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News From The Annals Of Family Medicine, May/June 2013

Much of the May/June 2013 issue of Annals of Family Medicine and the entirety of an accompanying supplement published in partnership with the U.S. Agency for Healthcare Research and Quality are about changing primary care practice. Practice transformation on a large scale toward the patient-centered medical home model of care is a cornerstone of health care reform efforts in the United States, and the research and commentary in this issue can serve as a roadmap to achieve practice transformation. Not only do the articles address the opportunities, challenges, costs, processes and determinants of such change, but importantly, many also consider contextual factors – information important to understanding what happened and why and factors that would be critical to others attempting to transport the findings to different times, settings or situations. The journal editors hope that by including these contextual factors, the important research findings detailed in this issue can be more readily translated into practice.

Median Cost of Practice Facilitation to Improve Chronic Illness Care About $10,000 for Small Primary Care Practice

Widely recognized as a promising method for achieving large-scale practice redesign, practice facilitation using outside consultants, researchers estimate, cost a small primary care practice between $9,670 and $15,098 per year, or the cost of two to three hospitalizations. Reporting on the direct costs of providing practice facilitation that focuses on improving chronic illness care to a sample of 19 small primary care clinics with one to four clinicians, the researchers found the median total variable costs of all practice facilitation intervention activities, including six meetings over a 12-month period from start-up through monitoring was $9,670 per practice (range = $8,050 to $15,682). These estimates do not include overhead costs to the practice for staff and systems. The authors note that because much of the cost of practice facilitation is devoted to start-up and practice assessment (47 percent), the costs of ongoing facilitation activities in subsequent years would likely be much lower.

Cost Estimates for Operating a Primary Care Practice Facilitation Program
By Steven D. Culler, PhD, et al
Emory University, Atlanta, Ga.

Editorial: Payers Should Bear the Cost of Practice Transformation and Clinicians Should be Held Accountable for Providing Value to Patients

Researchers address the opportunities as well as the challenges and costs of transforming practice toward the patient-centered medical home model of care in this editorial. The authors assert that primary care practices cannot bear the costs of transformation unless they are reimbursed for the costs they incur. For the needed changes to occur on a wide and sustainable basis, they argue that payers should fund the full cost to primary care practices, which is estimated at a minimum of $7-12 per patient per month in addition to usual fee-for-service reimbursement. They call for payment reform and cast a vision for an alternative system that fosters a shared sense of responsibility for cost, quality and service in which primary care physicians are held accountable for providing value to patients, and are compensated for the value they provide.

Practice Transformation? Opportunities and Costs for Primary Care Practices
By James M. Gill, MD, MPH, and Bruce Bagley, MD
Delaware Valley Outcomes Research, Newark, Delaware, and American Academy of Family Physicians, Leawood, Kan.

Dextrose Prolotherapy Effective Treatment for Knee Osteoarthritis

Dextrose prolotherapy – injection therapy using a sugar solution to relieve musculoskeletal pain – offers sustained improvement of pain, function and stiffness for patients with knee osteoarthritis. Ninety adults who had at least three months of painful knee osteoarthritis were randomized to receive dextrose prolotherapy injections, saline injections or at-home exercise. Injections were done at one, five and nine weeks with as-needed additional treatments at weeks 13 and 17. Researchers found patients receiving dextrose prolotherapy improved more (P < .05) at 52 weeks than patients receiving saline and exercise as measured by their composite score on the Western Ontario McMaster University Osteoarthritis Index (score change: 15.3 ± 3.5 vs. 7.6 ± 3.4, and 8.2 ± 3.3 points, respectively) and Knee Pain Scale. In terms of functionality, dextrose patients reported significantly better function than both saline and exercise participants for a change of 16.25 compared with 5.45 and 7.31 points respectively, at 52 weeks. Individual knee pain scores also improved more in the prolotherapy group (P = .05). Patient satisfaction with prolotherapy was high, and no adverse events were reported. With most of the population showing radiographic evidence of osteoarthritis by the age of 65 years, the authors call for future research to compare the effectiveness of prolotherapy for knee osteoarthritis with that of other current therapy, including intraarticular corticosteroid and hyaluronic acid injections, in a larger effectiveness trial that includes biomechanical and imaging outcomes.

