Among primary care patients with subthreshold depression, mindfulness meditation training reduces the incidence of major depression and improves depression symptoms.  A randomized controlled trial of adults with subthreshold depression compared a usual care group in which there was no psychological intervention (n=116) with a behavioral activation group focused on mindfulness training (n=115). Intervention participants were invited to attend weekly two-hour mindfulness training sessions for eight consecutive weeks. At 12 months, there was a statistically significant difference in the incidence of major depressive disorder between groups (11 percent in the mindfulness group compared to 27 percent in usual care).  Mindfulness training also had a small effect in reducing depression symptoms (between-group mean difference = 3.85). Other secondary outcomes demonstrated no significant change. The authors suggest that, for patients with subthreshold depression who have not had a major depressive episode in the past six months, mindfulness training is a feasible method of preventing major depression. The authors plan future research into the cost-effectiveness, health service use implications, and acceptability of mindfulness training.

Treating Subthreshold Depression in Primary Care: A Randomized Controlled Trial of Behavioural Activation With Mindfulness

Samuel Y.S. Wong, MD, et al

The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong

Kong, New Territories, Hong Kong

Asthma Management Tools Improve Asthma Control and Reduce Hospital Visits

A set of comprehensive asthma management tools helps decrease asthma-related visits to the emergency department, urgent care or hospital and improves patients’ asthma control. The Asthma APGAR tools, including an asthma control assessment completed by patients and linked to an asthma management algorithm, were tested in a randomized controlled study of 18 family medicine and pediatric practices across the United States. The study compared outcomes in more than 1,000 patients with persistent asthma aged five to 45 years using Asthma APGAR tools versus usual care. The proportion of patients reporting an asthma-related emergency department, urgent care or hospital visit in the final six months of the study differed significantly between groups: 11 percent for intervention groups and 21 percent for usual care groups.  Between baseline and one year, the percentage of patients whose asthma was in control increased significantly in the intervention group (14 percent) compared to the usual care group (3 percent), with a trend toward better control scores and asthma-related quality of life in the intervention group at 12 months. Intervention practices also significantly increased their adherence to three or more elements of the National Asthma Education and Prevention Program guidelines compared to usual care practices. Participating practices reported that changing practice to incorporate the Asthma APGAR tools was challenging, but the tools themselves were perceived as useful and efficient. The authors suggest that the Asthma APGAR tools are effective for asthma management in the primary care practice setting.

Use of Asthma APGAR Tools in Primary Care Practices: A Cluster-Randomized, Controlled Trial

Barbara P. Yawn, MD MSc FAAFP, et al
Olmsted Medical Center, Rochester, Minnesota

New Analysis Recommends Against Using Digital Rectal Exam in Primary Care

Although the digital rectal exam is widely used in primary care to screen for prostate cancer, a new study finds limited data to support its effectiveness. The study, a meta-analysis of previous research, found that the quality of available evidence was very low and that existing studies were at risk of bias. In the analysis, pooled sensitivity of the digital rectal exam among primary care physicians was 0.51 and pooled specificity was 0.59. Given the considerable lack of evidence supporting its efficacy, the authors recommend against routinely performing digital rectal exams to screen for prostate cancer in the primary care setting.

Digital Rectal Examination for Prostate Cancer Screening in Primary Care: A Systematic Review and Meta-Analysis
Jason Profetto, MD, CCFP, et al

McMaster University, Hamilton, Ontario, Canada

Patients with Multiple Conditions Receive Higher Level of Care in Affluent Areas

Patients with multimorbidity—two or more long-term medical conditions—have complex health care needs, often requiring higher levels of care than other patients. According to a new study, however, patients with multimorbidity in affluent areas receive longer doctor visits, greater perceived empathy, and more patient-centered care than comparable patients in socioeconomically deprived areas. Researchers in Scotland analyzed 659 routine visits to general practitioners in deprived and affluent areas, as well as patient ratings of general practitioner empathy. In affluent areas, multimorbid patients received longer consultations than other patients (13 minutes versus 9 minutes) while in deprived areas, consultation length was about the same for both groups (10 minutes). Similarly, patients with multimorbidity in affluent areas found GPs to be more empathetic and, according to video analysis, more attentive to their disease and illness experience. There were no such differences between similar groups in deprived areas. If primary care is to succeed in narrowing health inequalities, the authors state, action is needed to ensure that patients with multimorbidity in lower socioeconomic areas receive the same level of care and attention as patients in affluent areas.

Multimorbidity and Socioeconomic Deprivation in Primary Care Consultations

Stewart W Mercer, MBchB, PhD, et al

University of Glasgow, Glasgow, Scotland

Oseltamivir Does Not Increase Risk of Suicide in Children

A new study finds that use of oseltamivir, an antiviral drug used to treat influenza A and B, does not increase risk of suicide in children. Researchers identified 21,047 children between one and 18 years of age who attempted suicide during the 2009-2013 influenza seasons. Of those, 251 had been exposed to oseltamivir. Mean age was approximately 15 years, and underlying mental health diagnoses were common (65 percent). Because the observed association between oseltamivir and suicide could potentially be confounded by underlying influenza infection, the analysis was repeated with influenza diagnosis alone (without oseltamivir use) as the exposure. Using this novel study design, which reduced statistical concerns found in previous studies, researchers did not find an association between oseltamivir or influenza diagnosis (only) and suicide.

