January/February 2020 Annals of Family Medicine tip sheet

Research Suggests No Difference in Morning Versus Evening Dosing for Warfarin

Patients taking warfarin to reduce the risk of stroke and pulmonary embolisms are often advised to take the medication in the evening. But does time of day really matter? A new study shows evidence that morning versus evening dosing has insignificant bearing on how long the drug provides the most benefit for preventing adverse health events. Two hundred and seventeen adults who regularly used warfarin in the evenings were randomized to the trial, with about half switching to morning medication use for seven months. Researchers measured the effectiveness of the drug by tracking the proportion of time that patients spent outside of the range for maximum effectiveness of the drug. Therapeutic changes did not significantly differ for patients who switched to morning administration. The clinical research team concluded that the time of day a patient takes the medicine has no effect on the stability of warfarin’s anticoagulant effect. Patients should take warfarin whenever regular compliance would be easiest.

The Effect of Warfarin Administration Time on Anticoagulation Stability (INRange): A Pragmatic Randomized Controlled Trial


Scott R. Garrison MD, PhD, et al

University of Alberta, Department of Family Medicine, Edmonton, Alberta, Canada


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When the Best Treatment for Hypertension is to Wait: A Study of “Therapeutic Inertia” and Home Blood Pressure Follow-Up

A new study from the University of Missouri concluded that a physician’s decision not to intensify hypertension treatment is often a contextually appropriate choice. In two-thirds of cases where physicians did not change treatment for patients with hypertension, patients’ blood pressure returned to normal in follow-up readings taken at home. This pre- and post-study tracked 90 patients with hypertension to understand the role that follow-up home blood pressure measures could play in understanding cases of “therapeutic inertia.” Sixty-six percent of patients who had a blood pressure reading of 140/90 or higher when they were in the clinic and whose doctors did not change their treatment, had average readings under 140/90 when patients took their blood pressure at home.

According to the authors, there are implications for health care quality metrics. Doctors’ success rates in controlling hypertension are based solely on clinic blood pressure rates. The authors extrapolated the home blood pressure metrics to show that when home metrics replaced clinical ones, the department’s hypertension control success rates rose from 58% to 86%. They conclude, “Most validated home blood pressure should be accepted and preferred for physician hypertension performance measures.”

Additionally, when surveyed after the home blood pressure reading intervention, participants shared that home blood pressure monitoring enhanced their understanding of blood pressure control. Eighty-three percent of participants agreed that they would consider buying a home blood pressure monitor if it was covered by insurance.

Home Blood Pressure Monitoring in Cases of Clinical Uncertainty to Differentiate Appropriate Inaction From Therapeutic Inertia


Sonal J. Patil, MD, MSPH, et al

University of Missouri, Department of Family and Community Medicine, Columbia, Missouri


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A Blueprint for Building Transgender Health Programs in Primary Care

Leading educators and clinical experts on transgender health care from Harvard, Fenway Health, and The Fenway Institute address access issues for transgender patients seeking care by providing a plan to integrate gender-affirming hormone therapy, surgical referrals, or wrap-around services into primary care. Such programs provide a much-needed service for this underserved but increasingly visible population that experiences significant health inequities. Authors provide a concise and practical guide to developing transgender health programs within existing primary care practices. Programs may be as streamlined as having one or two clinicians who provide hormone therapy within a welcoming primary care practice. The guide provides tips on how to access low-cost clinical training and how to generate organizational buy-in for the development of new services. The plan can be adapted across primary care practices of varying sizes and resources. This is the first peer-reviewed publication that provides a guide to implementing a transgender health program in primary care settings.

A Blueprint for Planning and Implementing a Transgender Health Program

Alex S. Keuroghlian, MD, MPH,

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The Fenway Institute, Harvard Medical School, and Massachusetts General Hospital, Department of Psychiatry, Boston, Massachusetts


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Cancer Screening Among Women Prescribed Opioids

U.S. women who take prescription opioids are no less likely to receive key cancer screenings when compared to women who are not prescribed opioids. Researchers at the University of California, Davis analyzed data from a nationally representative sample of 53,982 women in the United States. Findings revealed that women who are prescribed opioids were more likely to receive breast, cervical, and colorectal cancer screenings for the simple fact that they are frequent users of the health care system. They had a median number of doctor visits that was five times higher than their non-prescribed counterparts. When this factor was controlled for, analysis showed no association between prescription opioid use and cancer screening. This study is one of the first to examine access to key preventive health services for opioid versus non-opioid users. Authors suggest that “the key driver of whether women receive recommended cancer screening is simply how often they see the doctor.”

