July/August 2013 Annals of Family Medicine tip sheet

(Press-News.org) The Need for Discussion About Prostate Cancer Screening Choices, Optimizing Shared Decision Making Three research studies and an accompanying editorial address the importance of shared decision making around prostate cancer screening. Although prostate cancer is among the most common cancers among men in the United States, the value of screening for prostate cancer by measuring prostate-specific antigen levels remains highly controversial because screening can lead to invasive procedures and treatments that in turn can cause substantial harm. Because such harms may outweigh any population-level benefit, the U.S. Preventive Services Task Force in 2012 downgraded its PSA screening recommendation to recommend against screening for average-risk men and recommended clinicians inform patients of the pros, cons and uncertainties of PSA screening before offering the test. Shared decision making, in which clinicians collaboratively help patients understand medical information to reach value-congruent medical decisions, can be effective, especially in cases of such medical uncertainty. This cluster of articles explores the prevalence, mediators, mutability and meaning of shared decision making around prostate cancer screening.

Shared Decision Making Is an Uncommon Occurrence in PSA Screening, Especially in Men Who Do Not Receive Screening Most U.S. men report little shared decision making in PSA screening, and a lack of shared decision making is more prevalent in nonscreened than in screened men. Analyzing data from a nationally representative survey of 3,427 men aged 50 to 74 years, researchers examined the prevalence of three key elements of shared decision making: physician-patient discussion of the advantages, disadvantages, and scientific uncertainty of PSA screening. Nearly two-thirds (64 percent) of men reported no past physician-patient discussion of any of the three elements (no shared decision making); 28 percent reported discussion of one to two elements only (partial shared decision making); and 8 percent reported discussion of all three elements (full shared decision making). Forty-four percent of participants reported no PSA screening, 28 percent reported less-than-annual screening and 25 percent reported nearly annual screening. Notably, the absence of shared decision making was more prevalent in men who were not screened – 88 percent of nonscreened men reported no shared decision making compared with 39 percent of men undergoing nearly annual screening. These findings, the authors assert, provide justification for a broader focus in the current policy debate about PSA screening. While much of this debate has historically focused on PSA screening in the absence of shared decision making and the potential harm of undesired and unnecessary treatment, these findings suggest the more prevalent problem is nonscreening in the absence of shared decision making – the harm of which is the failure to allow individuals to decide for themselves if screening is beneficial. The authors also found the extent of shared decision making was associated with black race, Hispanic ethnicity, higher education, health insurance and physician recommendation. Screening intensity was associated with older age, higher education, usual source of medical care and physician recommendation, as well as with partial shared decision making. National Evidence on the Use of Shared Decision Making in Prostate-Specific Antigen Screening
By Paul K. J. Han, MD, MA, MPH, et al
Maine Medical Center Research Institute, Portland

Pairing Physician Education with Patient Activation Improves Rates of Shared Decision Making and Affects Physician Attitudes About Prostate Cancer Screening Pairing a brief 20- to 30-minute Web-based educational intervention for physicians with a companion intervention for patients about counseling for prostate cancer screening appears to improve shared decision making rates and influence physicians' attitudes about screening. Analyzing data on 120 physicians and 712 male patients aged 50 to 75 years, researchers compared usual education (control) with physician education alone (MD-Ed) and paired physician education and patient activation (MD-Ed+A). They found MD-Ed+A patients had higher prostate cancer screening discussion rates (65 percent) than MD-Ed (41 percent) or control (38 percent). Standardized patients – actors trained to simulate real patient cases and later report on the encounter – also reported that physicians seeing MD-Ed+A patients were more likely to be neutral in their final recommendations about whether the patient should obtain a PSA blood test (MD-Ed+A=50 percent, MD-Ed=33 percent, control=33 percent). (Further reporting on this secondary measure can be found in an accompanying study by Feng and colleagues. Please see the full summary below.) The shift in the physicians' attitudes toward screening from a pro screening bias toward neutral counseling persisted three months after participating in the intervention. Notably, the researchers found no difference in patients' ratings of shared decision making between the groups. Coupling physician education with patient activation, the authors conclude, has the potential to improve the appropriate utilization of medical services by encouraging shared decision making around issues of medical uncertainty such as prostate cancer screening. Pairing Physician Education With Patient Activation to Improve Shared Decisions in Prostate Cancer Screening: A Cluster-Randomized Controlled Trial
By Michael S. Wilkes, MD, PhD, et al
University of California, Davis

