September/October 2019 Annals of Family Medicine tip sheet

Fewer Children Seeing Family Physicians in Rural Areas

A Vermont study suggests that a declining proportion of children receive care in family medicine practices. These same children, particularly those in isolated rural areas, are more likely to visit pediatric practices. Using statewide all-payer claims data from 2009-2016, the study looked at 184,794 children with at least two claims in that period. The data revealed that a child’s odds of attending a family practice vs. a pediatric practice declined by an average of 5% each year during the study period. Reasons for this trend may include the national decline in family physicians providing prenatal care and lack of capacity for new patients in family medicine practices. The study also showed that the likelihood of attending a family medicine practice went up with increased child age, if the patient was female, or if the patient was enrolled in Medicaid. The results confirm a continuing challenge for the specialty of family medicine.

Change in Site of Children’s Primary Care: A Longitudinal, Population-based Analysis

Dr. Richard Wasserman, MD, MPH, et al

University of Vermont Larner College of Medicine, Burlington, Vermont

Comparison of Patient and Doctor Priorities in Chronic Disease Management Reveals Discrepancies

When asked to identify and rank a patient’s most important chronic conditions, there is only modest agreement between patients and their physicians. Furthermore, physicians failed to identify what condition mattered most to patients in 29% of cases. A study in France asked 233 patient-physician pairs to identify the patient’s chronic conditions from a list of 124 items and to rank the three most important conditions. Of the 153 pairs that generated priority lists, 29% of patients’ first priorities did not appear anywhere on their corresponding physician’s list, and 12% of pairs had no matching priority conditions. Agreement between patients and physicians varied by condition and were stronger for conditions like hypothyroidism, diabetes, and high blood pressure, and poorer for anxiety and sleep issues. The study was exploratory in nature, yet it points to a need for improved doctor-patient communication in the management of multiple chronic conditions.

Patient-physician Agreement in Reporting and Prioritizing Existing Chronic Conditions

Stéphanie Sidorkiewicz, MD, PhD, et al

Paris Descartes University, Department of General Medicine, Paris, France

Smartphone-operated Electrocardiogram is Highly Accurate for Detecting Arrhythmias in Non-acute Patients in Primary Care Setting

Performing a traditional electrocardiogram (ECG) in primary care can be cumbersome and is unavailable in some primary care practices. A new alternative–a handheld, smartphone-enabled 1-lead ECG–may provide physicians with a viable alternative for detecting cardiac arrhythmias in patients presenting with non-acute cardiac concerns in primary care. In a multi-center validation study of the device’s diagnostic accuracy, blinded cardiologists assessed data from 214 Dutch primary care patients collected simultaneously from the 1-lead and 12-lead devices. The handheld device showed excellent diagnostic accuracy, as cardiologists were able to detect all cases of atrial fibrillation and atrial flutter from the device’s readings. The study also compared expert review of the handheld device’s readings to the smartphone-integrated diagnostic algorithm’s interpretation of the device’s output. The algorithm correctly identified 87% of atrial fibrillation cases and 98% of non-atrial fibrillation cases. The algorithm was less accurate in categorizing other abnormalities. The smartphone-operated ECG may be a viable alternative for physicians in need of a point-of-care device to detect key arrhythmias in the preventive care of stroke.

Diagnostic Accuracy of a Smartphone-operated Single-lead Electrocardiogram to Detect Rhythm and Conduction Abnormalities in Primary Care

Jelle C.L. Himmelreich, MD, MSc, et al

Amsterdam UMC, University of Amsterdam, Department of General Practice, The Netherlands

Assessing Risk of Future Dementia in Primary Care May Be Most Effective With a Stepwise Approach

Primary care physicians rely on a battery of instruments to assess the risk of dementia in older patients. Analysis of data from a longitudinal cluster-randomized controlled trial of 3,526 adults aged 70 to 78 showed that assessment of dementia risk using three common screening tools at baseline predicts incident dementia over the course of about seven years. A single screening question to assess subjective memory loss was associated with future dementia. Furthermore, participants who showed subjective memory loss, who then reached a threshold score on two cognitive function instruments–the Visual Association Test and the delayed recall item of the Mini-Mental State Examination (item 5)–showed rates of dementia up to 30% at follow-up. The authors recommend starting with the single question on subjective memory loss, followed by a brief assessment of cognitive delay from the MMSE-5 and then the VAT.

