out of Touch: Connecting With Patients During the Virtual Visit
Martina Ann Kelly , and colleagues
Background The use of touch between primary care physicians and their patients has been hindered due to COVID-19. Touch, the authors write, is central to the practice of medicine, including the physical examination that guides diagnoses and informs health care management. It is also what connects doctors and patients physically and emotionally as human beings.
What This Study Found In first-person narratives, both authors, who each practice medicine on two different continents, reflect on the meaning of touch in their respective clinical practices and how virtual care is transforming this aspect of care. They write that touch is a "silent language" that fulfills a deeper symbolic function, enabling doctors to acknowledge their patients' concerns in a tangible way. With the current COVID global pandemic, doctors� acumen now relies more on verbal histories supported by visual images, including videos or photographs. There is a sense of emotional inadequacy in sight and words, which the authors deem as lacking when treating patients.
Implications
- Though doctors have never been more connected through the use of video conferencing for medical discussion, learning and providing patient care, family physicians should also pause to consider any unintended consequences, such as loss of opportunity to build a sense of trust with patients, especially when they are at their most vulnerable.