Dextrose Prolotherapy for Knee Osteoarthritis: A Randomized Controlled Trial
By David Rabago, MD, et al
University of Wisconsin, Madison

Chronic Abdominal Pain Common Among Children in Primary Care

Researchers in the Netherlands find a surprisingly high prevalence and long duration of chronic abdominal pain among children consulting in primary care. Analyzing data from a 12-month prospective study of 305 children ages 4 to 17 years who visited a primary care physician for abdominal pain, researchers found most had or developed chronic abdominal pain – pain at least one time a month during at least three consecutive months that has an impact on daily activities. Chronic abdominal pain was present in 47 percent of the children at the initial visit, and 79 percent fulfilled the criteria for abdominal pain at one or more of the follow-up points (three, six, nine and 12 months). The median duration of abdominal pain was 8.3 months, with children aged 10 to 17 years having the longest duration (median = 9 months; (interquartile range = 7.5-12.4 months). Notably, girls had chronic abdominal pain more frequently during follow-up than boys (relative risk = 1.23; 95 percent, 0.94-1.61) and duration was longer in girls (median = 9.0 months vs. 7.5 months). Given this poor prognosis, the authors call for follow-up of these children.

Prognosis of Abdominal Pain in Children in Primary Care – A Prospective Cohort Study
By Yvonne Lisman-van Leeuwen, PhD, et al
University of Groningen, the Netherlands

Depression Increases Diabetic Patients’ Risk of Severe Hypoglycemic Episodes

Patients with diabetes and comorbid major depression are at increased risk of severe hypoglycemic episodes requiring hospitalization or a visit to the emergency room. Analyzing data on 4,117 adult diabetic patients over a five-year period, researchers found depressed patients compared to non-depressed patients with diabetes had a significantly higher risk of a severe hypoglycemic episode (hazard ratio = 1.42, 95 percent, confidence interval 1.03-1.96) and a greater number of hypoglycemic episodes (odds ratio = 1.34, 95 percent, CI 1.03-1.75). They suggest the increased risk of severe hypoglycemic episodes in patients with comorbid depression may be due to poor self-care or psychobiologic changes associated with depression. They call for future research to assess whether recognition and effective treatment of depression among diabetic patients prevents severe hypoglycemic episodes, as well as the increased risk of complications and mortality.

Association of Depression With Increased Risk of Severe Hypoglycemic Episodes in Patients With Diabetes
By Wayne J. Katon, MD, et al
University of Washington Medical School, Seattle

Commercial Weight Loss Programs Should Be Included Among Weight Management Interventions in Primary Care

Expanding on the findings of a previously published international trial that found a commercial Weight Watchers program was more successful in helping people lose weight than a standard primary care-based intervention, researchers analyzed the accounts of a small sample of 16 participants’ experiences with these two programs. They found that referral to a commercial provider resonated with the participants’ general explanatory model of being overweight; they wanted support and motivation rather than education within a medical context, and they valued the ease of access and the frequent contact the commercial provider offered. Many reported a resistance to the medicalization of being overweight. Some patients, the authors note, preferred individual-level support through their physician, and all were positive about the opportunity to access support through the primary care setting. The authors conclude these findings support providing patients with a range of options for weight management in primary care, including commercial programs and other interventions outside the traditional medical setting, to find what best suits their needs and lifestyle.

