Top 20 Research Studies of 2021 for Primary Care Physicians.

This article summarizes the top 20 research studies of 2021 identified as POEMs (patient-oriented evidence that matters) that did not address the COVID-19 pandemic. Sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonists prevent adverse cardiovascular and renal outcomes in patients with type 2 diabetes mellitus and also reduce all-cause and cardiovascular mortality. Most older adults (mean age, 75 years) with prediabetes do not progress to diabetes. Among patients in this age group with type 2 diabetes treated with medication, an A1C level of less than 7% is associated with increased risk of hospitalization for hypoglycemia, especially when using a sulfonylurea or insulin. For patients with chronic low back pain, exercise, nonsteroidal anti-inflammatory drugs, duloxetine, and opioids were shown to be more effective than control in achieving a 30% reduction in pain, but self-discontinuation of duloxetine and opioids was common. There is no clinically important difference between muscle relaxants and placebo in the treatment of nonspecific low back pain. In patients with chronic pain, low- to moderate-quality evidence supports exercise, yoga, massage, and mindfulness-based stress reduction. For acute musculoskeletal pain, acetaminophen, 1,000 mg, plus ibuprofen, 400 mg, without an opioid is a good option. Regarding screening for colorectal cancer, trial evidence supports performing fecal immunochemical testing every other year. For chronic constipation, evidence supports polyethylene glycol, senna, fiber supplements, magnesium-based products, and fruit-based products. The following abdominal symptoms carry a greater than 3% risk of cancer or inflammatory bowel disease: dysphagia or change in bowel habits in men; rectal bleeding in women; and abdominal pain, change in bowel habits, or dyspepsia in men and women older than 60 years. For secondary prevention in those with established arteriosclerotic cardiovascular disease, 81 mg of aspirin daily appears to be effective. The Framingham Risk Score and the Pooled Cohort Equations both overestimate the risk of cardiovascular events. Over 12 years, no association between egg consumption and cardiovascular events was demonstrated. Gabapentin, pregabalin, duloxetine, and venlafaxine provide clinically meaningful improvements in chronic neuropathic pain. In patients with moderate to severe depression, initial titration above the minimum starting dose of antidepressants in the first eight weeks of treatment is not more likely to increase response. In adults with iron deficiency anemia, adding vitamin C to oral iron has no effect. In children with pharyngitis, rhinosinusitis, acute bronchitis, or acute otitis media, providing education combined with a take-and-hold antibiotic prescription results in 1 in 4 of those children eventually taking an antibiotic.

Profile of acupuncture use among primary care physicians working in the Brazilian public healthcare system.

BACKGROUND: An introductory acupuncture course has been offered to primary health care physicians and family medicine residents in southern Brazil since 2011. OBJECTIVE: To analyze the profile of acupuncture utilization of primary care physicians who completed an introductory course of acupuncture between 2011 and 2018. METHOD: A survey using an electronic questionnaire was sent to all 119 physicians who completed the course. RESULTS: Fifty-five physicians answered the questionnaire. The majority of them reported continuation of the practice of acupuncture in scheduled appointments and on spontaneous demand. The most commonly used principles of point selection were traditional acupuncture point function, myofascial trigger point needling and point protocols. As barriers to the practice of acupuncture, time limitation and inadequate physical space were predominant. The participants described the problem-solving potential of the procedure and good patient acceptance as facilitators. The most common problems treated with acupuncture were musculoskeletal pain, and mood and anxiety disorders. A reduction in referrals to specialists and reduced prescription of pain medications were also reported. Most physicians answered that they often combined acupuncture with other medications or associated acupuncture with other complementary practices. The main adverse events reported by the participants were vascular trauma and fainting. CONCLUSION: Most primary care physicians who completed the introductory course and answered the survey still used acupuncture in their routine, primarily for the management of musculoskeletal conditions and mental health conditions. These physicians reported reductions in specialist referrals and prescription of pain medication after integrating basic acupuncture skills into primary care practice.

Practitioner Education and Feedback to Decrease Ciprofloxacin Prescriptions in Patients with Acute Uncomplicated Cystitis.

