March/April 2021 Annals of Family Medicine Tip Sheet

Study Reveals New Hope for Men With Common Urinary Issues

A new systematic review of evidence recommends the use of behavioral self-management treatments for common urinary issues experienced by upwards of 70 percent of older men. Common symptoms include trouble urinating, increased frequency and incontinence. These symptoms can have a substantial negative impact on sleep, social functioning and quality of life. Several guidelines recommend self-management techniques like health education, advice on fluid intake, and bladder retraining; however, in practice, self-management is often excluded from the menu of treatment options that include medication and surgery.

Researchers at Bond University’s Institute for Evidence-Based Healthcare found that self-management interventions reduced the severity of lower urinary tract symptoms. The reduction in symptoms appeared similar in groups receiving medications versus self-management interventions. However, compared with drugs alone, individuals who had both drug and self-management intervention experienced a small but meaningful reduction in symptom severity after six weeks. The authors recommend further research to determine the optimal components and delivery methods for self-management interventions so that these strategies can become standard options for men with lower urinary tract symptoms.

Self-Management for Men With Lower Urinary Tract Symptoms: A Systematic Review and Meta-Analysis


Loai Albarqouni, MD, MSc, PhD, et al

Bond University, Queensland, Australia


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Treating Incontinence in Primary Care: A Doctor Versus Mobile App Trial

A mobile app designed to help women manage urinary incontinence was as effective as usual, in-person treatment of incontinence in primary care, according to new research from the Netherlands. The study included 262 women with frequent stress incontinence, overactive bladder or a mix of symptoms. Participants were randomly assigned to use a standalone mobile app called URinControl, which offered pelvic floor muscle and bladder training exercises. Those in a control group received standard care and were referred to their own primary care doctors who were broadly advised to follow the Dutch guidelines for primary care. After four months, women who used only the incontinence app and those who continued with standard care experienced similar results, with a decline in the severity of their symptoms, less frequent leakage and improved quality of life. Statistical analysis showed just over a one-half percentage point difference between the two groups’ average decline in symptom severity. Therefore, the authors conclude that primary care physicians can offer care-as-usual and/or app-based treatment to women seeking help for urinary incontinence. Most importantly, the authors note, a mobile app will only be clinically relevant if it can demonstrate that it is either a less expensive option or offers an accessible and user-friendly alternative with significant long-term outcomes.

App-Based Treatment in Primary Care for Urinary Incontinence: A Pragmatic, Randomized Controlled Trial


Anne M. M. Loohuis, MD, et al

University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands


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App-based and self-management tools have the potential to help individuals take control of their common urinary issues. In a corresponding editorial, Joel Heidelbaugh, MD, a clinical professor of family medicine and urology at the University of Michigan, discusses the significance of Loohuis et al’s mobile app study and Albarqouni et al’s review of self-management interventions, and highlights their value to both patients and primary care physicians. For patients, new e-health programs could help individuals manage their symptoms and improve their quality of life without medication, or they may experience additional benefits when combined with medication. For primary care physicians, apps and self-management tools might be a cost-effective and empowering strategy compared to usual care.

Self-Directed Technology to Improve Urinary Symptoms


Joel J. Heidelbaugh, MD

University of Michigan Medical School, Ann Arbor, Michigan


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Perspectives of US Youth During the Initial Month of the COVID-19 Pandemic

According to two national surveys by researchers at the University of Michigan Medical School, US teens and young adults are engaged in the ongoing COVID-19 pandemic with most being knowledgeable about the disease, concerned about its impacts on others, and practicing social distancing. On March 6, 2020, 70 percent reported knowledge of the pandemic, with 46 percent noting they got information from news sources. By March 20, 2020, nearly all respondents, 95 percent, reported impact. Worry about the pandemic increased from 25 to 51 percent. For some young people who weren’t worried early on about the pandemic, staying at home and engaging in other preventive public health guidelines made them feel safer. Between the two surveys, pandemic preparation seemed to shift. Initially, respondents primarily reported doing nothing (36 percent), but by March 20th, 50 percent reported practicing social distancing. The authors recommend that, as public health planning evolves, it will be important to acknowledge young people’s concern for others as a driver of their behavior and to create programs that are informed by their beliefs and perspectives.

