PCOM Library / Hot Topics in Research / Archive for "Family Medicine"

Category: Family Medicine

Hot Topics: ACE Inhibitors Less Effective for Hypertension

jackiewe Family Medicine, Hot Topics in Research, Pharmaceutical Sciences

Comprehensive comparative effectiveness and safety of first-line antihypertensive drug classes: a systematic, multinational, large-scale analysis

Suchard, M. A., Schuemie, M. J., Krumholz, H. M., You, S. C., Chen, R., Pratt, N., . . . Ryan, P. B. (2019). Comprehensive comparative effectiveness and safety of first-line antihypertensive drug classes: A systematic, multinational, large-scale analysis https://doi.org/10.1016/S0140-6736(19)32317-7

Background

Uncertainty remains about the optimal monotherapy for hypertension, with current guidelines recommending any primary agent among the first-line drug classes thiazide or thiazide-like diuretics, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, dihydropyridine calcium channel blockers, and non-dihydropyridine calcium channel blockers, in the absence of comorbid indications. Randomised trials have not further refined this choice.

Methods

We developed a comprehensive framework for real-world evidence that enables comparative effectiveness and safety evaluation across many drugs and outcomes from observational data encompassing millions of patients, while minimising inherent bias. Using this framework, we did a systematic, large-scale study under a new-user cohort design to estimate the relative risks of three primary (acute myocardial infarction, hospitalisation for heart failure, and stroke) and six secondary effectiveness and 46 safety outcomes comparing all first-line classes across a global network of six administrative claims and three electronic health record databases. The framework addressed residual confounding, publication bias, and p-hacking using large-scale propensity adjustment, a large set of control outcomes, and full disclosure of hypotheses tested.

Findings

Using 4·9 million patients, we generated 22 000 calibrated, propensity-score-adjusted hazard ratios (HRs) comparing all classes and outcomes across databases. Most estimates revealed no effectiveness differences between classes; however, thiazide or thiazide-like diuretics showed better primary effectiveness than angiotensin-converting enzyme inhibitors: acute myocardial infarction (HR 0·84, 95% CI 0·75–0·95), hospitalisation for heart failure (0·83, 0·74–0·95), and stroke (0·83, 0·74–0·95) risk while on initial treatment. Safety profiles also favoured thiazide or thiazide-like diuretics over angiotensin-converting enzyme inhibitors. The non-dihydropyridine calcium channel blockers were significantly inferior to the other four classes.

Interpretation

This comprehensive framework introduces a new way of doing observational health-care science at scale. The approach supports equivalence between drug classes for initiating monotherapy for hypertension—in keeping with current guidelines, with the exception of thiazide or thiazide-like diuretics superiority to angiotensin-converting enzyme inhibitors and the inferiority of non-dihydropyridine calcium channel blockers.

Hot Topics: Community Organizations Can Improve Healthcare

jackiewe Family Medicine, Hot Topics in Research

Transforming community well-being through patients’ lived experiences

Gallan AS, McColl-Kennedy JR, Barakshina T, et al. Transforming community well-being through patients’ lived experiences. Journal of Business Research. 2019;100:376-391.  https://doi.org/10.1016/j.jbusres.2018.12.029.

The purpose of this article is to (1) explicate micro-to-meso linkages of well-being, (2) provide a theoretical framework to guide research on connecting patient experiences to community well-being, and (3) offer guidelines to policymakers. We develop a conceptual framework establishing connections between micro and meso levels through the expansion of patients’ lived ecosystems. We introduce the concept of patient ecosystem management (PEM), an organizational process that focuses on treating patients differently in terms of assessing, managing, and expanding resources to achieve patient health and well-beinggoals. This process establishes a foundational perspective that is necessary to connect patients’ ecosystems and to facilitate community well-being. Theoretically, this research creates ties between micro-level interactions and a collective measure (community well-being). Policymakers and healthcare professionals should take a PEM perspective, which will require new roles and behaviors, and leverage technology to expand and overlap patients’ individual service ecosystems (intra-alignment), thus enlarging community well-being (inter-alignment).