CONTEXT: Current guidelines recommend a nonfluoroquinolone agent as first-line treatment of acute uncomplicated cystitis (AUC) because of concerns of antimicrobial resistance and adverse effects. OBJECTIVE: To test whether a multifaceted intervention involving education and feedback reduced primary care practitioners' ciprofloxacin prescriptions for AUC therapy. DESIGN: Primary care practitioners at 3 medical offices participated: 65 in the intervention group and 51 in the control group. Intervention group participants received an educational lecture and emailed summary of antimicrobial guidelines, their AUC prescriptions were audited, and feedback was provided on inappropriate antibiotic choices. Prescriptions at AUC encounters were tracked during baseline, intervention, and postintervention periods. MAIN OUTCOME MEASURES: Proportion of AUC encounters at which ciprofloxacin was prescribed vs recommended first-line antibiotics. RESULTS: Intervention group participants had 5262 eligible AUC encounters, and control group participants had 5473. At baseline, ciprofloxacin was prescribed at 29.7% and 33.7% of eligible AUC encounters in the intervention and control groups, respectively (p = 0.003). After intervention, ciprofloxacin was prescribed at 10.8% of eligible AUC encounters in the intervention group and 34.3% in the control (p < 0.001). Adjusted odds ratios of ciprofloxacin prescription for AUC therapy were significantly lower in the intervention group during postintervention and intervention periods vs baseline (0.29, 95% confidence interval = 0.20-0.44, p < 0.001 and 0.80, 95% confidence interval = 0.66-0.97, p = 0.03). Adjusted odds ratios did not change over time in the controls. CONCLUSION: Educating primary care practitioners and conducting audit and feedback reduced their prescriptions of ciprofloxacin for AUC therapy.

Nutrition care by primary-care physicians: advancing our understanding using the COM-B framework.

OBJECTIVE: To investigate the nutrition education provided by primary-care physicians (PCP). DESIGN: An integrative review was used to examine literature on nutrition care provided by PCP from 2012 to 2018. A literature search was conducted in MEDLINE, PubMed, Cumulative Index of Nursing and Allied Health Literature (CINAHL) and Scopus using key search terms. SETTING: USA, Netherlands, Germany, Denmark, UK, Lebanon, Australia and New Zealand. PARTICIPANTS: Primary-care physicians. RESULTS: Sixteen qualitative and quantitative studies were analysed thematically using meta-synthesis informed by the COM-B model of behaviour (capability, motivation and opportunity), to understand the influences on PCP behaviours to provide nutrition care. PCP perceive that they lack nutrition capability. While PCP motivation to provide nutrition care differs based on patient characteristics and those of their own, opportunity is influenced by medical educators, mentors and policy generated by professional and governmental organisations. CONCLUSIONS: The development of PCP capability, motivation and opportunity to provide nutrition care should begin in undergraduate medical training, and continue into PCP training, to create synergy between these behaviours for PCP to become confident providing nutrition care as an integral component of disease prevention and management in contemporary medical practice.

Association of a Multimodal Educational Intervention for Primary Care Physicians With Prescriptions of Buprenorphine for Opioid Use Disorders.