Perspectives of US Youth During Initial Month of the COVID-19 Pandemic


Eric Waselewski, MD, et al

University of Michigan Medical School, Ann Arbor, Michigan


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Bonus: Visual Abstract

Primary Care Big Data Can Provide Opportunity for Rapid Research to Inform Patient Care, Policy During COVID-19 Pandemic

Members of the COVID-19 Primary Care Database Consortium explain how the use of big data containing millions of primary care medical records provides an opportunity for rapid research to help inform patient care and policy decisions during the COVID-19 pandemic. Established in April 2020, the Consortium brings together experts in big data, epidemiology, intensive care, primary care and statistics, as well as journal editors, patient and public representatives, and front-line clinical staff from the universities of Oxford, Cambridge, Southampton, Bristol and Nottingham

The consensus statement that the consortium has developed and described in the article aims to facilitate transparency and rigor in methodological approaches, as well as consistency in defining and reporting cases, exposures, confounders, stratification variables and outcomes in relation to the pharmacoepidemiology (i.e. the potential influence of old and new drug therapies on outcomes) of COVID-19. This is important, the authors write, because the vast majority of drugs for common conditions such as hypertension, diabetes or heart failure are prescribed in primary care practitioners in the U.K. For example, ACE-inhibitors widely prescribed by primary care doctors may impact COVID-19 outcomes. Using big data in collaborative databases may help answer questions about the interactions between medicines and COVID-19 outcomes.

The Use of Primary Care Big Data in Understanding the Pharmacoepidemiology of COVID-19: A Consensus Statement From the Covid-19 Primary Care Database Consortium


Hajira Dambha-Miller, MRCGP, PhD, et al

University of Southampton, Southampton, United Kingdom


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New Collaborative Care Model Offers Insight into Providing Help for Patients With Mental Health Needs

Members of the Perelman School of Medicine at the University of Pennsylvania and its health system developed and implemented a new model of collaborative care called The Penn Integrated Care (PIC) program. PIC includes a resource center to support intake, triage and referral management and collaborative care services in primary care practices. PIC was created to increase access to and engagement with mental health professionals to improve mental and physical health outcomes. Primary care physicians were able to refer patients with any mental health symptom or condition to PIC. In 12 months, 6,124 unique patients were referred from eight primary care clinics to either the PIC Resource Center or were connected with a mental health professional. Most were triaged to collaborative care or specialty health care with active referral management.

Among patients enrolled in collaborative care, the mean length of treatment was 7.2 encounters over 78 days. Remission of symptoms was achieved by almost 33 percent of patients with depression and almost 40 percent of patients with anxiety. Stakeholders viewed the program favorably. Primary care physicians perceived they were providing patients with higher quality care, and patients appreciated having someone to talk to in addition to, or instead of, receiving a medication prescription. Results provide insight into a model for launching and implementing collaborative care to meet the needs of a diverse group of patients who have a full range of mental health conditions often seen in primary care.

Addressing Common Challenges in the Implementation of Collaborative Care for Mental Health: The Penn Integrated Care Program


Courtney Benjamin Wolk, PhD, et al

University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania


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Use of Patient Data Guides Outreach to Treat and Monitor People With Diabetes

Researchers from the HealthPartners Institute and University of Minnesota in Minneapolis conducted an observational analysis of interviews and characteristics of primary care clinics, comparing the strategies, facilitators and barriers to high performance in treating patients with diabetes. The purpose of the study was to learn what strategies and factors seem most important to leaders of primary care clinics to ensure high performance. The percentage of Minnesota diabetes patients who achieved optimal diabetes care measures increased from 12 to 45 percent between 2004 and 2017, while national measures of diabetes care outcomes did not improve significantly around the same time span.

The main difference among the strategies and factors was the degree to which top performing clinics used patient data to guide proactive and outreach methods to intensify treatment and monitor impact. The authors state that while confirmatory studies are needed, clinic leaders should consider the value of this paradigm shift in approach to care.

Strategies and Factors Associated With Top Performance in Primary Care for Diabetes: Insights From a Mixed Methods Study


Leif I. Solberg, MD, et al

HealthPartners Institute, Minneapolis, Minnesota

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Standardized vs. Customized Patient Care: Finding the Right Balance

Authors from the American Medical Association and the University of Wisconsin write a commentary about finding the right balance between standardization and customization of patient care processes. They write that, in most situations, patients receive better care when physicians and their teams have the ability to exercise professional judgment about workflow and task distribution, supported by best practices of systems engineering, rather than when they are expected to perform a rigid sequence of transactions mandated by well-intentioned but distant health care designers. The authors present four principles to guide decisions between standardization and customization: develop processes and policies in collaboration with end users; share decision authority with the clinicians closest to the patients; seek measures of customization; and not all variation is bad. Finding the balance between standardization and customization is important for patient care and should be considered by organizational leadership, those who determine patient treatment standards, and health care regulators, according to the authors.

