Public Release: 

November/December 2017 Annals of Family Medicine tip sheet

American Academy of Family Physicians

Simple Diagnostic Test Helps Primary Care Physicians Rule out Pathologic Heart Murmur in Children

Although heart murmur in children is usually harmless (referred to as innocent murmur), in a small number of cases it is symptomatic of cardiac disease (referred to as pathologic murmur). A new study finds that disappearance of heart murmur while standing reliably rules out pathologic heart murmurs. Using an acoustic-based, non-electronic stethoscope, researchers at two French universities noted heart sound characteristics of 194 consecutive children referred to pediatric cardiologists for heart murmur, first with patients in the supine (flat on their back) position, and then for at least one minute in the standing position. After observational data were collected, an echocardiogram was performed to assess the presence or absence of cardiac anomalies that could explain the murmur. Eight-five percent of children (n=164) referred to a cardiologist for heart murmur did not have cardiac disease. Thirty children (15 percent) had an abnormal echocardiogram that explained the heart murmur. Of 100 children (51 percent) who had heart murmur while supine but not standing, two had an organic murmur and only one required follow up. The disappearance of heart murmur while standing, therefore, excluded a pathologic murmur with a high predictive positive value of 98 percent and a specificity of 93 percent, but with a poor sensitivity of 60 percent. In an era of highly technical medicine, physical examination should remain the first step in diagnosis, according to the authors. They conclude that the disappearance of heart murmur in children upon standing is a valuable clinical test to exclude a pathologic cardiac murmur and avoid costly referral to a cardiologist.

Auscultation While Standing: A Basic and Reliable Method to Rule Out a Pathologic

Heart Murmur in Children

Bruno Lefort, MD, et al

Children Hospital Gatien de Clocheville, Tours, France

http://www.annfammed.org/content/15/6/523.full

Text Message Reminders Increase Rates of Influenza Vaccination

Text message reminders are a low-cost effective strategy for increasing rates of influenza vaccination. A randomized controlled trial in Western Australia identified patients who were at high risk of serious influenza illness and had a mobile phone number on record in their physician's office. Among 12,354 eligible patients, half were randomly assigned to an intervention group, which received a vaccination reminder by text message, while the other half (control group) received no text message reminder. Approximately three months after the messages were sent, 12 percent (n=768) of the intervention group and 9 percent (n=548) of the control group were vaccinated during the study period. For every 29 messages sent, at a cost of $3.48 (USD), one additional high-risk patient was immunized. The greatest effect was observed for children under five years of age, whose parents were more than twice as likely to have their child vaccinated if they received a text reminder (RR: 2.43, 95 percent CI: 1.79-3.29). There was no significant effect among pregnant women or Indigenous Australians. The authors suggest that several factors could influence the effectiveness of text message reminders, including who sends the message, reliability of the contact information, content of the message, and when it is sent. In light of the substantial burden of influenza on high-risk individuals and health systems, cost-efficient mechanisms to improve vaccine uptake remain an important focus for research and practice.

Randomized Controlled Trial of Text Message Reminders for Increasing Influenza Vaccination

Annette K Regan, PhD, MPH, et al

Curtin University, Perth, Western Australia

http://www.annfammed.org/content/15/6/507.full

Discontinuity of Care Puts Older Patients at Higher Risk of Emergency Hospitalization

Older patients who experience more discontinuity of care in general practice are at higher risk of emergency hospital admissions. In a UK study of 10,000 randomly selected patients over age 65, medical records were linked with hospital episode statistics. The study used two research approaches: a prospective cohort approach to assess the general impact of continuity of care on emergency admission, and a nested case-control approach to test if seeing a different GP from usual increases the risk of emergency admission during the following 30 days. The prospective approach found a graded non-significant inverse relationship between continuity of care and risk of emergency hospitalization, though patients experiencing least continuity had a risk more than twice as high than those who had complete continuity. The retrospective approach found a graded inverse relationship between continuity of care and emergency hospitalization, with an odds ratio of 2.32 for those experiencing least continuity compared with those with most continuity. Initiatives to enhance continuity of care, the authors suggest, could potentially reduce hospital admissions.