Importance: Opioid use disorder (OUD) is a public health crisis in the United States, but only 5% of US physicians have obtained a Drug Addiction Treatment Act (DATA) waiver to prescribe buprenorphine to treat OUD. Increasing the number of primary care physicians (PCPs) who have obtained the waiver and are able to treat patients with OUD is of utmost importance. Objective: To determine whether a multimodal educational intervention of PCPs is associated with an increase in the number of buprenorphine waivers obtained and patients initiated into treatment in a primary care setting. Design, Setting, and Participants: This quality improvement study was conducted in primary health care clinics within a large, integrated health care system. Patients included those who had received a diagnosis of OUD, and had Providence Health Plan Medicare or Medicaid insurance. Included PCPs were divided into 2 groups: those who obtained a DATA waiver after an education intervention (uptake PCPs) vs those who did not obtain a DATA waiver (nonuptake PCPs). The study took place between January 1, 2016, and December 31, 2017. Data analyses were conducted from December 2017 to August 2019. Exposures: Multimodal educational intervention including video, in-person visits to clinical practitioner meetings by physician champions, and a primary care toolkit with training resources and clinic protocols. Main Outcomes and Measures: The number of new uptake clinics where at least 1 PCP obtained a DATA waiver, the number of new PCPs with DATA waivers, the number of patients receiving a buprenorphine prescription, and the number of patients who received 12 or more weeks of treatment. Results: Twenty-seven of 41 invited clinics implemented the intervention, and 620 PCPs were included. The number of PCPs with DATA waivers increased from 5 PCPs (0.8%) to 44 PCPs (7.1%), and the number of clinics with at least 1 buprenorphine prescriber increased from 3 clinics (7.3%) to 17 clinics (41.5%). In total, 213 patients underwent buprenorphine treatment, and 140 patients received 12 or more weeks of treatment. A total of 646 patients had Providence Health Plan Medicare or Medicaid insurance and were eligible for the study (mean [SD] age, 61.7 [16.5] years; 410 [63.5%] women). There was a statistically significant difference in treatment with buprenorphine between patients with uptake PCPs vs patients with nonuptake PCPs (23 patients [16.4%] vs 18 patients [3.5%]; odds ratio, 4.61 [95% CI, 2.32-10.51]; P = .01) after the intervention. Conclusions and Relevance: In this quality improvement study, an educational intervention was associated with an increase in the number of PCPs and clinics that could provide buprenorphine treatment for OUD and with an increase in the patients who were able to access care with medications for OUD.

Pain chronification: what should a non-pain medicine specialist know?

OBJECTIVE: Pain is one of the most common reasons for an individual to consult their primary care physician, with most chronic pain being treated in the primary care setting. However, many primary care physicians/non-pain medicine specialists lack enough awareness, education and skills to manage pain patients appropriately, and there is currently no clear, common consensus/formal definition of "pain chronification". METHODS: This article, based on an international Change Pain Chronic Advisory Board meeting which was held in Wiesbaden, Germany, in October 2016, provides primary care physicians/non-pain medicine specialists with a narrative overview of pain chronification, including underlying physiological and psychosocial processes, predictive factors for pain chronification, a brief summary of preventive strategies, and the role of primary care physicians and non-pain medicine specialists in the holistic management of pain chronification. RESULTS: Based on currently available evidence, we propose the following consensus-based definition of pain chronification which provides a common framework to raise awareness among non-pain medicine specialists: "Pain chronification describes the process of transient pain progressing into persistent pain; pain processing changes as a result of an imbalance between pain amplification and pain inhibition; genetic, environmental and biopsychosocial factors determine the risk, the degree, and time-course of chronification." CONCLUSIONS: Early intervention plays an important role in preventing pain chronification and, as key influencers in the management of patients with acute pain, it is critical that primary care physicians are equipped with the necessary awareness, education and skills to manage pain patients appropriately.

Perceived competency deficits and challenges of family medicine trainees in sub-Saharan Africa.

BACKGROUND: A competency-based approach to family medicine (FM) post graduate (PG) training falls short of a holistic process if it focuses only on patients' needs without eliciting those of trainees. AIM: To identify perceived competency deficits of trainees and challenges hindering achievement of learning outcomes. SETTING: PG FM programmes in sub-Saharan Africa. METHODS: We conducted a cross-sectional survey using a web-based questionnaire with a list of competency items and challenges. Common Factor Analysis was used to ascertain which competency items and challenges accounted for the highest shared variability. A perceived competency deficit was assumed for any item with a component loading of <0.5. For challenges, higher component loadings denoted higher levels of agreement with the annotated item. Data were analysed using SPSS (version 16). RESULTS: A total of 150 trainees took the survey. Appraising and utilising scientific knowledge was the item with a perceived competency deficit, while poor mentor-mentee relationship was considered the foremost challenge that hindered learning outcomes. CONCLUSION: Critical appraisal and utilisation of scientific knowledge should be part of every stage of the African FM trainee's learning experience. To achieve this and other learning outcomes, improving mentor-mentee relationships are essential.

