Journal Article•
Competing demands and opportunities in primary care
01 Sep 2017-Canadian Family Physician (The College of Family Physicians of Canada)-Vol. 63, Iss: 9, pp 664-668
TL;DR: Preventive interventions have yielded dramatic improvements in population health, with substantial benefits in patient-oriented outcomes including death from infectious disease and infant mortality.
Abstract: Historically, preventive interventions have yielded dramatic improvements in population health, with substantial benefits in patient-oriented outcomes including death from infectious disease and infant mortality. As medicine evolves, greater numbers of preventive and screening recommendations are
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01 Feb 2021
TL;DR: The transition from acute to chronic low back pain (LBP) is highly prevalent, with a presumed favorable prognosis; however, once chronic, LBP becomes a disabling and expensive condition, and it is unknown whether a standardized prognostic tool (i.e., Subgroups for Targeted Treatment Back tool [SBT]) can estimate this transition or whether early non-guideline concordant treatment is associated with the transition as discussed by the authors.
Abstract: Importance Acute low back pain (LBP) is highly prevalent, with a presumed favorable prognosis; however, once chronic, LBP becomes a disabling and expensive condition. Acute to chronic LBP transition rates vary widely owing to absence of standardized operational definitions, and it is unknown whether a standardized prognostic tool (ie, Subgroups for Targeted Treatment Back tool [SBT]) can estimate this transition or whether early non–guideline concordant treatment is associated with the transition to chronic LBP. Objective To assess the associations between the transition from acute to chronic LBP with SBT risk strata; demographic, clinical, and practice characteristics; and guideline nonconcordant processes of care. Design, Setting, and Participants This inception cohort study was conducted alongside a multisite, pragmatic cluster randomized trial. Adult patients with acute LBP stratified by SBT risk were enrolled in 77 primary care practices in 4 regions across the United States between May 2016 and June 2018 and followed up for 6 months, with final follow-up completed by March 2019. Data analysis was conducted from January to March 2020. Exposures SBT risk strata and early LBP guideline nonconcordant processes of care (eg, receipt of opioids, imaging, and subspecialty referral). Main Outcomes and Measures Transition from acute to chronic LBP at 6 months using the National Institutes of Health Task Force on Research Standards consensus definition of chronic LBP. Patient demographic characteristics, clinical factors, and LBP process of care were obtained via electronic medical records. Results Overall, 5233 patients with acute LBP (3029 [58%] women; 4353 [83%] White individuals; mean [SD] age 50.6 [16.9] years; 1788 [34%] low risk; 2152 [41%] medium risk; and 1293 [25%] high risk) were included. Overall transition rate to chronic LBP at six months was 32% (1666 patients). In a multivariable model, SBT risk stratum was positively associated with transition to chronic LBP (eg, high-risk vs low-risk groups: adjusted odds ratio [aOR], 2.45; 95% CI, 2.00-2.98;P Conclusions and Relevance In this cohort study, the transition rate to chronic LBP was substantial and increased correspondingly with SBT stratum and early exposure to guideline nonconcordant care.
87 citations
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TL;DR: Patients with multimorbidity who experienced joint decision making and responsibility taking in the primary care setting also had significantly higher scores for all eight PCC dimensions, indicating the instrument’s construct validity.
Abstract: Validated instruments are needed to assess the delivery of patient-centred care (PCC) to patients with multimorbidity in the primary care setting. Eight dimensions of PCC have been identified: respect for patients’ preferences, access to care, emotional support, information and education, involvement of family and friends, continuity and secure transition between health care settings, physical comfort, and coordination of care. The main objective of this study was to validate an instrument for the assessment of PCC among patients with multimorbidity in the primary care setting: the 36-item patient-centred primary care (PCPC) instrument. We included patients with multimorbidity from seven health care practices in the region of Tilburg, the Netherlands. All patients enrolled in at least two chronic care programmes (involving diagnosis of and treatment for combinations of diabetes, asthma and/or chronic obstructive pulmonary disease, cardiovascular diseases and conditions, and age-related frailty) were selected from the practices’ data registries and included as eligible participants. A total of 216 patients with multimorbidity filled in the study questionnaire (55% response rate). We tested the instrument using structural equation modelling, and examined its validity and reliability. Confirmatory factor analyses revealed good indices of fit and overall internal consistency, as represented by Cronbach’s alpha values. All eight dimensions of PCC were related positively to satisfaction with care (all p ≤ 0.001). Patients with multimorbidity who experienced joint decision making and responsibility taking in the primary care setting also had significantly higher scores for all eight PCC dimensions, indicating the instrument’s construct validity. We conclude that the psychometric properties of the 36-item PCPC instrument are good. Based on these results the PCPC instrument seems a promising tool for the assessment of PCC among patients with multimorbidity in the primary care setting.
15 citations
Cites background from "Competing demands and opportunities..."
...Primary care providers are currently not equipped to deal with the complexities of ageing populations [51]....
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TL;DR: Primary care practices should consider integrating phone call reminders into their practice, possibly as part of a targeted or staged approach to outreach for cancer screening, because phone calls were more expensive than letters.