Associations of Subjective Memory Complaints and Simple Memory Task Scores With Future Dementia in a Primary Care Setting

Lennard L van Wanrooij, MSc, et al

Amsterdam University Medical Center, University of Amsterdam, Department of Neurology, The Netherlands

Professional Communication and Job Satisfaction in Primary Care Clinics

There has been much discussion regarding how communication among health care professionals improves the quality of care for primary care patients, but less insight is available about how communication promotes job satisfaction among health care providers. In a cross-sectional study of 143 physicians and clinical staff from five US primary care clinics, researchers evaluated job satisfaction as it relates to face-to-face communication among staff about patient care. After adjusting for job title, gender, the number of years working at the clinic, and percent full-time employment, researchers found that job satisfaction was higher for those more actively engaged in face-to-face communication than those less engaged. Strategies to support frequent daily face-to-face communication among all team members, such as daily team huddles, may improve job satisfaction among primary care physicians and staff.

Professional Communication Networks and Job Satisfaction in Primary Care Clinics

Marlon P Mundt, PhD, et al

University of Wisconsin – Madison, Department of Family Medicine and Community Health, Madison, Wisconsin

Several Factors Are Associated With Longer Wait Times in Colorectal Cancer Specialty Care Referrals

Delay in referral to specialty care for patients who have symptoms of colorectal cancer may lead to poor health outcomes. A retrospective cohort study in the Netherlands reviewed the time to specialty referral for a group of 309 patients with colorectal cancer who initially presented with symptoms to their primary care doctor. In univariable and multivariable analyses, those who initially presented with red flag symptoms, such as rectal bleeding or unintended weight loss, experienced shorter wait time than those who presented with non-alarming gastrointestinal symptoms. Univariable analysis showed that female patients and patients without a registered family history of the disease were also more likely to have a longer wait period. Of the 10% of patients with the longest wait times for referral to specialty care all patients had received an alternative initial diagnosis from their primary care physicians. These patients usually presented with conditions that obscured concern for colorectal cancer, such as hemorrhoids, fissures and inflammatory bowel disease. Initial diagnoses were not always reconsidered when complaints persisted and follow-up consultations were sometimes omitted.

The study points to a relationship between long time to referral of colorectal cancer in primary care and low cancer suspicion. There is potential for reducing longest times to referral of colorectal cancer patients in primary care by earlier reconsideration of the initial hypothesis and implementing strict follow-up consultations.

Potential for Reducing Time to Referral for Colorectal Cancer Patients in Primary Care

Nicole van Erp, MD, et al

University Medical Centre Utrecht, Julius Center for Health Sciences and Primary Care, Utrecht, The Netherlands

When Earlier Diagnosis of Cancer Doesn’t Save Lives: Recognizing the ‘Waiting Time Paradox’ and Confounding Variables in Cancer Diagnostic Delay Research

The conventional wisdom shared by medical providers, cancer researchers and health policymakers, is that early diagnosis and treatment of cancer can save lives. In an editorial accompanying Helsper, et al, Sherri Sheinfeld Gorin, Ph.D., FSBM, argues that the assumed causal relationship between reduced diagnostic wait time and reduced cancer mortality “is not yet consistently supported by the evidence.” The editorial describes contrary evidence, including studies that show a “waiting time paradox” with a correlation between shorter wait times and increased cancer mortality. Sheinfeld Gorin identifies weaknesses in the research, including ethical limitations, methodological biases and confounding variables and identifies ways to strengthen research data and methodologies to reduce bias. Sheinfeld Gorin highlights Helsper’s use of inductive analysis and free-text data from primary care electronic medical records as a methodological strength and calls for the use of data from “more than one source and by more than one method.” The author suggests “the systematic application of natural language processing programs for categorizing narrative data in medical records and the use of mixed methods to triangulate qualitative and quantitative findings.”