Continuity of Primary Care and Emergency Hospital Admissions Among Older Patients in England

Peter Tammes, MA, PhD, et al

University of Bristol, Bristol, UK

http://www.annfammed.org/content/15/6/515.full

Lower Cost, Higher Quality Primary Care Practices Are Distinguished by Six Attributes

Six attributes of primary care delivery are associated with high value, according to a new study: decision support for evidence-based medicine, risk-stratified care management, careful selection of specialists, coordination of care, standing orders and protocols, and balanced physician compensation. The findings are the result of a mixed methods study of diverse primary care practices that are well positioned for the shift toward medical reimbursement based on quality and efficient resource use rather than volume. Thus, researchers sought to identify care delivery attributes associated with value as defined by payers. They analyzed commercial health insurance claims data from 2009 to 2011 for more than 40 million PPO patients and 53,000 primary care practice sites, excluding sites operated by large national health care organizations subject to population-based payment. The six statistically significant attributes relate to three themes: the need for "care traffic control" to help patients with complex conditions navigate the fragmented US health care system (risk-stratified care management, careful selection of specialists, and coordination of care), the need for tools to ease the cognitive burden of physicians and staff (decision support for evidence-based medicine and standing orders and protocols), and the importance of reimbursement based on value rather than volume (balanced compensation). According to the authors, awareness of care delivery attributes associated with high value may help physicians respond successfully to incentives from Medicare and private payers intended to lower health care spending and improve quality of care.

Exploring Attributes of High-Value Primary Care

Arnold Milstein, MD, MPH, et al

Stanford University, Stanford, CA

http://www.annfammed.org/content/15/6/529.full

General Practitioners Trained in Compression Ultrasonography Accurately Diagnose Deep Vein Thrombosis

General practitioners trained in compression ultrasonography have excellent accuracy and agreement in diagnosing symptomatic proximal deep vein thrombosis. In a study of more than 1,000 outpatients with clinically suspected deep vein thrombosis, diagnosis was performed by physician experts in vascular ultrasonography and GPs trained in the technique. Expert physicians diagnosed deep vein thrombosis in 200 patients, corresponding to an overall prevalence of 18 percent. The agreement between trained GPs and experts was excellent (95 percent CI, 0.84 to 0.88). Compression ultrasonography performed by GPs had sensitivity of 90 percent and specificity of 97 percent with diagnostic accuracy for deep vein thrombosis of 96 percent. Because sensitivity achieved by GPs appeared suboptimal, the authors call for future studies to evaluate the implementation of proper training strategies to maximize skill. More rapid diagnosis, directly obtained by GPs in primary care, could improve appropriate management of deep vein thrombosis and help address the growing need for professionals trained in compression ultrasonography.

General Practitioner-Performed Compression Ultrasonography for Diagnosis of Deep Vein Thrombosis of the Leg: A Multicenter, Prospective Cohort Study

Nicola Mumoli, MD, et al

Ospedale Civile di Livorno, Livorno, Italy

http://www.annfammed.org/content/15/6/535.full

Optimal Gout Treatment Requires Ongoing Monitoring for Urate Lowering Therapy

Managing gout as a chronic, rather than an acute, condition could help prevent recurrences. A new study of more than 8,000 medical records found a positive association between starting treatment with allopurinol, a medication that helps prevent gout by lowering production of uric acid, and recurring doctor visits for the condition. Clinicians may therefore be more likely to offer allopurinol, or patients may be more likely to accept it, after multiple acute gout attacks. Specifically, while patients eligible for allopurinol at baseline were more likely to receive it than ineligible patients, time-varying covariates indicate a change in the strength of the association with each additional unit of time; for every additional month of follow up, the hazard ratio for allopurinol initiation in men increased by 0.007 (0.004-0.01). The authors suggest that more frequent chronic disease reviews to evaluate patients' preferences and eligibility for allopurinol could reduce barriers to successfully treating gout.