Analysis of Unannounced Standardized Patient Visits Shows Educational Intervention Can Improve Shared Decision Making and Change Physician Attitudes About Prostate Cancer Screening In a more detailed discussion and analysis of the standardized patient visit data reported as a secondary measure in the previous study by Wilkes, et al, researchers discuss how the Web-based educational intervention appears to improve shared decision making, encourage neutrality in recommendation and reduce PSA test ordering. Analyzing transcripts from unannounced standardized patient encounters with the 118 participating primary care physicians in which trained actors prompted physicians to address prostate cancer screening, researchers found intervention physicians showed more shared decision making behaviors (intervention 14 items vs. control 11 items), were more likely to mention no screening as an option (intervention 63 percent vs. control 26 percent), to encourage patients to consider different screening options (intervention 62 percent vs. control 39 percent) and seek input from others (intervention 25 percent vs. control 7 percent). The authors conclude that by analyzing standardized patient transcripts of the actual conversations between physicians and patients, this study offers unique and important insights into how physicians actually behaved when prompted to discuss the risk and uncertainty of prostate cancer screening. They assert that in light of the USPSTF's recent recommendation against screening, interventions such as this one may be important adjuvants to help influence physicians' behaviors regarding controversial medical topics with public health implications and may potentially decrease utilization of tests with uncertain value. Physician Communication Regarding Prostate Cancer Screening: Analysis of Unannounced Standardized Patient Visits
By Bo Feng, PhD, et al
University of California, Davis

Editorial: Shared Decision Making Should be Approached as a Learned Skill Cultivated Within the Context of an Ongoing Relationship An accompanying editorial explores the importance of viewing shared decision making not as an episodic event but as a learned skill and ongoing process that is cultivated through repeated application within the context of meaningful physician-patient relationships. The authors assert the research in the current issue is consistent with previously published literature that shared decision making remains poorly integrated into primary care practices largely because it is considered in isolation. They encourage clinicians to reframe their approach to shared decision making, viewing it in a broader context and giving attention to unanswered questions, conflicting demands and systems implications. Shared Decision Making, Contextualized
By Robert L. Ferrer, MD, MPH, and James M. Gill, MD, MPH
Annals of Family Medicine

Patients with Chronic Illnesses More Likely to Receive Recommended Preventive Services In contrast to the oft-expressed concerns that increasing patient complexity impedes the delivery of preventive services because of competing demands, researchers find the presence of chronic illness is positively associated with receipt of recommended preventive services. In a study of 667,379 adult patients from 148 primary care practices across the United States, researchers found strong positive associations between the receipt of clinical preventive services and the presence of chronic illnesses. For each preventive service examined, they found a curvilinear relationship with the number of chronic conditions, with an increased likelihood of being up-to-date with preventive services as the number of chronic conditions increases from zero to four or five. At this point, they note, the association largely plateaus with no further increases in the proportion of patients up-to-date with the preventive service as the number of chronic conditions increases above five. The associations between the odds of being up-to-date and the presences of chronic illness persisted even after adjustment for age and encounter frequency. The authors conclude these findings suggest that it is something about the nature of the care provided to these patients that accounts for the finding of increased attention to prevention. They assert primary care practices, facilitated by tools like electronic health records, can overcome competing demands and effectively deliver preventive services to the growing number of patients with multiple chronic illnesses. Preventive Services Delivery in Patients With Chronic Illnesses: Parallel Opportunities Rather Than Competing Obligations
By Steven M. Ornstein, MD, et al
Medical University of South Carolina, Charleston

