September/October 2015 Annals of Family Medicine tip sheet

Cost of Sustaining a Patient-Centered Medical Home More than $100,000 per Full Time Physician Annually

With primary care practices in the United States aggressively shifting to the patient-centered medical home model of care, researchers examine the costs to deliver PCMH functions and find even partial implementation costs approximately $105,000 per full time equivalent provider annually. Using a PCMH cost dimensions tool, researchers assessed costs associated with activities uniquely required to maintain PCMH functions at a diverse group of 20 primary care practices in Colorado and Utah. They found PCMH costs per physician FTE were $7,691 in Utah and $9,658 in Colorado, and PCMH incremental costs per encounter were $32.71 and $36.68, respectively. Further analysis showed the average estimated costs per member per month for an assumed panel of 2,000 patients were $3.85 in Utah and $4.83 in Colorado. The authors point out that previous research has demonstrated a significantly reduced total cost of health care resulting from investment in PCMH services - savings that could off-set the costs incurred by practices. The authors assert that payment reform is essential for primary care practices to sustain medical home services. Maintenance and ongoing support of PCMH functions, the authors write, require additional time and new skills, which may be provided by existing staff, additional staff or both. They conclude that adequate compensation for ongoing and substantial incremental costs is critical for practices to sustain PCMH functions.

The Cost of Sustaining a Patient-Centered Medical Home: Experience from 2 States
By Michael K. Magill, MD, et al
University of Utah, Salt Lake City

Family Physician HIV Experience Associated With HIV Patients' Receipt of Antiretroviral Therapy

In a three-year study of HIV-positive patients in Ontario, researchers report that family doctors who take care of more HIV-positive patients in the context of their regular practice are more likely to adhere to antiretroviral therapy protocols than those who care for fewer. Analyzing data on 13,417 HIV-positive patients, researchers found the majority (53 percent) saw family physicians exclusively for their care. Among these patients, those who saw a family physician with the highest level of HIV experience were almost twice as likely to receive ART as counterparts seeing less experienced family physicians. Specifically, the researchers found receipt of antiretroviral therapy was significantly lower among those receiving care from family physicians with five or fewer and six-49 HIV patients compared with those with 50 or more HIV patients, with a mean ART adherence (95 percent CI) of 0.34 (0.30-0.39) and 0.40 (0.34-0.45), respectively, versus 0.77 (0.74-0.80). Sixteen percent of the patients studied received care exclusively from family physicians with lower HIV experience, suggesting potential disparities in ART among these patients. The authors note that cancer screening and health service use were not influenced by family physician HIV experience. They also note that the influence of family physician HIV experience appears to be mitigated by having an HIV specialist within the model of care. Given these findings, the authors conclude that in order to ensure adequate ART prescribing, care delivery models for people with HIV should include either an HIV specialist or a family physician with considerable HIV experience.

A Population-Based Study Evaluating Family Physicians' HIV Experience and Care of People Living with HIV in Ontario
By Claire E. Kendall, MD, MSc, et al
University of Ottawa, Ontario, Canada

Hastening Death by Voluntary Stopping of Eating and Drinking

A cluster of three articles in this issue address the sometimes controversial practice of patients deliberately hastening death by voluntarily stopping eating and drinking.

First, in a report from the Netherlands, researchers examine physicians' involvement with VSED to better understand the characteristics and motives of their VSED patients and describe the process in terms of duration and prevalent symptoms in the last days of life. The survey of 285 family physicians revealed VSED is not uncommon in Dutch primary care and seems to be a relatively comfortable way to hasten death if sufficient palliative care is available. Specifically, the researchers found almost one-half (46 percent) of respondents had cared for a patient who hastened death by VSED, and they found that patients' motives to do so were both physical and psychosocial. Patients who decided to use VSED were mostly older than 80 years (70 percent), in poor health (76 percent had severe disease), and were dependent on others for everyday care (88 percent). Data showed the median time until death was seven days, and the most common symptoms before death were pain, fatigue, cognitive decline and thirst or dry throat. Most patients electing VSED involved others for support (86 percent); family physicians were involved in 62 percent of cases. The authors conclude that family physicians can play an important role in caring for VSED patients and their proxies by providing them with information on VSED, support and symptom management.