Factors Influencing Allopurinol Initiation in Primary Care

Lorna E. Clarson, MBChB, MS, PhD, et al

Keele University, Keele, Staffordshire, UK

http://www.annfammed.org/content/15/6/557.full

A Physician Explores Her Own Experience with Postpartum Depression

"I thought I knew what it meant for patients to hear a diagnosis of postpartum depression," writes family physician Tara Frankhouser, DO. After the birth of her first child, however, she found that the reality of the condition was much different than she anticipated. In a qualitative study using autoethnography -- a method of self-reflection and analysis of personal and cultural experiences -- Dr. Frankhouser identifies issues that shape the experience of postpartum depression, including standards of intensive mothering, feelings of guilt, and the stigma of mental illness. She encourages physicians to let patients know that postpartum depression does not define them, that there is healing ahead, and that, as her story exemplifies, they are not alone.

An Autoethnographic Examination of Postpartum Depression

Tara Lynn Frankhouser, DO, et al

Piedmont HealthCare Family Medicine, Statesville, NC

http://www.annfammed.org/content/15/6/540.full

Reports of Shared Decision Making Increase in the United States, but Disparities Exist

Between 2002 and 2014, reports of shared decision making increased significantly among adult Americans. Analyses of data from a nationally representative survey found that the mean shared decision making composite increased from 4.4 to 5. In multivariable modeling, blacks reported more shared decision making, while Asians, those without insurance, and those in poor health reported less. When a respondent and their clinician were of the same race/ethnicity, the respondent reported improved shared decision making. The authors suggest that efforts to improve shared decision making target Americans without a same-race/ethnicity usual source of care and those with poor perceived health.

Trends in Patient-Perceived Shared Decision Making Among Adults in the United States, 2002 - 2014

David M Levine, MD MA, et al

Brigham and Women's Hospital, Boston, MA

http://www.annfammed.org/content/15/6/552.full

Most Older Adults Prefer to Participate in Medical Decisions

Although most older Americans prefer to actively participate in making health care decisions, those with four or more chronic conditions are less likely to prefer active decision making. Researchers analyzed a random sample of 2,017 older adults who, with sample weights, represented approximately 33 million Medicare beneficiaries aged 65 and older. They found that 85 percent of older Americans in a community setting preferred to actively participate in medical decision making, but approximately one in every seven older Americans preferred a passive role, leaving health care decisions to doctors (15 percent, n=4.9 million). Approximately one-quarter of older adults with four or more chronic conditions preferred a passive role, which was more than twice the odds of those that did not have multiple conditions after controlling for socio-demographic characteristics. Older adults with multiple condition clusters were relatively less likely to prefer active decision making compared to those with none or a single condition cluster. The authors encourage primary care clinicians to invite older adults with four or more conditions or multiple condition clusters to participate in decision making and to elicit goals and outcome preferences in those older adults who prefer less active participation.

Multimorbidity and Decision Making Preferences Among Older Adults

Winnie C. Chi, PhD, et al

RTI International, Washington, DC

http://www.annfammed.org/content/15/6/546.full

Family Physician Calls for a Return to Human Connection

How can medical practices create and sustain healthy cultures at a time of rapid and often stressful change? The answer, according to family physician David Loxterkamp, MD, lies in human connection. Based on the book "Tribe: On Homecoming and Belonging," by Sebastian Junger, Loxterkamp suggests that both medical professionals and their patients need to feel useful and connected. For physicians, however, a feeling of connection is increasingly hard to find, as medical practice focuses more on productivity and guidelines and less on relationships. By adopting such values as connection, egalitarianism, and loyalty, practices could strengthen their cultures in creative ways including viewing the practice (rather than teams or individuals) as the unit of care, encouraging employees to apply their ingenuity and problem-solving skills, and sharing both sacrifice and decision making. Loxterkamp calls on medical professionals to demand the kind of practice community that patients long for: one characterized by deeper connection and sense of purpose.