Study Shows the Potential for Health Plans to Implement Interventions to Improve Colon Cancer Screening Rates A previously proven telephone outreach intervention delivered by research-based staff to increase colorectal cancer (CRC) screening was successfully translated to the health plan arena with staff of a Medicaid managed care organization (MMCO) increasing (CRC) screening rates by one-third to nearly double among publicly insured urban women in this study. The trial involving 2,240 women overdue for screening and insured by one of three New York City MMCOs found intervention women were significantly more likely than usual care women to become up-to-date on CRC screening during the study period with screening rates 6 percent higher in the intervention arm. The authors note, however, that the increases varied from 1 percent to 14 percent across the participating MMCOs, with the overall increase being driven by increases at one particular MMCO. At this MMCO, telephone outreach focused solely on CRC screening, while at the other two MMCOs, telephone outreach included support for cervical and breast cancer screening as well as CRC screening. Comparing eligible intervention women reached by telephone with eligible usual care women with whom no contact was attempted, they found intervention arm screening rates were between 12 percent and 26 percent higher than usual care at the three MMCOs, with an overall increase of 15 percent (again, primarily due to screening increases at one of the MMCOs). The authors conclude these findings show that MMCOs, key players in the delivery of health care to publicly insured and underserved populations, can successfully implement interventions to increase CRC screening, reducing health care disparities among a difficult to reach population. Telephone Outreach to Increase Colon Cancer Screening in Medicaid Managed Care Organizations: A Randomized Controlled Trial
By Allen J. Dietrich, MD, et al
The Geisel School of Medicine at Dartmouth and the Norris Cotton Cancer Center, Lebanon, New Hampshire Primary Care Physicians Examine the Causes of Potentially Avoidable Hospitalizations Exploring the causality hospitalizations for illnesses that can typically be managed effectively on an outpatient basis, researchers found primary care physicians deemed most to be potentially avoidable, attributing the causes to five possible categories: system-related, physician-related, medical, patient-related and/or social. Interviews with 12 German primary care physicians regarding 104 hospitalizations of 81 patients with ambulatory care-sensitive conditions revealed participating physicians rated 41 percent of the hospitalizations as potentially avoidable. During the interviews, the cause of hospitalization fell into one or more of five principal categories: system-related (e.g., unavailability of outpatient services), physician related (e.g., suboptimal monitoring), medical (e.g., medication side effects), patient-related (e.g., delayed help-seeking) and social (e.g., lack of social support). System-related causes were attributed to 30 hospitalizations (29 percent), physician-related causes to 32 (31 percent), medical causes to 101 (97 percent), patient-related causes to 83 (80 percent) and social causes to 20 (19 percent). Based on these findings, the authors posit strategies to avoid such hospitalizations, including after-hours care, optimal use of outpatient services, intensified monitoring of high-risk patients and initiatives to improve patients' willingness and ability to seek timely help as well as patients' medication adherence. Strategies for Reducing Potentially Avoidable Hospitalizations for Ambulatory Care-Sensitive Conditions
By Tobias Freund, MD, et al
University Hospital Heidelberg, Germany

Intervention to Improve Primary Care Practices' Fitness Culture Did Not Translate Into Differential Improvements in Physical Activity and Healthy Eating Evaluating the effect of the American Academy of Family Physician's Americans in Motion – Healthy Interventions public health initiative to promote physical activity, healthy eating, and emotional well-being as part of routine patient care, researchers found impressive before-after improvements in patient outcomes but no differences between two different implementation approaches. The authors assessed the outcomes of 610 enrolled patients at 24 family medicine practices randomized to either an enhanced practice (asked to use AIM-HI tools to help office staff make personal changes and create a healthy practice environment) or a traditional practice (trained and asked to use the tools directly with patients). They hypothesized that practices which used the AIM-HI tools as a group to improve physician and office staff lifestyle behaviors and actively advertised their commitment to AIM-HI principles to their patients would be more successful in improving patient-level outcomes; however, they found no significant differences in the patient-outcomes between the two practice groups. Regardless of practice group, 16 percent of patients who completed a 10-month visit (378 patients) and 10 percent of all patients enrolled lost 5 percent or more of their body weight. Moreover, of the patients who completed a 10-month visit, 17 percent had a 2-point or greater increase in their fitness level, and 29 percent lost 5 percent or more of their body weight and/or increased their fitness level by 2 or more points. The authors posit several reasons for the lack of a between-group difference, including study design, patient selection, the nonprescriptive approach to AIM-HI, and already established physician workplace wellness activities that motivated the clinicians to intervene with patients. Effectiveness of 2 Methods of Implementing the Americans in Motion: Healthy Interventions (AIM-HI) Approach to Promoting Physical Activity, Healthy Eating, and Emotional Well-being
By Wilson D. Pace, MD, et al
University of Colorado, Aurora