Dyslexia in general practice education: considerations for recognition and support.

Dyslexia is a common developmental learning difficulty, which persists throughout life. It is highly likely that those working in primary care will know, or even work with someone who has dyslexia. Dyslexia can impact on performance in postgraduate training and exams. The stereotypical characteristics of dyslexia, such as literacy difficulties, are often not obvious in adult learners. Instead, recognition requires a holistic approach to evaluating personal strengths and difficulties, in the context of a supportive relationship. Strategies to support dyslexic learners should consider recommendations made in formal diagnostic reports, and aim to address self-awareness and coping skills.

Comparison of the Effectiveness of Interactive Didactic Lecture Versus Online Simulation-Based CME Programs Directed at Improving the Diagnostic Capabilities of Primary Care Practitioners.

INTRODUCTION: Diagnostic errors in primary care contribute to increased morbidity and mortality, and billions in costs each year. Improvements in the way practicing physicians are taught so as to optimally perform differential diagnosis can increase patient safety and lower the costs of care. This study represents a comparison of the effectiveness of two approaches to CME training directed at improving the primary care practitioner's diagnostic capabilities against seven common and important causes of joint pain. METHODS: Using a convenience sampling methodology, one group of primary care practitioners was trained by a traditional live, expert-led, multimedia-based training activity supplemented with interactive practice opportunities and feedback (control group). The second group was trained online with a multimedia-based training activity supplemented with interactive practice opportunities and feedback delivered by an artificial intelligence-driven simulation/tutor (treatment group). RESULTS: Before their respective instructional intervention, there were no significant differences in the diagnostic performance of the two groups against a battery of case vignettes presenting with joint pain. Using the same battery of case vignettes to assess postintervention diagnostic performance, there was a slight but not statistically significant improvement in the control group's diagnostic accuracy (P = .13). The treatment group, however, demonstrated a significant improvement in accuracy (P < .02; Cohen d, effect size = 0.79). DISCUSSION: These data indicate that within the context of a CME activity, a significant improvement in diagnostic accuracy can be achieved by the use of a web-delivered, multimedia-based instructional activity supplemented by practice opportunities and feedback delivered by an artificial intelligence-driven simulation/tutor.

A review of a national training initiative to increase provider use of MAT to address the opioid epidemic.

BACKGROUND AND OBJECTIVES: The Providers' Clinical Support System for Medication Assisted Treatment (PCSS-MAT) initiative focuses on training and mentoring health professionals in the treatment of opioid use disorders (OUD) using pharmacological strategies. Led by the American Academy of Addiction Psychiatry (AAAP), PCSS-MAT is a consortium representing four of the five national professional organizations authorized by DATA 2,000-AAAP, American Osteopathic Academy of Addiction Medicine, American Psychiatric Association, and American Society of Addiction Medicine. DATA organizations are authorized to train physicians to prescribe buprenorphine for OUD treatment. The primary aim of PCSS-MAT is to substantially increase evidence-based practices with medications for OUD. METHODS: This review describes the development of PCSS-MAT, an ongoing national initiative funded by the Substance Abuse and Mental Health Services Administration (SAMHSA), to address the training needs posed by this critical public health problem. Core initiatives include: (1) Training and mentoring activities for primary care physicians; (2) Outreach to multidisciplinary professional organizations, (3) Creating a resource portal for families, patients, and communities for OUD treatment. RESULTS: Educational outreach to providers addresses the needs of patients with OUD and common co-occurring psychiatric and medical disorders. DISCUSSION AND CONCLUSIONS: The overall scope of PCSS-MAT is to increase access to evidence-based treatment of substance use disorders as a public health priority. Recently enacted legislation requires office-based opioid treatment programs to offer all Food and Drug Administration-approved (FDA) forms of MAT. SCIENTIFIC SIGNIFICANCE: Working with health care providers to effectively deliver MAT is key to integrating behavioral and physical medicine. (Am J Addict 2016;25:603-609).

[Barriers restricting postpartum depression treatment in Chile]. / Barreras de acceso a tratamiento de la depresión posparto en Centros de Atención Primaria de la Región Metropolitana: un estudio cualitativo.

