November/December 2012 Annals of Family Medicine tip sheet

(Press-News.org) 52,000 More Primary Care Physicians Needed by 2025 to Meet Anticipated Demand Researchers project the United States will need 52,000 additional primary care physicians by 2025 — a 25 percent increase in the current workforce — to address the expected increases in demand due to population growth, aging, and insurance expansion following passage of the Affordable Care Act. Analyzing nationally representative data, the researchers conclude population growth will be the single greatest driver of increased primary care utilization, requiring approximately 33,000 additional primary care physicians by 2025, while 10,000 additional physicians will be needed to accommodate population aging. Insurance expansion, they estimate, will require approximately 8,000 additional primary care physicians, a 3 percent increase in the current workforce. Projecting US Primary Care Physician Workforce Needs: 2010-2025
By Stephen M. Petterson, PhD, et al
The Robert Graham Center, Policy Studies in Family Medicine and Primary Care, Washington, D.C.

Which Guidelines Belong in Primary Care Practice? The Case of Prostate Cancer Screening Using the example of prostate cancer screening, researchers tackle the question of whether overextended primary care clinicians should adopt guidelines developed primarily by specialists when there is limited direct evidence of benefit. The authors argue there is no direct evidence that the benefits of starting PSA screening at age 40, as recently recommended by two specialty organizations, instead of the previously recommended age of 50. Although well-meaning, the specialty guidelines, they assert, distract primary care physicians from providing services with proven benefit and value for patients. They note the US Preventive Services Task Force currently recommends delivering 35 adult preventive services, for which it found high certainty of moderate or high net benefit — services that investigators estimate require 7.4 hours a day to deliver. Given the limited time in a typically rushed primary care visit, the authors conclude there is insufficient evidence that the benefits of starting PSA screening at age 40 justifies the additional counseling time. The researchers call on primary care professional societies to vet specialty guidelines using evidence-based processes to determine which belong in primary care, thus enabling physicians to focus on providing patients services with proven effectiveness and value. Moreover, they call for primary care physicians and experts in evidence synthesis to participate on guideline review panels to ensure guidelines are based on systematic review of evidence and not solely on expert opinion. Reconciling Primary Care and Specialist Perspectives on Prostate Cancer Screening
By Richard M. Hoffman, MD, MPH, et al
University of New Mexico School of Medicine, Albuquerque

How Unrealistic Expectations are Contributing to the Health Care Crisis and the Challenge of Confronting False Beliefs In an accompanying editorial, Steven H. Woolf at Virginia Commonwealth University contends a major contributor to the alarming rise in health care costs is patients' unrealistic expectations about the benefits of health services. Confronting these beliefs, he asserts, is a potentially more effective way to bend the cost curve than many current reforms. He writes, "If patients and clinicians widely hold that a procedure is life-saving and harmless, any reform is unlikely to curb demand until those misconceptions are addressed." Yet, he points out, such beliefs and behaviors are difficult to change with facts alone because they are shaped by affective influences: beliefs and fears; vulnerability; faith and trust; longstanding routines; personal experiences; messages conveyed by advertising and medicine; and the advice, testimonials and transmitted knowledge imparted by trusted sources. He points to encouraging hints of a shift in societal attitudes about the overutilization of medical services, overdiagnosis and profligate use of screening tests, and he calls on the medical profession to act as a change agent in bringing more realistic expectations to patient care. The Price of False Beliefs: Unrealistic Expectations as a Contributor to the Health Care Crisis
By Steven H. Woolf, MD, MPH
Virginia Commonwealth University, Richmond

Patients in New Zealand Overestimate Benefits of Screening and Preventive Treatments Many patients appear willing to undergo preventive care on the basis of overly optimistic expectations of the benefits of preventive interventions and screening. Analyzing data from 354 patient questionnaires on the perceived benefit of screening for breast and bowel cancer, and medication to prevent hip fracture and cardiovascular disease, researchers in New Zealand found participants overestimated the degree of benefit conferred by all interventions. A lower level of education was associated with higher estimates of minimum acceptable benefit for all interventions. Increasing age was associated with higher levels of minimum acceptable benefit for all interventions other than hip fracture prevention. The authors conclude physicians should consider these misperceptions, which may impair informed decision making about the use of such interventions, when counseling patients. Clinicians should also consider using decision aids when discussing these interventions, especially with older patients and those with a lower level of education, as they may reduce patients' tendency to overestimate intervention benefits. Patients' Expectations of Screening and Preventive Treatments
By Ben Hudson, MRCGP, FRNZCGP, et al
University of Otago, Christchurch, New Zealand