Standardization vs Customization: Finding the Right Balance


Christine A. Sinsky, MD, et al

American Medical Association, Chicago, Illinois

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Increased Collaboration between Primary Care Doctors, Oncologists May Improve Fragmented Cancer Care

Cancer patients often experience fragmented care, particularly as they undergo cancer treatments. Although family physicians seek to provide continuous and comprehensive care, they often lose touch with their cancer patients during the treatment phase. Researchers conducted a randomized intervention that aimed to improve continuity of care and interprofessional collaboration as perceived by lung cancer patients and their family physicians.

The components of the intervention included the bidirectional exchange of patient information and care summaries between oncology teams and family physicians. Oncology teams recommended that patients see their family physicians after their cancer diagnosis. At the same time, cancer patients received priority access to their family physicians when needed.

The authors conclude that the intervention improved patient and family physician perceptions of interprofessional collaboration. Patients reported improved care continuity. In its objective to address fragmented cancer care, the study implemented pragmatic strategies to improve information exchange between family practitioners and the oncology team that could be integrated into routine practice. These findings provide valuable insight into potential strategies to bridge the gap between primary care and oncology care.

Continuity of Cancer Care and Collaboration Between Family Physicians and Oncologists: Results of a Randomized Clinical Trial


Michele Aubin, MD, PhD, et al

Laval University, Quebec City, Québec, Canada


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Using Health Behavior Outcomes Can Help Determine Efficacy of Patient-Centered Intervention for People With Multiple Morbidities

Intervention research focusing on patients with multiple, simultaneous chronic illnesses is a priority for health organizations such as the National Institutes of Health and Canadian Institutes of Health Research. This is important as physicians seek to better understand how one disease may influence the course of another coexisting one, and how to best care for patients who are battling multiple health issues. Researchers conducted a controlled trial in patients 18 to 80 years with three or more chronic conditions. They collected quantitative data and conducted in-depth interviews with patients, family members and health care providers, then measured the effectiveness of a four-month intervention based on changes in care delivery. For the study, health care professionals were trained to coach patients on adopting healthy lifestyle changes and managing their own health.

After four months, the intervention showed no effect on quantitative measures of self-management or self-efficacy. However, patients reported in qualitative interviews that the intervention improved their self-management and self-efficacy. The authors warn that complex interventions can be difficult to evaluate and important effects may be missed in evaluations that only include quantitative assessments.

Scaling Up Patient-Centered Interdisciplinary Care for Multimorbidity: A Pragmatic Mixed-Methods Randomized Controlled Trial


Martin Fortin, MD, MSc, et al

Universite de Sherbrooke, Sherbrooke, Québec, Canada


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It’s Time to Expand Chlamydia Treatment for Gay and Bisexual Men

In most US states, many gay and bisexual men are excluded from one effective approach to treating the sexually transmitted infection chlamydia. Because of nearly decade-old CDC guidelines that have been adopted in most states, health care practitioners are discouraged from offering an extra dose of antibiotic treatment for chlamydia for a patient’s partner, without requiring that partner to be tested or examined, a practice that is called expedited partner therapy (EPT). Although EPT remains a highly effective way to break the cycle of reinfection, the CDC recommends against offering EPT to men who have sex with men, citing the lack of clinical trial evidence in this population and the risk of undetected coinfections like HIV. The authors of this essay note that changes in the HIV prevention landscape over the past ten years should prompt policy makers and public health officials to reevaluate the risks and benefits of expedited partner therapy for gay and bisexual men and their sexual networks. PrEP, or pre-exposure prophylaxis, was introduced to US markets in 2012. The popularity of PrEP among certain gay and bisexual men, the authors argue, connects patients who might not otherwise engage in preventive care to more frequent and comprehensive infection screenings and services. Additionally, they argue that limiting EPT to heterosexual people may discourage open and accurate conversations between doctor and gay and bisexual patients and point to an urgent need for data to understand the effectiveness and downstream effects of expedited partner therapy in this population.

It’s Time to Expand Chlamydia Treatment for Gay and Bisexual Men


Hannan M. Braun, MD and Jessica L. Taylor, MD

Boston Medical Center, and Boston University, Boston, Massachusetts


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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:

Combination of Home-Based Hormonal and Mobile Technology for Virtual Monitoring of Menstrual Cycles–Smartphone applications combined with home-based hormonal tests can be effectively used for virtual physician monitoring of patients/ menstrual cycles.

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The Impact of COVID-19 Proactive Outreach With Somali Seniors–The COVID-19 positivity rate for Somalis in Minneapolis is disproportionately high. A targeted health outreach program paired bilingual volunteers with high-risk patients to provide education on COVID-19 and general health support over the phone.

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Medical School Affiliation Accelerates the Development of Community Health Centers in China–A program to build a bridge between China’s community health centers and academic institutions has resulted in a relationship that has the potential to improve how family medicine is delivered.

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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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