Caring for the Tribe: From Addiction to Zen

David Loxterkamp, MD

Seaport Community Health Center, Belfast, Maine

http://www.annfammed.org/content/15/6/578.full

Anticholinergic Cognitive Burden Scale Helps Identify Risk of Adverse Outcomes

Anticholinergic burden assessed with the Anticholinergic Cognitive Burden Scale consistently shows dose-response relationships with a variety of adverse outcomes. In a study of long-term associations between adverse clinical outcomes in older adults and three scales for anticholinergic burden (the cumulative effect of using multiple medications that block the effects of acetylcholine in the body), the ACB showed the strongest, most consistent dose-response relationships with risk of all four adverse outcomes studied: emergency department visits, all-cause hospitalizations, hospitalizations for fractures, and incident dementia. Among those 65 to 74 years old, for example, when going from an ACB score of 1 to a score of 4 or greater, individuals' adjusted odds ratio increased from 1.41 to 2.25 for emergency department visits; from 1.32 to 1.92 for all-cause hospitalizations; from 1.10 to 1.71 for fracture-specific hospitalizations; and from 3.13 to 10.01 for incident dementia. Because medications with anticholinergic properties comprise 30 to 50 percent of all medications commonly prescribed to older adults, the authors suggest that the ACB may be a useful tool to identify high-risk populations for future research.

Comparative Associations Between Measures of Anticholinergic Burden and Adverse Clinical Outcomes

Fei-Yuan Hsiao, PhD, et al

National Taiwan University, Taipei, Taiwan

http://www.annfammed.org/content/15/6/561.full

New Framework for Multimorbidity Care Identifies Changes and Gaps

Researchers have developed a new framework for reporting and designing models of care for multimorbidity. The framework describes each model in terms of its theoretical basis and target population (the foundations of the model), and elements of care implemented to deliver the model. Elements of care, including clinical focus, organization of care, and support for model delivery, have changed over time, with a decrease in models implementing home care and an increase in models offering extended appointments. Nearly half of all models lacked a mental health focus (although mental health focus increased over time), and few models directly focused on treatment burden. As health systems begin to implement new models of care for multimorbidity, careful design, implementation and reporting can assist in the development of an evidence base. The authors offer the framework as a tool for standardized reporting and research on multimorbidity interventions and the contributions and interactions of different elements that provide cost-effective care and support health system redesign.

The Foundations Framework for Developing and Reporting New Models of Care for Multimorbidity

Jonathan Stokes, PhD, MPH, BSc, et al

University of Manchester, Manchester, UK

http://www.annfammed.org/content/15/6/570.full

Resident Physician is Shaped by a Difficult Patient's Life and Death

When a patient dies in the early years of a resident's training, the resident gains insights into the complicated relationships that can mark patients' lives and deaths. Although she had a conflicted relationship with her insensitive patient, the resident finds that the experience taught her to reach toward rather than away from the people she treats.

Hatpins

Irene Koplinka-Loehr, MD

University of Rochester, Rochester, NY

http://www.annfammed.org/content/15/6/581.full

Editorial: Statistical Elements of Great Manuscripts

Annals of Family Medicine statistical editor Miguel Marino, PhD, offers quantitative researchers tips for transforming a promising project into a great manuscript, including addressing differential dropout, striking a balance between detailed and succinct reporting, accounting for clustered data, taking advantage of study design in the analytic approach, not overestimating prediction performance, and treating observational studies like randomized trials. He encourages researchers to employ variability in analytic approaches and how they report results while continually improving the rigor of their quantitative work.

Reflections From a Statistical Editor: Elements of Great Manuscripts

Miguel Marino, PhD

Oregon Health & Science University, Portland, Oregon

http://www.annfammed.org/content/15/6/504.full

Innovations in Primary Care: Promoting Healthy Eating and Expanding Clinic Huddles

Innovations in Primary Care are brief one-page articles that describe novel innovations from health care's front lines. This issue's innovations include:

* How Health Systems Can Promote Healthier Eating -- A health system has developed a community strategy to increase the supply of and demand for healthier foods and reduce promotion and availability of less healthful options. http://www.annfammed.org/content/15/6/583.full

* Huddling Up: Expanding Clinic Huddles -- Clinicians huddle not only with their medical assistants but also with front desk staff, behavioral health staff, RN care manager, and practice leadership, leading to improved communication, teamwork and efficiency. http://www.annfammed.org/content/15/6/584.full

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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.

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