The Relationship Between Oseltamivir and Suicide in Pediatric Patients

James W. Antoon, MD, et al

Children’s Hospital University of Illinois, Chicago, Illinois

No Increase in Shared Decision-Making for PSA Testing but Discussions Have Broadened

Although health care organizations differ in their recommendations for use of prostate-specific antigen testing for prostate cancer screening, they agree that the decision to undergo PSA testing should be shared by patients and clinicians. A new study finds that although there has been no increase in shared decision-making for PSA testing, the content of discussions has become more comprehensive. The study compared responses to the National Health Interview Survey in 2010 and 2015 among men age 50 and older (n=9598). In this nationally representative sample, a similar proportion (approximately 60 percent) of men with recent PSA testing reported one or more elements of shared decision-making in both 2010 and 2015. They also reported a modest shift away from discussions limited to the advantages of PSA testing toward full shared decision-making in which advantages, disadvantages, and uncertainties were discussed (12 percent of recently-tested men in 2010 compared to 17 percent in 2015). One in 10 men who did not receive PSA testing reported receiving one or more elements of shared decision-making, a number which did not change during the study period. The results suggest that, contrary to guideline recommendations, many men receiving PSA testing still do not receive shared decision-making and a limited number of men without PSA testing receive one or more shared decision-making elements. The authors call for new and innovative strategies to achieve more widespread application of shared decision-making for men considering PSA testing.

Recent Patterns in Shared Decision Making for Prostate-Specific Antigen Testing in the United

States

Stacey A Fedewa, PhD, MPH, et al
American Cancer Society, Atlanta, Georgia

Electronic Consultation System Improves Access to Specialty Care

An electronic consultation system designed to reduce excessive wait times for appointments with specialists experienced exponential growth during a recent five-year period. The Champlain BASE eConsult service was created to provide primary care clinicians in Ontario, Canada with a range of high quality and timely (up to one week) specialty input. Unlike electronic consultation systems that provide direct links between clinicians, this service enables primary care clinicians to search a directory, select a specialist, and contact her/him through a secure channel. The system, created in 2010, had four completed eConsult cases in April, 2011 compared to 769 cases in April, 2016, with primary care clinicians submitting 14,105 cases to 56 specialties during the 5-year period. Specialties receiving the highest number of eConsults were dermatology (17 percent); endocrinology, obstetrics/gynecology, and hematology (7 percent each); cardiology (6 percent); and neurology (6 percent). Specialists responded in a median of 21 hours; in 75 percent of cases they responded within three days. Self-reported billing time for specialists ranged from less than 10 minutes (in 48 percent of cases) to more than 20 minutes (4 percent of cases). By the end of the study period, approximately 80 percent of primary care clinicians in the region had adopted the eConsult service, which is poised for expansion across Canada. The study demonstrates that, once integrated into a practice’s specialty referral workflow, the eConsult service has the potential to reduce wait times for specialty care.

Sustainability of a Primary Care-Driven eConsult Service

Clare Liddy, MD, MSc, CCFP, et al

C.T. Lamont Primary Health Care Research Centre, Ottawa, Ontario, Canada

Health Care Reform and EHR Design Should Be Built Around Patients’ Goals

Meaningful reform of primary care should not only address the provision, documentation and payment of care; it should be based on patients’ goals for their lives and health, with corresponding redesign of electronic health records. A report from an international team of primary care researchers recommends that the current problem-oriented fee-for-documentation structure of EHRs be replaced by a framework built around life and health goals. This focus would not only better serve patients; it would also help refocus medical professionals on the full scope of human health. To begin the process of creating goal-directed electronic health records, the authors suggest incorporating core patient profile and health planner functions into existing EHRs and creating linkages between patient characteristics and other parts of the EHR. If patient attributes captured by EHRs are expanded to include actionable sociocultural and socioeconomic information, life and health goals, care preferences, and personal risk factors, they can be leveraged by other EHR components so that patients and clinicians can work together to develop personalized care. The authors point out that, although numerous systemic and administrative health care innovations have been tried, the problem-oriented approach to care and its conceptual image coded into the medical record remain the same across innovations. If patient life and health goals are to drive health care and medical record design, shifts will also need to occur in health care delivery, measurement, and payment. The authors call for research into how patients and health care teams can partner effectively using goal-directed health records.