Participants’ Explanatory Model of Being Overweight and Their Experiences of 2 Weight Loss Interventions
By Amy L. Ahern, PhD, et al
MRC Human Nutrition Research, Cambridge, United Kingdom

Intervention to Improve Colorectal Cancer Screening Rates Does Not Improve Screening Rates But Yields Insights into Successful Practice Transformation

Evaluating a practice-based quality improvement intervention that included facilitated team meetings and learning collaboratives to improve colorectal cancer screening rates, researchers found no significant improvement in screening rates among intervention practices when compared with control practices. Analyzing outcomes on 23 New Jersey primary care practices randomized to either a control group or a six-month intervention, researchers found a nonsignificant trend toward greater net increase in screening rates among the intervention compared with control practices. Notably, successful implementation of the quality improvement program did not always translate into improved screening rates. One intervention practice’s overall screening rate actually got much worse. Additional qualitative analyses of 12-month follow-up data found associations between how well practice leaders fostered team development and the extent to which team members felt safe to engage in the change process. High-performing practices, they found, had moderate-to-strong leadership and psychological safety for the intervention, whereas the low-performing practices evidenced weak leadership and psychological safety. Moreover, high-performing practices appeared to improve their capacity for change more so than low-performing practices through the use of a reflective adaptive process. The researchers call for future research into quality improvement interventions to address not only whether the interventions work but also why they work.

Effects of Facilitated Team Meetings and Learning Collaboratives on Colorectal Cancer Screening Rates in Primary Care Practices: A Cluster Randomized Trial
By Eric K. Shaw, PhD, et al
Mercer University, Savannah, Ga.

Editorial: Group-level Research Should Use Multimethod Designs to Explore Important Variations and Unexpected Outcomes

In an accompanying editorial, Annals of Family Medicine associate editor Robert L. Williams, MD, MPH, at the University of New Mexico commends Shaw and colleagues for their innovative reporting of important variations and unexpected outcomes among the groups, along with their use of a multimethod approach to report the context in which wide variations in the effects of the intervention occurred. While not definitive, this added information, Williams asserts, represents an important step toward understanding the causes of the variations recorded by the researchers. He concludes researchers should monitor, report and seek to explain unexpected outcomes, random variation and unrelated changes occurring in study groups in the same manner they do the effects of research activities on individuals. On behalf of the Annals of Family Medicine editorial team, Williams encourages future research using group-based research designs to adopt similar innovative methodological practices, examining and reporting important variations within groups and using multimethod designs to seek and report explanations for those variations.

Encouraging Innovation, Unintended Consequences, and Group-Level Research
By Robert L. Williams, MD, MPH
University of New Mexico, Albuquerque

Researchers Develop and Test Primary Care Practice Transformation Model

Developing and testing a model of the natural history of practice transformation among a group of 18 primary care practices in North Carolina over a two-year period, researchers identify three transformation trajectories practices can follow – transformed, activated and engaged – as well as factors affecting practices’ engagement in change efforts, the rate of quality improvement and sustainability. According to the model, transformed practices experience robust, broad-based improvement, have highly engaged leadership and use data to drive decisions. Activated practices experience moderate change on a slower improvement trajectory, usually encountering one or more barriers that take time to overcome. Engaged practices do not improve or are unable to sustain change because of multiple competing distractions that interfere with practice transformation. The authors conclude that internal and external practice motivations (e.g., improved reimbursement, office efficiencies, better patient outcomes, institutional leadership, pay-for-performance programs, and provider comparisons) and specific supports (e.g., information technology support, practice facilitators, continuing medical education, and learning sessions) affect engagement, rate of quality improvement and long-term sustainability. Moreover, they assert, early successes play a key role as practices learn how to change their performance.