BACKGROUND: In Chile, postpartum depression is a prevalent and disabling condition. Universal screening is available but has not been translated into better treatment rates, suggesting the existence of access barriers. AIM: To describe access barriers to postpartum depression treatment in six primary health care clinics in Metropolitan Santiago, Chile. MATERIAL AND METHODS: Twenty women with postpartum depression and 18 primary health care professionals were subjected to a semi-structured interview. A qualitative methodology based on Grounded Theory was used. RESULTS: There are user associated barriers such as lack of knowledge about the disease, a negative conceptualization and rejection of available treatment options. There are also barriers associated with poor network support and some features of the health care system such as long waiting times and lack of coordination between clinical and administrative decisions. CONCLUSIONS: Patient and provider related barriers restricting treatment of postpartum depression were identified.

Psychopharmacologic Management in Integrated Care: Challenges for Residency Education.

The integration of psychiatric care in primary care is becoming a reality. Psychiatric training programs are facing multiple challenges to accommodate this transition. We here present the perspectives of Group for the Advancement of Psychiatry Committee on Psychopharmacology. The members of the group respond to the concerns raised by a resident currently confronting this changing landscape. By discussing the training, clinical, and communicating challenges of integrated care, they shed light on many of the questions being tackled by residency training programs. This commentary on the timely discussion about integrated care seeks to provide insight on the future of training in psychiatry by outlining the core questions of this change.

Barreras de acceso a tratamiento de la depresión posparto en Centros de Atención Primaria de la Región Metropolitana: un estudio cualitativo / Barriers restricting postpartum depression treatment in Chile

Background: In Chile, postpartum depression is a prevalent and disabling condition. Universal screening is available but has not been translated into better treatment rates, suggesting the existence of access barriers. Aim: To describe access barriers to postpartum depression treatment in six primary health care clinics in Metropolitan Santiago, Chile. Material and Methods: Twenty women with postpartum depression and 18 primary health care professionals were subjected to a semi-structured interview. A qualitative methodology based on Grounded Theory was used. Results: There are user associated barriers such as lack of knowledge about the disease, a negative conceptualization and rejection of available treatment options. There are also barriers associated with poor network support and some features of the health care system such as long waiting times and lack of coordination between clinical and administrative decisions. Conclusions: Patient and provider related barriers restricting treatment of postpartum depression were identified.

Organizational correlates of implementation of colocation of mental health and primary care in the Veterans Health Administration.

This study explored the role of organizational factors in the ability of Veterans Health Administration (VHA) clinics to implement colocated mental health care in primary care settings (PC-MH). The study used data from the VHA Clinical Practice Organizational Survey collected in 2007 from 225 clinic administrators across the United States. Clinic degree of implementation of PC-MH was the dependent variable, whereas independent variables included policies and procedures, organizational context, and leaders' perceptions of barriers to change. Pearson bivariate correlations and multivariable linear regression were used to test hypotheses. Results show that depression care training for primary care providers and clinics' flexibility and participation were both positively correlated with implementation of PC-MH. However, after accounting for other factors, regressions show that only training primary care providers in depression care was marginally associated with degree of implementation of PC-MH (p = 0.051). Given the importance of this topic for implementing integrated care as part of health care reform, these null findings underscore the need to improve theory and testing of more proximal measures of colocation in future work.

Model of care for the management of complex Type 2 diabetes managed in the community by primary care physicians with specialist support: an open controlled trial.