In a pair of point-counterpoint editorials, two authors explore the ethical quandaries and practice issues in end of life care. Lynn A. Jansen, RN, PhD, at the Center for Ethics in Health Care in Portland, Oregon, asserts that if one has reservations about physician-assisted death, then one ought to have reservations about VSED as well. She writes that advocates of PAD often present VSED as an alternative treatment option for end of life suffering that avoids moral controversy. In reality, she argues, because VSED is understood as a clinical practice or treatment option presented by physicians, it raises challenging moral questions about the permissibility of physician collaboration in patient decisions to end their life as a means to ending their suffering.

Timothy E. Quill, MD, at the University of Rochester Medical Center in New York, asserts that VSED can be an important option for some suffering patients who wish and early death, but he concurs it is similar to PAD in many ways and should be subject to guidelines similar to those that cover PAD, including 1) clear understanding of the disease and prognosis, 2) careful evaluation of the patient's unacceptable suffering 3) full access to modern palliative measures, 4) ensuring the patient's full decision-making capacity, and 5) an independent second opinion by a palliative care expert. He concludes both PAD and VSED should be available as a last resort, but cautions the meaning attached to VSED can vary considerably from a welcomed, patient-controlled escape to an absurd end that adds to suffering as much or more than alleviating it because of the time it takes.

Primary Care Patients Hastening Death by Voluntarily Stopping Eating and Drinking
By Eva E. Bolt, MD
VA University Medical Center, Amsterdam, The Netherlands

Voluntary Stopping of Eating and Drinking (VSED), Physician-Assisted Death (PAD), or Neither in the Last Stage of Life? PAS: No; VSED: It Depends
By Lynn A. Jansen, RN, PhD
Center for Ethics in Health Care, Portland, Oregon

Voluntary Stopping of Eating and Drinking (VSED), Physician-Assisted Death (PAD), or Neither in the Last Stage of Life? Both Should be Available as a Last Resort
By Timothy E. Quill, MD
University of Rochester Medical Center, New York

Systematic Review: Cancer Risk Assessment Tools Increase Patients' Screening Intentions but not Screening Behavior

A systematic review of cancer risk assessment tools used in primary care finds that although the tools may increase patients' risk perception, knowledge and screening intentions, they do not necessarily change screening behavior. The analysis, which included 11 trials of seven risk tools found that overall, uptake of a tool was greater if a discussion was initiated by patients, if used by a dedicated clinician, and when combined with decision support. The researchers found no increase in cancer worry, and they found that health promotion messages within the tool actually demonstrated positive effects on behavior change. The authors conclude that these findings suggest that while risk tools may increase actual intentions to have cancer screenings, additional interventions at the clinician or health system level may be needed to increase risk-appropriate cancer screening behavior.

Cancer Risk Assessment Tools in Primary Care: A Systematic Review of Randomized Controlled Trials
By Jennifer Walker, MPH, PhD, et al
University of Melbourne, Australia

Nearly One in Three Adults in Indian State of Odisha Have Multiple Chronic Conditions

Examining the prevalence of multimorbidity in primary care in Odisha, India, researchers find almost 30 percent of patients suffer from multiple physical and mental health problems, a finding that is consistent with prevalence studies around the world. Specifically, analysis of self-reported data on 22 chronic conditions from 1,649 adult primary care patients revealed 28 percent of patients had two or more chronic conditions, with the prevalence ranging from 6 percent in patients aged 18 to 29 years to 44 percent in patients 70 and older. Patients who were female, of older age, of higher socioeconomic status and had higher education had higher odds of having multimorbidities. Additionally, researchers found consultation in private versus public hospitals and the addition of more chronic conditions were associated with a significant increase in the number of medicines prescribed. Interestingly, the authors point out that India's higher prevalence of multimorbidity and hospitalizations among those with higher socioeconomic status contrasts with findings in Western countries where lower socioeconomic status is associated with greater morbidity burden. They speculate this negative SES gradient of multimorbidity could be attributed to contrasting socioeconomic patterns of risk factors for noncommunicable diseases in India, as well as lower health care seeking behavior and higher probability of underdiagnosis among low-income populations. Based on these findings, the authors call for redesigned national health programs that shift the focus from single diseases to managing the complexity of multimorbidity.