Abstract: Background: There is good evidence that cancer-specific patient outreach improves rates of cervical, breast, and colorectal cancer screening. However, it is unclear how primary care practices should implement integrated outreach for all 3 types of cancer screening. We aimed to understand whether integrated outreach using mailed letters or phone calls were more effective at increasing screening uptake in a primary care organization. Method: We conducted a pragmatic randomized trial comparing outreach by mailed letter or personalized phone call for patients overdue for cervical, breast, or colorectal cancer screening. The study was conducted at 6 clinics within an academic primary care organization in Toronto, Canada. Our primary outcome was an uptake of at least 1 screening test for which the patient was overdue. Our primary analysis was an intention-to-treat, unadjusted comparison of proportions, using a χ 2 test. We also compared costs per additional patient screened. All analyses were stratified by sex. Results: A total of 3733 females and 1537 males were randomized to receive 1 of the interventions. Among women, 33.0% allocated to receive a reminder letter and 41.2% allocated to receive a reminder phone call received at least 1 screening test for which they were due (absolute difference, 8.1%; 95% CI, 5.1%–11.2%, P P = .073). For women and men, the letters cost approximately CaD $5.07 and CaD $7.16, respectively, for each completed screening test compared with CaD $8.71 and CaD $12.00 for the phone calls. Conclusions: Phone calls were more effective than mailed letters at increasing uptake for cervical, breast, and colorectal cancer screening among women. However, phone calls were more expensive than letters. Primary care practices should consider integrating phone call reminders into their practice, possibly as part of a targeted or staged approach to outreach for cancer screening.
12 citations
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TL;DR: In this pilot study, structural and logistical challenges appeared to make the biggest impact on adult vaccination for the responding family medicine physicians.
Abstract: Purpose: This study was conducted to characterize the vaccination practices and challenges of family medicine physicians in Los Angeles County, California.Methods: The Los Angeles Academy of Family...
12 citations
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TL;DR: Patient enrollment in Endo ECHO was associated with increased outpatient and ED utilization and increased uptake of prescription-related quality measures and no impact was observed on hospitalization.
8 citations
References
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TL;DR: Since intensive glucose control with metformin appears to decrease the risk of diabetes-related endpoints in overweight diabetic patients, and is associated with less weight gain and fewer hypoglycaemic attacks than are insulin and sulphonylureas, it may be the first-line pharmacological therapy of choice in these patients.
7,395 citations
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TL;DR: PSA-based screening reduced the rate of death from prostate cancer by 20% but was associated with a high risk of overdiagnosis.
Abstract: In the screening group, 82% of men accepted at least one offer of screening. During a median follow-up of 9 years, the cumulative incidence of prostate cancer was 8.2% in the screening group and 4.8% in the control group. The rate ratio for death from prostate cancer in the screening group, as compared with the control group, was 0.80 (95% confidence interval [CI], 0.65 to 0.98; adjusted P = 0.04). The absolute risk difference was 0.71 death per 1000 men. This means that 1410 men would need to be screened and 48 additional cases of prostate cancer would need to be treated to prevent one death from prostate cancer. The analysis of men who were actually screened during the first round (excluding subjects with noncompliance) provided a rate ratio for death from prostate cancer of 0.73 (95% CI, 0.56 to 0.90). Conclusions PSA-based screening reduced the rate of death from prostate cancer by 20% but was associated with a high risk of overdiagnosis. (Current Controlled Trials number, ISRCTN49127736.)
3,606 citations
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TL;DR: Atorvastatin 10 mg daily is safe and efficacious in reducing the risk of first cardiovascular disease events, including stroke, in patients with type 2 diabetes without high LDL-cholesterol.
3,578 citations
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TL;DR: It is found that breast cancer mortality was an unreliable outcome that was biased in favour of screening, mainly because of differential misclassification of cause of death.
Abstract: Screening with mammography uses X-ray imaging to find breast cancer before a lump can be felt. The goal is to treat cancer earlier, when a cure is more likely. The review includes seven trials that involved 600,000 women in the age range 39 to 74 years who were randomly assigned to receive screening mammograms or not. The studies which provided the most reliable information showed that screening did not reduce breast cancer mortality. Studies that were potentially more biased (less carefully done) found that screening reduced breast cancer mortality. However, screening will result in some women getting a cancer diagnosis even though their cancer would not have led to death or sickness. Currently, it is not possible to tell which women these are, and they are therefore likely to have breasts or lumps removed and to receive radiotherapy unnecessarily. If we assume that screening reduces breast cancer mortality by 15% after 13 years of follow-up and that overdiagnosis and overtreatment is at 30%, it means that for every 2000 women invited for screening throughout 10 years, one will avoid dying of breast cancer and 10 healthy women, who would not have been diagnosed if there had not been screening, will be treated unnecessarily. Furthermore, more than 200 women will experience important psychological distress including anxiety and uncertainty for years because of false positive findings.
Women invited to screening should be fully informed of both the benefits and harms. To help ensure that the requirements for informed choice for women contemplating whether or not to attend a screening programme can be met, we have written an evidence-based leaflet for lay people that is available in several languages on www.cochrane.dk. Because of substantial advances in treatment and greater breast cancer awareness since the trials were carried out, it is likely that the absolute effect of screening today is smaller than in the trials. Recent observational studies show more overdiagnosis than in the trials and very little or no reduction in the incidence of advanced cancers with screening.
1,640 citations