Moving From Problem-Oriented to Goal-Directed Health Records

Zsolt J. Nagykaldi, PhD, et al

University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma

Physicians’ Work Should Focus on Personalized Care, Not Transactional Tasks

Shifting physicians’ roles from transactional tasks to personalized care would best serve patients, physicians and society. According to a newly-articulated vision of shared care, physicians should reduce their roles in transactional aspects of care, such as gathering and entering data, providing disease-specific patient education, and providing most preventive care. Instead, such duties should be filled by other members of the health care team with complementary skills, leaving physicians to diagnose and help patients meet personal goals and objectives. Physicians’ would provide personalized care by synthesizing data from diverse, often discordant sources; adjudicating the competing needs of multiple conditions; adjusting patients’ treatment plans to align with their goals and preferences; and advocating for patients in a complicated, fragmented health care environment. To make this approach a reality, changes would need to occur on multiple levels including health care organization and delivery, technology, reimbursement, medical education, and practice and physician “buy-in.” The authors state that their vision would meet the needs of patients and society while closing the gap between physicians’ intended patient care mission and their current transactional roles. In the process, they explain, physicians could discover joy, purpose, and meaning in their work.

From Transactional Tasks to Personalized Care: A New Vision of Physicians' Roles

David B. Reuben, MD, et al

David Geffen School of Medicine at UCLA, Los Angeles, California

Clinicians’ Skills in Narrative Can Help Chronically Ill Patients Heal

“What patients bring to their clinicians is their stories,” writes behavioral scientist Thomas Egnew. It is through these stories that clinicians try to understand and treat patients’ health. When patients experience chronic or life-threatening illness and their suffering increases, clinicians can take on the role of holistic healer by addressing the inevitable existential conflicts in patients’ narratives and helping them edit their stories to promote acceptance and meaning. In this guiding role, Egnew explains, clinicians can help patients transcend suffering, “assume the mantle of their heritage as healers,” and find meaning in their work.
A Narrative Approach to Healing Chronic Illness
Thomas R. Egnew, EdD, LICSW

University of Washington School of Medicine, Seattle, Washington

A Patient Embraces the “Pathless Trek” into Chronic Illness

For a young woman with ulcerative colitis, a total colectomy (removal of the colon) marks the end of an illness and the beginning of a journey of personal discovery. Adi Finkelstein, PhD, describes her physical illness and the decision to undergo a colectomy after which, her surgeon promised her, she would have a new life. Over time, she did indeed build a new life, although perhaps not the one her surgeon envisioned. Her journey included letting go of her desire to be an exemplary patient and embracing the liberation that came with accepting her disability, as well as a career researching and teaching medical and nursing students about chronic illness. Living with her own disability while helping others better understand chronic illness is, she writes, “[a] paradox that sustains me.”
You Will Have a New Life

Adi Finkelstein, PhD

Jerusalem College of Technology, Jerusalem, Israel

A Family Physician Reflects on Community, Retirement, and Our Sagging Bodies

As a family physician approaches retirement, he reflects on the next chapter of his life with feelings of freedom and fear. “To live without the vestments of a career,” he realizes, “is a test of faith.” He finds comfort in knowing that his community will be well cared for by a new generation of physicians. On a more personal level, he is both surprised and freed by his aging body, encouraging us to “relax our grip on life, just as our skin has relaxed its grip on us.” Ultimately, he puts his faith in the knowledge that, more than three decades ago, he was called to a career in medicine. “Therein lies the hope that I will be called again.”

When It’s Time to Retire: Notes From the Afterlife

David Loxterkamp, MD
Seaport Community Health Center, Belfast, Maine

Core Outcomes Established for Multimorbidity Research

According to a panel of international experts, clinical trials of multimorbidity should measure and report, at minimum, quality of life, mortality, and mental health outcomes. Twenty-six multimorbidity researchers, clinicians, and patients from 13 countries participated in a Delphi Panel and reached consensus on 17 core outcomes for multimorbidity research. The highest ranked outcomes were health related quality of life, mental health outcomes and mortality. Other outcomes were grouped into overarching themes of patient-reported impacts and behaviors (treatment burden, self-rated health, self-management behavior, self-efficacy, adherence); physical activity and function (activities of daily living, physical function, physical activity); outcomes related to the medical visit (communication, shared decision making, prioritization); and health systems outcomes (healthcare utilization, costs, quality of healthcare). The authors suggest that, when designing studies to capture important domains in multimorbidity, researchers consider the full range of outcomes based on study aims and interventions.

A Core Outcome Set for Multimorbidity Research (COSmm)

Susan Smith, MD, MSc, et al
HRB Centre for Primary Care Research, Royal College of Surgeons, Dublin, Ireland

Innovations in Primary Care: Citizen Engagement and Team-Based Ordering of Labs

Innovations in Primary Care are brief one-page articles that describe novel innovations from health care’s front lines. In this issue:

• Citizen Engagement in Primary Care – A primary care organization uses methods of citizen engagement to gather recommendations from a representative group of patient advisors to prioritize areas for practice improvement.
• Ordering Labs as a Team – A primary care practice shifted its lab ordering procedure from a clinician activity to a team-based process.