Cancer Screening Among Women Prescribed Opioids: A National Study

Alicia Agnoli, MD, MPH, MHS, et al

University of California, Davis School of Medicine, Department of Family and Community Medicine, Sacramento, California


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Social Factors Play a Key Role in Missed Well-Child Care Visits

Despite the benefits of well-child care visits (WCV), up to half of WCVs are missed. A team of researchers and pediatricians at Virginia Commonwealth University, University of Washington, and the University of Vermont sought to understand the challenges that prevent families from attending their child’s scheduled appointment. They interviewed caregivers of children who had missed WCVs as well as family and pediatric physicians from a large safety-net health system in Richmond, Virginia. Caregivers and physicians alike identified social factors as key barriers to attendance, including transportation, difficulty taking time off from work, childcare, and underlying financial stressors. The researchers conclude, “Our findings suggest there is a need to further explore the potential relationship between WCV attendance and social determinants of health.”

Caregiver and Clinician Perspectives on Missed Well-Child Visits

Elizabeth R. Wolf, MD, MPH, et al

Virginia Commonwealth University, Department of Pediatrics, and the Children’s Hospital of Richmond at VCU, Richmond, Virginia


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Certification as a Medical Home: Does It Make a Difference in Diabetes Care?

Researchers compared 258 certified medical home primary care practices in Minnesota to 136 non-certified practices, to see if certification had any bearing on performance measures related to the quality of diabetes care. Certified practices were found to have slightly more medical home practice systems than uncertified practices. Additionally, certified practices had somewhat better performance outcomes on quality measures related to diabetes care. Uncertified practices, comprising 39 percent of the surveyed practices, were noted to be more rural but had similar patient populations. Practices certified as medical homes have more systems and improved performance for diabetes care, but the differences are modest.

Differences in Diabetes Care With and Without Certification as a Medical Home

Leif I. Solberg, MD, et al

HealthPartners Institute, Minneapolis, Minnesota


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Primary Care Patients Assess eConsult Model for Provider-to-Specialist Consultations

A study across five academic medical centers examined the reaction of patients to the use of an electronic consultation (eConsult) service for primary care provider-to-specialist consultation. This focus group study of adult primary care patients was conducted to better understand patients’ opinions, as most previous eConsult studies focused on clinical and financial impacts and clinician responsibility. Fifty-two participants across five focus groups were introduced to the eConsult model and were asked to discuss potential benefits and drawbacks, as well as acceptability of a hypothetical copay and preferences for involvement in future eConsult decision making and communication. Participants in all five focus groups reacted favorably to the eConsult concept; quicker access to specialty care and convenience were cited as key benefits, with approval rates particularly high among those having a trusted primary care provider. Some patients wanted to be involved in eConsult decision making and communication. They also expressed a decreased enthusiasm about eConsults if a copay were to be introduced. A small number of participants were also concerned about potential misuse of the system and about the exclusion of the patient’s illness narrative in the eConsult exchange.

Patients Assess an eConsult Model’s Acceptability at 5 US Academic Medical Centers

Sara L. Ackerman, PhD, MPH, et al

University of California, San Francisco, California


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Offering Cognitive Behavior Therapy Programs for Diabetes Self-Management Leads to Improved Physical Activity and Health Outcomes

A peer-delivered program for managing diabetes and chronic pain was shown to be beneficial for rural adults in communities that might otherwise lack access to physician-led services. Trained community members in rural Alabama delivered a diabetes self-management program that incorporated cognitive behavioral approaches to overcoming pain as a barrier to physical activity. Peer trainers were African American women who had personal experiences with diabetes and were lifelong community members. Similarly, participants were mostly low-income African American women recruited through community connections and assigned to the intervention by town block randomization. Adults who completed the 10-week program showed significant improvements in functional status, pain, and quality of life, when compared to a peer-led general health advice control group. At the end of the program, adults in the cognitive behavioral therapy-based program were more likely to report having no pain or finding alternative exercises when pain prevented them from walking. These results demonstrate that peers trained to deliver CBT-based interventions can improve health outcomes in areas where access is limited.

Peer-Delivered Cognitive Behavioral Training to Improve Functioning in Patients With Diabetes: A Cluster-Randomized Trial


Monika M. Safford, MD, et al

Weill Cornell Medicine, Department of Medicine, New York, New York


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Health Coaching Shown to Improve Inhaler Use Among Low-Income COPD Patients

Over 14 million U.S. adults have chronic obstructive pulmonary disease, and many face barriers to using inhaled medications regularly and effectively. Although inhaled medications can improve daily life and long-term outcomes, only 25 to 43% of people with COPD use them regularly. In addition, inhalers can be complex to use–requiring users to master a series of six to eight steps that differ across devices. Physicians and health teams have not yet found a solution to bring COPD medication adherence to the level of other chronic diseases.