Prevalence, Correlates, and Outcomes of Multimorbidity Among Patients Attending Primary Care in Odisha, India
By Sanghamitra Pati, MBBS, MD, MPH, et al
Indian Institute of Public Health-Bhubaneswar, Public Health Foundation of India

Medication, Not Error, Is the Leading Threat to Older Patients' Safety According to New Zealand Injury Compensation Claims

Analysis of no-fault claims data from New Zealand reveals that the greatest threat to older patients' safety in primary care is the risk posed by treatment itself, not error. Examination of four years of primary care treatment injury claims data showed that antibiotics were the biggest threat to safety and thus a key target for injury prevention initiatives. Claims data confirmed that most medication injuries were allergic and idiosyncratic reactions, for which there was no suggestion of error (91 percent of medication injuries and 34 percent of all injuries). The author concludes that to improve patients' safety, we need to look beyond reducing error to reducing patients' exposure to treatment risk where appropriate - in particular the risk posed by medication, especially antibiotics.

Learning From No-Fault Treatment Injury Claims to Improve the Safety of Older Patients
By Katharine Ann Wallis, MBChB, PhD
University of Auckland, New Zealand

Specialist Heart Failure Nurses Key to Ensuring Quality of Care for Heart Failure Patients in the United Kingdom

Recognizing that management of patients with heart failure is uniquely challenging, researchers in the United Kingdom explored the perceptions and experiences of health care clinicians working in multidisciplinary teams that include specialist heart failure nurses whose role as caseworkers has evolved in recent years. These experienced senior nurses, the authors explain, become involved with patients at the initial diagnosis of heart failure and continue for the course of the patients' illness, offering medical, psychological and emotional support. The 24 clinicians interviewed identified two areas that represent particular challenges when working with heart failure patients: 1) communication with patients, in particular, explaining the diagnosis and helping patients understand the condition, and 2) communication within the care team to coordinate multidisciplinary involvement in managing patients' treatment regimens. All of the interviewed clinicians regarded specialist heart failure nurses as the lead clinicians for their patients, helping to ensure coordination, continuity and quality of care. The nurses were perceived as being able to bridge the gap between primary and secondary care by ensuring recommendations from specialist physicians were acted upon and by taking the lead in medication issues so that prescribing decisions reflected input from secondary care providers. The authors conclude these findings highlight the critical role of specialist heart failure nurses in delivering tailored education to patients and facilitating better liaison among all clinicians to ensure better quality of care. The way in which they are able to serve as caseworkers, they researchers write, is vital in ensuring coordination and continuity of care for heart failure patients.

Managing Patients With Heart Failure: A Qualitative Study of Multidisciplinary Teams With Specialist Heart Failure Nurses
By Margaret Glogowska, PhD, et al
University of Oxford, United Kingdom

How Physicians Conceptualize Patient Complexity - More Than the Number of Health Conditions or Medications

Recognizing that algorithms that focus on numbers of conditions, medications or both may not align with clinicians' definitions of patient complexity, researchers in Colorado interviewed physicians to better understand how they conceptualize patient complexity in hopes that the insights gained could inform new models. In-depth interviews with 15 primary care physicians from two university clinics and three community health centers revealed a multidimensional concept of patient complexity. The interviewed physicians perceived patients to be complex if they had an exacerbating factor - a medical illness, mental illness, socioeconomic challenge or behavior or trait (or some combination thereof) - that complicated care for chronic medical illnesses. Most of the physicians interviewed broadly defined complex patients as those who did not easily fit into guidelines or algorithms. The authors write that the insights offered by physicians in this study integrate well into two recently proposed conceptual models: 1) the Agency for Healthcare Research and Quality's Multiple Chronic Conditions Research Network Model that defines complexity as the gap between patient needs and the services available to them, incorporating economic, social and physical factors as "contextual factors" influencing patient needs, the services available or both, and 2) a model based on comorbidity interrelatedness developed by Zulman et al, which emphasizes the characteristics of medical conditions such as symptom intensity and comorbidity interrelatedness. The authors assert the perspectives offered by physicians in this study can help refine these existing models of complexity and better inform the organization of care for complex patients.