Low Cesarean, High VBAC Rates and Good Perinatal Outcomes at Amish Birthing Center In light of U.S. policymakers' efforts to lower the rapidly increasing primary cesarean delivery rate and recent national guidelines encouraging trial of labor after cesarean, researchers find encouraging outcomes at a Wisconsin Amish birthing center. Analyzing data on 927 deliveries in this nonhospital setting, the authors found a cesarean rate of 3.8 percent (compared with the cesarean rate of 33 percent in the United States in 2009), a TOLAC rate of 100 percent, and a vaginal birth after cesarean rate of 95 percent (compared with the VBAC rate of 8 percent in the United States in 2006). There were no cases of uterine rupture or maternal death, and the neonatal mortality rate of 5.4 of 1,000 was comparable to that of Wisconsin (4.6 of 1,000 in 2008) and the United States (4.5 of 1,000). The authors conclude these findings demonstrate that in the right circumstances and practice environment, cesarean rates can be decreased and VBAC rates increased in a safe and evidence-based manner. These results, they assert, support a low-tech approach to delivery. Low Primary Cesarean Rate and High VBAC Rate With Good Outcomes in an Amish Birthing Center
By James Deline, MD, et al
La Farge Medical Clinic-VMH, Wisconsin

Vitamin D Supplementation May Provide Pain Relief for Vitamin D-deficient Patients High-dose vitamin D supplementation may have a positive effect on persistent musculoskeletal pain among vitamin D-deficient patients. A small study of 84 non-Western immigrants in Western Europe, a population prone to vitamin D deficiency and musculoskeletal problems, revealed a small positive effect on pain six weeks after supplementation with 150,000 IU of Vitamin D3 on vitamin D-deficient patients. Specifically, patients randomized to receive vitamin D supplementation were significantly more likely than those in a control group to report pain relief six weeks after treatment (35 percent vs. 20 percent). The former were also more likely to report an improved ability to walk stairs (21 percent vs. 8 percent). In a nonsignificant trend, patients receiving vitamin D over 12 weeks were more likely to report an improvement than patients receiving it over six weeks. The authors call for future investigation involving greater numbers of participants with longer follow-up and higher doses. Vitamin D Supplementation for Nonspecific Musculoskeletal Pain in Non-Western Immigrants: A Randomized Controlled Trial
By Ferdinand Schreuder, et al
Erasmus MC, Rotterdam, The Netherlands

Which Interventions Improve Influenza and Pneumococcal Vaccination Rates?
A Review of the Research With influenza and pneumococcal immunization rates below national targets, researchers review the evidence for the effectiveness of different quality improvement interventions aimed at increasing vaccination rates. The analysis of 106 studies involving more than 470,000 patients revealed the best chance for improving vaccination rates may be achieved by 1) shifting vaccine administration from physicians to members of the primary care team with clear responsibilities for chronic and preventive care and 2) activating patients through personal contact. The authors note the impact of these interventions is modest, and they call on policy makers to temper their expectations of such interventions. They call for further research to develop and evaluate more potent approaches and better understand how and why they work. Interventions to Improve Influenza and Pneumococcal Vaccination Rates Among Community-Dwelling Adults: A Systematic Review and Meta-Analysis
By Darren Lau, BMSc, et al
University of Alberta, Edmonton, Canada