AIMS: To evaluate patient outcomes for a novel integrated primary/specialist model of community care for complex Type 2 diabetes mellitus management compared with outcomes for usual care at a tertiary hospital for diabetes outpatients. METHODS: This was a prospective open controlled trial performed in a primary and tertiary care setting in Australia. A total of 330 patients with Type 2 diabetes aged >18 years were allocated to an intervention (n=185) or usual care group (n=145). The intervention arm was a community-based model of care led by a general practitioner with advanced skills and an endocrinologist partnership. Usual care was provided via the hospital diabetes outpatient department. The primary end point was HbA(1c) concentration at 12 months. Secondary end points included serum lipids and blood pressure. RESULTS: The mean change in HbA1c concentration in the intervention group was -9 mmol/mol (-0.8%) at 12 months and in the usual care group it was -2 mmol/mol (-0.2%) (95% CI -5,1). The percentage of patients in the intervention group achieving the HbA(1c) target of ≤53 mmol/mol (7%) increased from 21 to 42% (P<0.001); for the usual care group there was a 1% increase to 39% of patients attaining this target (P=0.99). Patients in the intervention group experienced significant improvements in blood pressure and total cholesterol compared with those in the usual care group. The percentage of patients achieving clinical targets was greater in the intervention group for the combined target of HbA(1c) concentration, blood pressure and LDL cholesterol. CONCLUSIONS: A community-based, integrated model of complex diabetes care, delivered by general practitioners with advanced skills, produced clinical and process benefits compared with a tertiary diabetes outpatient clinic.

Short- and long-term effectiveness of a supervised training program in spirometry use for primary care professionals.

INTRODUCTION: Despite the importance of spirometry, its use and quality are limited in the Primary Care setting. There are few accredited training programs that have demonstrated improvement in the quality of spirometric studies. In this paper, we analyze the short- and long-term effectiveness of a supervised training program for performing and interpreting spirometries. METHODOLOGY: Ours is an intervention study with before and after measurements. The target population included teams of physicians and nursing staff at 26 health-care centers in the area of Vigo (Galicia, Spain). The structured training program involved 2 theoretical and practical training sessions (that were 2months apart), an intermediate period of 30 supervised spirometries performed in the respective centers and weekly e-mail exercises. Effectiveness was evaluated using exercises at the beginning (test 1) and the end (test 2) of the 1st day, 2nd day (test 3) and one year later (test 4), as well as the analysis of spirometries done in month1, month2 and one year later. Participants also completed a survey about their satisfaction. RESULTS: 74 participants initiated the program; 72 completed the program, but only 45 participated in the one-year evaluation. Mean test scores were: 4.1±1.9 on test 1; 7.5±1.6 on test 2; 8.9±1.3 on test 3, and 8.8±1.4 on test 4. During month1, the percentage of correctly done/interpreted tests was 71%, in month two it was 91% and after one year it was 83% (P<.05). CONCLUSIONS: A training program based on theoretical and practical workshops and a supervised follow-up of spirometries significantly improved the ability of Primary Care professionals to carry out and interpret spirometric testing, although the quality of the tests diminished over time.

Genetic educational needs and the role of genetics in primary care: a focus group study with multiple perspectives.

BACKGROUND: Available evidence suggests that improvements in genetics education are needed to prepare primary care providers for the impact of ongoing rapid advances in genomics. Postgraduate (physician training) and master (midwifery training) programmes in primary care and public health are failing to meet these perceived educational needs. The aim of this study was to explore the role of genetics in primary care (i.e. family medicine and midwifery care) and the need for education in this area as perceived by primary care providers, patient advocacy groups and clinical genetics professionals. METHODS: Forty-four participants took part in three types of focus groups: mono-disciplinary groups of general practitioners and midwives, respectively and multidisciplinary groups composed of a diverse set of experts. The focus group sessions were audio-taped, transcribed verbatim and analysed using content analysis. Recurrent themes were identified. RESULTS: Four themes emerged regarding the educational needs and the role of genetics in primary care: (1) genetics knowledge, (2) family history, (3) ethical dilemmas and psychosocial effects in relation to genetics and (4) insight into the organisation and role of clinical genetics services. These themes reflect a shift in the role of genetics in primary care with implications for education. Although all focus group participants acknowledged the importance of genetics education, general practitioners felt this need more urgently than midwives and more strongly emphasized their perceived knowledge deficiencies. CONCLUSION: The responsibilities of primary care providers with regard to genetics require further study. The results of this study will help to develop effective genetics education strategies to improve primary care providers' competencies in this area. More research into the educational priorities in genetics is needed to design courses that are suitable for postgraduate and master programmes for general practitioners and midwives.