Primary Care Physician Insights Into a Typology of the Complex Patient in Primary Care
By Danielle F. Loeb, MD, et al
University of Colorado, Aurora

Large-Scale Implementation of the Collaborative Care Model for Depression in Minnesota Fails to Improve Response and Remission Rates Compared with Usual Care

With data from previous clinical trials of the collaborative care model for depression showing improved patient outcomes, researchers evaluated a large-scale effort to implement the model throughout Minnesota but found it was unsuccessful in producing positive outcomes when put into clinical practice. Testing whether the Depression Improvement Across Minnesota--Offering a New Direction statewide initiative, which provided 75 primary care practices with payment change, intensive training and support, would improve patient-reported depression outcomes, researchers found while the intervention improved patient satisfaction, it had little impact on other outcomes. Despite enrolled patients reporting receiving more desired care processes, patients receiving DIAMOND care had neither better depression outcomes nor better improvement in work productivity or health status. Specifically, they found that patients who received DIAMOND care reported more collaborative care depression services than three other comparison groups (10.9 vs. 6.4-6.7, on a scale of 0 to 14, where higher numbers indicated more collaborative care) and more satisfaction with their care (4.0 vs. 3.4 on a sale of 1 to 5, where higher scores indicate higher satisfaction). Depression remission rates, however, were not significantly different among the four groups (36 percent for those who receive DIAMOND care vs. 34-36 percent for the other comparison groups). The authors conclude these findings illustrate the difficulties of widespread implementation of evidence-based practices that require major changes in roles and extensive financial and leadership support.

A Stepped-Wedge Evaluation of an Initiative to Spread the Collaborative Care Model for Depression in Primary Care
By Leif I. Solberg, MD, et al
HealthPartners Institute for Education and Research, Minneapolis, Minnesota

Computerized Simulation Model Enables Exploration of the Effects of Primary Care Beyond Disease-Specific Care

The discrepancy that exists between apparently poor disease-specific care and advantageous outcomes at the level of the whole person and system has been called the paradox of primary care. To explore and test the mechanisms that might account for this paradox and try and explain the effects of primary care beyond disease-specific care, researchers developed a novel computer simulation model, which is available for others to use and adapt, with the input of a community sample of 15 patients, caregivers and primary care clinicians. In an eight-session iterative process, the group worked with researchers to operationalize in a simple but explicit way some of the key features of primary care. They then used the resulting computer model to test hypotheses about how different primary care mechanisms can combine to add value beyond disease treatment and how these mechanisms can affect the health of different types of people. Using the model, the paradox persisted: where there was complexity and adequate primary care, patients did better, yet patients with single health problems did better in specialty care. Specifically, in a model run with the primary care features turned off, the group found primary care patients had poorer health. In a model run with all primary care features turned on, primary care patients who sought primary care had better population health, with a particularly pronounced effect for patients who were disadvantaged and had multiple chronic conditions. The authors assert the model allows users to develop and test hypotheses that would be difficult or impossible to test in the real world. They encourage readers to download the model, software and worksheet from the online appendices and undertake their own experiments by developing their own hypotheses, varying model parameters, running the model. Insights gleaned from these efforts, they conclude, can be used not only to develop more sophisticated models, but to guide empirical research and advance a more nuanced understanding of the value of primary care and the possible complex interactive mechanisms by which that value emerges over time.

A Participatory Model of the Paradox of Primary Care
By Kurt C. Stange, MD, PhD, et al
Case Western Reserve University, Cleveland, Ohio

Strategies for Addressing Challenges in the Changing Environment of Practice-Based Research

Research participants in Pediatric Research in Office Settings, the practice-based research network of the American Academy of Pediatrics, describe several practical strategies they used to overcome methodologic barriers in conducting a national intervention trial. They describe several key challenges they faced in the changing environment of practice-based research, including 1) identifying and recruiting practices, 2) enrolling and screening participants and 3) achieving an acceptable phone interview response rate. The authors assert that the strategies they used to address these challenges can assist research networks in conducting future outcomes research and practical clinical trials in primary care settings.