Outcomes of a Trial to Change Primary Care Physicians: Colorectal Cancer Screening

Sherri Sheinfeld Gorin, PhD, FSBM

University of Michigan School of Medicine, Department of Family Medicine, Ann Arbor, Michigan

Determining Characteristics of Case Management Interventions Leading to Positive Health Outcomes

In a systematic review, researchers identified three characteristics of case management programs that consistently yielded positive results: case selection for frequent users with complex problems, high-intensity case management interventions and a multidisciplinary care plan. This review included data from 20 studies, 17 of which were quantitative, of adult frequent users with chronic diseases in primary, secondary and tertiary care settings. Case management was delivered in a primary care setting in all of the studies. Factors such as health care system use, financial cost and patient outcomes were the primary outcomes assessed. All the case management interventions with positive outcomes included some method of identifying patients most likely to benefit. Most of the methods with positive outcomes included high-intensity case management interventions and care plans developed by multidisciplinary teams. The author suggests that policymakers and clinicians should focus on finding an appropriate method to identify patients most likely to benefit from case management. A high-intensity case management intervention and/or access to a multidisciplinary team may also improve outcomes.

Characteristics of Case Management in Primary Care Associated With Positive Outcomes for Frequent Users of Health Care: A Systematic Review

Catherine Hudon, MD, PhD, CFPC et al

Université de Sherbrooke, Department of Family Medicine and Emergency Medicine, Quebec, Canada

Addressing Food Insecurity in Health Care Settings

Many health care settings are exploring ways to reduce patient food insecurity, but there is little rigorously conducted research in this area. A review of articles covering food insecurity interventions in health care settings from 2000-2018 found that interventions focused on either referrals or direct provision of food or vouchers both suffered from poor follow-up, a general lack of comparison groups, and limited statistical power and generalizability. Given the clear and convincing evidence that food insecurity has an adverse impact on health and well-being across the life course, more research is needed to better explore what makes for effective food interventions.

Interventions Addressing Food Insecurity in Health Care Settings: A Systematic Review

Emilia H. De Marchis, MD, MAS, et al

University of California, San Francisco, Department of Family & Community Medicine, San Francisco, California

Essay: Addressing Health Disparities Through Voter Engagement

Citizens of poor health or with limited access to healthcare are less likely to participate in elections as a result of voting barriers, but generally have differing views from their voting counterparts. For example, those who did not vote in the 2016 general election were more interested in inclusive health, social and economic policy than those who did vote. The election outcome that year demonstrates how patterns of voter participation can lead to a misrepresentation of health care priorities within government. Nonprofit and private health organizations, and community health centers–safety-net hospitals in particular–can help marginalized, voting-eligible individuals overcome barriers to the ballot. With augmented and more representative voter participation, elections may yield public policy that is more equitable, thereby reducing costly and preventable health disparities. Health organizations can promote comprehensive, nonpartisan voter engagement through registration, mobilization, education and protection of all voters.

Addressing Health Disparities Through Voter Engagement

Nicholas Yagoda, MD

CommUnityCare Health Centers; the University of Texas at Austin, Dell Medical School, Department of Population Health, Austin, Texas

Essay: Why Physician Guidance Matters: A Night of Neuralgia, Meningitis and WebMD

Initiated by a night of growing pain and discomfort, this essay explores how fear and uncertainty led to viewing the online resource WebMD to find possible diagnoses matching ongoing symptoms, including occipital neuralgia and meningitis. This information was presented to a physician, who explored opinions derived from the WebMD inquiries through a series of tests. Although no serious health issues were discovered, it led to noting the potential harm of internet-based self-diagnoses. It also spoke to the importance of patient-physician communication, which may have provided needed reassurance for the author. “My experience shows the need for a sense of trust woven into the fabric of a collaboration whose importance goes beyond the testing phase to effect better physician-patient communication and health outcomes,” the author wrote. “In this case, it would have afforded me a sense of security.”

Why Physician Guidance Matters: A Night of Neuralgia, Meningitis and WebMD

Anson Au, MSc, FRAS

University of Toronto, Department of Sociology, Toronto, Canada

Innovations in Primary Care

Innovations in Primary Care are brief one-page articles that describe novel innovations from health care’s front lines. In this issue: Pharmacist-led Chronic Care Management Services – Specially trained clinical pharmacists provide chronic care management, complimenting services from partnering physicians in a new sustainable practice model.

Running Medicine for Mind, Body, and Spirit Wellness – Culturally grounded wellness program brings together members of diverse American Indian tribes to meditate, run, walk, eat and practice wellness in a community together.

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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,

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