Natural History of Practice Transformation: Development and Initial Testing of an Outcomes-Based Model
By Katrina E. Donahue, MD, MPH, et al
University of North Carolina, Chapel Hill

High-Performing Practices Reveal Solutions to Common Primary Care Problems That Contribute to Physician Burnout

With primary care burnout threatening patient care in the United States as physicians spend more and more time on large volumes of clerical work that do not utilize their training, researchers gather from 23 high-performing family practices innovations they believe can facilitate joy in practice and mitigate physician burnout. The authors assert a shift from a physician-centric model of work distribution to a shared-care model with higher levels of clinical support per physician and frequent forums for communication can result in high-functioning teams, improved professional satisfaction and greater joy in practice. Site visits to the 23 practices revealed five key innovations: 1) proactive planned care, with previsit planning and previsit laboratory tests; 2) shared clinical care among a team with expanded protocols, standing orders and panel management; 3) shared clerical tasks with collaborative documentation (scribing), nonphysician order entry, and streamlined prescription management; 4) improved communication by verbal messaging and inbox management; and 5) improved team functioning through co-location, team meetings and work flow mapping. These innovations, they assert, can address barriers to the healing relationship between physician and patient, take advantage of the resources of the health care team, and improve care for patients, thereby enhancing physician joy in practices.

In Search of Joy in Practice: A Report of 23 High-Functioning Primary Care Practices
By Christine A. Sinsky, MD, et al
Medical Associates Clinic and Health Plans, Dubuque, Iowa

The Role of Leaders in Building Effective Health Care Teams

With the Affordable Care Act and other movements in health care spurring team approaches to care, researchers address the potential and challenges of using teams in health care. They explore how leaders of health care organizations can create environments to support team success and incentivize team function. They assert that leaders must be conscious of their role in shaping teams and recognize that creating effective teams requires 1) their support, 2) coaches who can facilitate the development of teams, 3) organizations that value teamwork, 4) space that encourages teamwork and 5) leadership that rewards team performance.

Organizational Leadership for Building Effective Health Care Teams
By Stephen H. Taplin, MD, MPH, et al
National Cancer Institute, Rockville, Md.

Continuity of Care from the Patient’s Perspective – Security Rather than Seamlessness

A metasummary of 33 qualitative studies on continuity of care finds patients experience continuity as security and confidence rather than as seamlessness. Patients’ desire for connectedness, the researchers find, extends beyond health care encounters to include connectedness between health care and the rest of the patient’s life, which translates to a sense of security and confidence more than of seamlessness. The authors conclude, though most continuity-related reforms emphasize information and service integration, the findings of this analysis underline the need to support and protect relational continuity with trusted and trustworthy clinicians who act as partners in care.

Experienced Continuity of Care When Patients See Multiple Clinicians: A Qualitative Metasummary
By Jeannie L. Haggerty, PhD, et al
McGill University, Montréal, Québec

One-third of Family Medicine Research Presentations Become Publications

More than one-third of all original research presentations from the academic family medicine meetings of the North American Primary Care Research Group and Society of Teachers of Family Medicine eventually become publications, according to an analysis of 1,329 oral and poster presentations from the 2007 and 2008 annual conferences. The mean time of about 15 months from presentation to publication for family medicine is comparable to that of other fields. Less than two out of every five publications were in a family medicine journal, indicating breadth in family medicine research. That two-thirds of research presentations at major academic family medicine meetings appear not to transition to peer-reviewed publications, the authors assert, suggests room for improvement in developing and disseminating scholarship. They cite several barriers to the discipline’s promotion of research development, including lack of faculty protected time, lack of mentorship, and lack of specific funding for family medicine research.

Publication of Research Presented at STFM and NAPCRG Conferences
By Robert E. Post, MD, MS, et al
Virtua Family Medicine Residency, Voorhees, N.J.

Annals Publishes an Anthology of Essays from Its Reflections Section

Annals of Family Medicine is proud to announce the publication of its first book, “The Wonder and the Mystery: 10 Years of Reflections from the Annals of Family Medicine,” an anthology of intimate personal stories and innovative ideas published in the Annals’ Reflections sections. The compilation includes a wide range of articles, from influential pieces on urgent topical issues to exceptional stories of unique individuals, and features a foreword by Rachel Naomi Remen, one of the earliest pioneers in the holistic health movement and author of “Kitchen Table Wisdom.” Ordering details are available at http://www.AnnFamMed.org.


American Academy of Family Physicians