Adding a Contraceptive Vital Sign to Avoid Potentially Harmful Prescriptions and Increase Preconception Counseling in Primary Care Evaluating the feasibility and efficacy of adding a "contraceptive vital sign" to help spur preconception counseling and safe prescribing of teratogenic medications (drugs known to cause congenital malformations) in primary care, researchers found a contraceptive vital sign improves documentation of pregnancy intentions and contraception in a manner that is acceptable to patients, but had little effect on the rate of family planning counseling and prescribing of potentially teratogenic medications. Specifically, the randomized controlled trial that included data on more than 2,304 women found documentation of contraception increased from 23 percent to 57 percent in the intervention group but remained 28 percent in the control group. For visits involving a teratogenic prescription, documentation increased from 14 percent to 48 percent in the intervention group and decreased from 29 percent to 26 percent in the control group. Provision of new family planning services increased only minimally, however, including among visits with potentially teratogenic prescriptions. When women with documented nonuse of contraception were prescribed potential teratogens, family planning services were provided to only 7 percent. The authors conclude that because the majority of potentially teratogenic medications are prescribed by primary care physicians, ongoing efforts are needed to ensure these patients receive preconception counseling and family planning services. They note that although the intervention was designed to limit primary care physicians' liability when a potential teratogen was prescribed, it may have inadvertently increased liability when contraceptive nonuse was explicitly documented alongside a potential teratogenic prescription. Promoting Safe Prescribing in Primary Care With a Contraceptive Vital Sign: A Cluster-Randomized Controlled Trial
By Eleanor Bimla Schwarz, MD, MS, et al
University of Pittsburgh, Penn.

High Risk of Undiagnosed Asthma and COPD in Patients with Acute Cough In a 12-country study, approximately one-fifth of adult patients without an established diagnosis of asthma or chronic obstructive pulmonary disease consulting their family physician for acute cough showed subsequent airway obstruction or bronchodilator responsiveness, both of which are suggestive of undiagnosed asthma or COPD. Analyzing data on 3,105 adult patients with acute cough in primary care practices in 12 European countries, researchers found 240 patients (12 percent) showed bronchodilator responsiveness and 193 patients (10 percent) had obstructive spirometry according to the Global Initiative for Chronic Obstructive Lung Disease grading system. The authors conclude that because both asthma and COPD benefit from appropriate and timely interventions, including pharmacological and lifestyle modifications, such as quitting smoking, clinicians should be aware and responsive to potential underdiagnosis. Additionally, they note that detection of asthma and COPD may help reduce unnecessary use of antibiotics in patients with acute cough. Airway Obstruction and Bronchodilator Responsiveness in Adults with Acute Cough
By Saskia van Vugt MD, MSc, et al
University Medical Centre Utrecht, the Netherlands

Clinically Relevant Incidental Findings on Chest Radiographs Uncommon Recognizing that imaging can sometimes produce unexpected or incidental findings that have consequences for patients and lead to further expensive and potentially harmful investigations, researchers find that clinically relevant incidental findings on chest radiographs in primary care adult patients with acute cough are uncommon. In this companion article, researchers in the Netherlands analyze 2,823 chest radiographs from patients complaining of acute cough in 16 different European primary care networks and find that although incidental findings were reported in 19 percent of patients, only 3 percent of these patients had clinically relevant incidental findings, including lung nodules and shadows. Notably, the frequency of the reporting of incidental findings varied dramatically between the different primary care networks, ranging from 0 percent to 36 percent. The authors assert these findings should inform decisions about the appropriate threshold for ordering chest radiographs in primary care, as well as guide clinicians in informing patients about the possibility of incidental findings. Incidental Chest Radiographic Findings in Adults With Acute Cough
By Saskia van Vugt, MD, MSc, et al
University Medical Centre Utrecht, the Netherlands

Modified Surgical Approach to Treating Ingrown Toenail With Excellent Results Researchers in Turkey describe a method for treating ingrown toenails that prevents recurrences. Reviewing outcomes from a series of 348 proximolateral partial matricetomies and phenol ablations in 225 patients with stage 2 or 3 ingrown toenail, they found only one recurrence during the 24-month follow-up period, no severe complications and excellent cosmetic results. The authors assert the surgical technique, which is more invasive than simple partial nail avulsion and easier to perform than wide wedge excision, is the most important determinant of the success rate. Treatment of Ingrown Toenail With Proximolateral Matrix Partial Excision and Matrix Phenolization
By Nezih Karaca, MD and Tugrul Dereli
Okmeydani Education and Research Hospital, Istanbul, Turkey

Proposed Model for the Electronic Support of Practice-Based Research Researchers propose a model for the electronic support of practice-based translational research, including the information architecture, processes, and software requirements needed to support practice-based research networks. The model, which identifies seven independent applications that interact over the Internet using standard Web services, scales to a size large enough to support every PBRN and primary care practice in the United States and supports local customization and enhancement. A Model for the Electronic Support of Practice-Based Research Networks
By Kevin Peterson, MD, MPH, et al
University of Minnesota, Minneapolis

### 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 Web site, www.annfammed.org.