Overcoming Challenges in the Changing Environment of Practice-Based Research
By Jonathan P. Winickoff, MD, MPH, et al
Massachusetts General Hospital, Boston

Physician Reflects on the Fundamental Humanity at the Core of his Work

A young physician reflects on the opportunity to care for an accident victim one-on-one at the scene, rather than in the hospital, and how it reminded him of the remarkable thing it is to be a physician and to know how to heal the sick. Given the badly broken industry of medicine, he asserts, it is easy for physicians to lose sight of the reasons they went into medicine.

I'm a Doctor. Can I Help?
By Jonathan Emerson Kohler, MD, MA
University of Wisconsin, Madison

Annals Publishes Special Supplement on Peer Support*

In late August, Annals of Family Medicine published a special Peers for Progress supplement featuring 11 articles addressing the efficacy, feasibility, reach, implementation, sustainability and adoption of peer support for patients with diabetes and other health challenges.

With substantial evidence documenting the benefits of peer support provided by community health workers, lay health advisors, promotores de salud and others, this new body of research offers additional evaluations of peer support interventions and addresses a number of issues in extending its reach and benefit. Topics covered in the supplement include examination of the peers who provide peers support, reaching the hardly reached, success factors in peers support interventions, proactive approaches, attention to emotions, peer support in behavioral health, dissemination models and their application in China, peer support in the patient-centered medical home, research challenges and policy implications. The supplement contributors conclude that beyond showing that peer support works, emerging research demonstrates it is both broadly feasible and sustainable. Perhaps most importantly, they assert, it shows strong potential for addressing key priorities in "bending the curve" through health care reform by reaching those whom conventional services too often fail to engage, mitigating and reducing costs associated with concurrent physical and psychological problems, and providing intervention models adaptable to diverse settings and populations.

The research included in the supplement was made possible by Peers for Progress, a program of the American Academy of Family Physicians Foundation dedicated to promoting peer support in health, health care and prevention around the world, with support from the Eli Lilly and Company Foundation and the Bristol Myers Squibb and Company Foundation.

• Contributions of Peer Support to Health, Health Care, and Prevention: Papers from Peers for Progress by Edwin B. Fisher, et al
• Puentes hacia una mejor vida (Bridges to a Better Life): Outcome of a Diabetes Control Peer Support Intervention by Guadalupe X. Ayala, et al
• Peer Coaches to Improve Diabetes Outcomes in Rural Alabama: A Cluster Randomized Trial by Monika M. Safford, MD, et al
• Peer-Led, Empowerment-Based Approach to Self-Management Efforts in Diabetes by (PLEASED): A Randomized Controlled Trial in an African American Community by Tricia S. Tang, PhD, et al
• Are Low-Income Peer Health Coaches Able to Master and Utilize Evidence-Based Health Coaching? by Matthew L. Goldman, MD, MS, et al
• Effects of Providing Peer Support on Diabetes Management in People With Type 2 Diabetes by Juliana C. N. Chan, MD, et al
• Peer Support for Diabetes Management in Primary Care and Community Settings in Anhui Province, China by Xuefeng Zhong, MD, MPH, PhD, et al
• What Peer Mentoring Adds to Already Good Patient Care: Implementing the Carpeta Roja Peer Mentoring Program in a Well-Resourced Health Care System By Lyndee Knox, PhD et al
• Challenges of Prolonged Follow-up and Temporal Imbalance in Pragmatic Trials: Analysis of the ENCOURAGE Trial by Joshua S. Richman, PhD, MD, et al
• Enriching Patient-Centered Medical Homes Through Peer Support by Timothy P. Daaleman, DO, MPH, et al
• Challenges in the Ethical Review of Peer Support Interventions by David Simmons, MD, et al

*Please note, the Peers for Progress supplement content posted August 24, 2015 and is not under embargo.

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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.

Annals of Family Medicine continues to be rated among the most influential journals in general and internal medicine. According to the recently released Thomson Reuters' 2015 Journal Citation Report, the journal's impact factor of 5.434, which measures the average number of citations to recent articles published in the journal, places it number one out of 19 journals in the primary healthcare category and number 16 among 153 journals in the larger category of general and internal medicine. Moreover, Annals' immediacy index rating, which measures the number of times an article is cited in the year it is published, places it at number seven of 153 in the general and internal medicine category. We are proud of these extremely high rankings, which suggest that Annals continues to address timely topics and is publishing articles that are highly relevant to the discipline and to a broad research community.