In a multi-site randomized controlled trial from the University of California, San Francisco, non-licensed, trained health coaches offered COPD patients one-on-one support in person and by phone, with contact at least every three weeks for nine months. Participants were primarily low-income, African American and Latino men in an urban area. Those who received health coaching showed significant improvement in adherence to controller inhalers and improved inhaler technique, with 40% of health-coached patients versus 11% of a control group able to demonstrate effective use of their inhalers after the intervention. Researchers conclude that “improved inhaler technique and adherence are one of multiple factors contributing to long-term COPD outcomes, but their research has confirmed one technique–use of lay health coaches–that may help patients get optimal benefit from their COPD medications.

Lay Health Coaching to Increase Appropriate Inhaler Use in COPD: A Randomized Controlled Trial

Rachel Willard-Grace, MPH, et al

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


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Lay Health Coaches “Share-the-Care” to Reduce Health Disparities

In an accompanying editorial, Sonal J. Patil summarizes two recent studies on lay health coaching in chronic disease self-management for low-resource, predominantly African American communities. Self-management training and support programs exist to support patients with chronic diseases like diabetes and chronic obstructive pulmonary disease. However, these programs are not equally utilized. Inequities in education, geographic accessibility, and other social factors can make it even harder for certain populations to access the coaching. Patil stresses the ability of peer coaching to adapt one-size-fits-all disease management training, helping patients fit interventions to their personal preferences and social context. Despite their potential utility in addressing health disparities, Patil notes that funding for lay health coaches can be precarious. Payment is often challenged by the lack of widespread reimbursement from insurers. Patil concludes, “Lay health coaches can potentially ‘share-the-care’ in communities, by assisting with the ‘work of being a patient’ with chronic disease, to supplement primary-care visits in low-resource settings where ‘no moment is wasted.'”

Task Sharing Chronic Disease Self-Management Training With Lay Health Coaches to Reduce Health Disparities

Sonal J. Patil, MD, MSPH

University of Missouri, Department of Family and Community Medicine, Columbia, Missouri


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Comparison of Primary Care Experience in Hospital-Based Practices and Community-Based Office Practices in Japan

A comparison of the strengths and challenges of primary care between hospital-based practices and community-based office practices was observed in a cross-sectional study in Japan. Each type of practice had its strengths in terms of patient experiences and challenges. Patients at community-based office practices reported better patient experiences of community orientation than those in hospital-based practices. Hospital-based practices were associated with better patient experience of first contact, compared with office-based practices. Six small and medium-sized hospitals and 19 community-based office practices participated in the study of 1,725 patients. Patient experience was measured using a Japanese version of the Primary Care Assessment Tool, which was comprised of first contact, longitudinality, coordination, comprehensiveness (services provided), and community orientation. Understanding the strengths of each practice type with respect to patient experience may inform future efforts to improve the patient experience overall.

Comparison of Primary Care Experience in Hospital-Based Practices and Community-Based Office Practices in

Japan

Takuya Aoki, MD, PhD, MMA, et al

Kyoto University, Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto, Japan


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The Phoenix: A 20-Year Patient-Doctor Healing Journey

Building from a previous story (“On Blindness and Blind Spots”) while seeking a greater understanding of the psychological causes behind a longtime patient’s many symptoms, the author’s discovery of more traumatic events provides a new perspective for understanding her patient. The patient-narrator shares short, poetic pieces which help explain her difficult childhood experiences and her efforts as a grown woman to heal emotionally. The author notes the value of belief in one’s patient, in addition to the patience and trust which can be built over many years between patient and physician. “As an experienced physician, I thought perhaps time would eventually unravel the many layers beneath the surface of your story. I have learned over the years that one of the benefits of caring for patients for what is now over two decades, is that a more comprehensive understanding of a patient’s symptoms emerges only after many years.”

The Phoenix: A 20-Year Patient-Doctor Journey


Ruth Kannai, MD, et al

Ben-Gurion University of the Negev, Department of Family Medicine, Beersheba, Israel


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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:

• Interdisciplinary Group Visits for Patients With Complex Social Needs – A redesigned Federally Qualified Health Center provided fluid and interdisciplinary care from a team of community health workers, public health nurse, behavioral health providers, family physician, pharmacist, and psychiatrist, with a combination of support from team members in any given patient visit.
  
  
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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: 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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