Most Pregnant Women in the United States Receive Care from Multiple Types of Clinicians, Number Seeing Family Physicians Remains Stable Over Past Decade Approximately one-third of pregnant women report having seen or talked to a family physician for medical care during the prior year, a percentage that has remained stable over the past decade. Analyzing nationally representative data on 3,204 women from 2000 to 2009, researchers found a substantial and steady proportion of pregnant women (36 percent) received some care from family physicians, with most reporting receiving care from multiple types of clinicians, including family physicians, obstetrician-gynecologists, midwives, nurse practitioners and physicians assistants. The authors conclude these findings underscore the importance of care coordination for this patient population. The researchers also identify regional differences in trends in family physician care, with pregnant women in the North Central United States increasingly reporting care from family physicians and women in the South reporting a decline (7 percent annual increase vs. 5 percent annual decrease). Care From Family Physicians Reported By Pregnant Women in the United States
By Katy Backes Kozhimannil, PhD, MPA, and Patricia Fontaine, MD, MS
University of Minnesota School of Public Health, Minneapolis-St. Paul and Health Partners Institute for Education and Research, Minnesota

Safety Climate in German Family Practices Generally Positive Evaluating the impact of different individual and practice features on perceptions of the safety climate – the shared employee perceptions of the priority of safety at an organization – in German primary care practices, researchers find though the safety culture is positive overall, health care professionals' use of incident reporting and a systems approach to errors was fairly rare. The researchers' analysis of more than 2,100 questionnaires revealed the safety climate as perceived by doctors and health care assistants was not significantly influenced by individual and practice team characteristics. They also found participation of the whole practice team in the survey had a positive influence on safety climate, and doctors had more positive perceptions of four of the seven climate factors evaluated than health care assistants. Because measurement of a safety climate aims to detect areas of deficiencies to improve patient safety, the authors assert these findings should prompt German primary care doctors and health care assistants to learn more about error causation and adopt a systems approach toward patient safety incidents as a method to develop a memory for past errors and to learn from them. They call for health care assistants, in particular, to contribute more to incident reporting and participate in an open and fair safety culture. Impact of Individual and Team Features of Patient Safety Climate: A Survey in Family Practices
By Barbara Hoffmann, MD, MPH, et al
Goethe University, Frankfurt, Germany

The Consequences of Postponing Motherhood in the Pursuit of a Career in Medicine Two female physicians reflect on the consequences of postponing motherhood in the pursuit of successful medical careers. They share their personal stories of difficulty conceiving, miscarriages and stillbirth, reflecting on how their intense career focus led them to gamble away their fertility. Because delayed childbearing can result in unintended childlessness, the need for assisted reproductive techniques, adoption and having smaller than desired family size, the authors call for training programs and employers to provide more information and support to women in medicine, and adopt policies that are consistent with today's trainees' and physicians' complex lives. They caution men and women in medicine to carefully consider how medical school, residencies and fellowships can impinge on family planning.Annals of Family Medicine Women in Medicine and the Ticking Clock
By Lisa N. Miura, MD and Rebecca S. Boxer, MD, MS
Legacy Emanuel Medical Center, Portland, Oregon

### 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, http://www.annfammed.org.