Hot Topics: Medical Selfies Empower Patients

jackiewe Family Medicine, Hot Topics in Research, Psychology and Psychiatry

Creating Consumer-Generated Health Data: Interviews and a Pilot Trial Exploring How and Why Patients Engage

Burns K, McBride CA, Patel B, FitzGerald G, Mathews S, Drennan J. Creating consumer-generated health data: Interviews and a pilot trial exploring how and why patients engage. Journal of Medical Internet Research. 2019;21(6):e12367. https://doi.org/10.2196/12367

Background: Consumer-generated health data (CGHD) are any clinically relevant data collected by patients or their carers (consumers) that may improve health care outcomes. Like patient experience measures, these data reflect the consumer perspective and is part of a patient-centric agenda. The use of CGHD is believed to enhance diagnosis, patient engagement, and thus foster an improved therapeutic partnership with health care providers.

Objective: The aim of this study was to further identify how these data were used by consumers and how it influences engagement via a validated framework. In addition, carer data has not been explored for the purpose of engagement.

Methods: Study 1 used interviews with CGHD-experienced patients, carers, and doctors to understand attitudes about data collection and use, developing an ontological framework. Study 2 was a pilot trial with carers (parents) of children undergoing laparoscopic appendectomy. For 10 days carers generated and emailed surgical site photographs to a tertiary children’s hospital. Subsequently, carers were interviewed about the engagement framework. In total, 60 interviews were analyzed using theme and content analysis.

Results: This study validates a framework anchored in engagement literature, which categorizes CGHD engagement outcomes into 4 domains: physiological, cognitive, emotional, and behavioral. CGHD use is complex, interconnected, and can be organized into 10 themes within these 4 domains.

Conclusions: CGHD can instigate an ecosystem of engagement and provide clinicians with an enhanced therapeutic relationship through an extended view into the patient’s world. In addition to clinical diagnosis and efficient use of health care resources, data offer another tool to manage consumers service experience, especially the emotions associated with the health care journey. Collection and use of data increases consumers sense of reassurance, improves communication with providers, and promotes greater personal responsibility, indicating an empowering consumer process. Finally, it can also improve confidence and satisfaction in the service.

Hot Topics: Primary Care Guidelines for Transgender Patients

jackiewe Ethics, Family Medicine, Hot Topics in Research

Care of the Transgender Patient

Safer JD, Tangpricha V. Care of the transgender patient. Annals of Internal Medicine. 2019;171(1):ITC16. https://doi.org/10.7326/AITC201907020.

Transgender persons are a diverse group whose gender identity differs from their sex recorded at birth. Some choose to undergo medical treatment to align their physical appearance with their gender identity. Barriers to accessing appropriate and culturally competent care contribute to health disparities in transgender persons, such as increased rates of certain types of cancer, substance abuse, mental health conditions, infections, and chronic diseases. Thus, it is important that clinicians understand the specific medical issues that are relevant to this population.

Hot Topics: Loan Forgiveness Drives DOs to Primary Care

jackiewe Family Medicine, Hot Topics in Research, Osteopathic Manipulative Medicine

Role of Debt and Loan Forgiveness/Repayment Programs in Osteopathic Medical Graduates’ Plans to Enter Primary Care

Scheckel CJ, Richards J, Newman JR, et al. Role of debt and loan forgiveness/repayment programs in osteopathic medical graduates’ plans to enter primary care. JAOA. 2019;119(4):227-235. https://doi.org/10.7556/jaoa.2019.038.

Context: Osteopathic medicine emphasizes partnering with patients to help them attain or maintain health. This philosophy encourages physicians to practice primary care and a mission of improving community health. However, there is currently a shortage of primary care physicians in many areas of the United States.

Objective: To determine whether intended practice patterns of recent graduates of colleges of osteopathic medicine favor primary care and whether practice patterns correlate with medical education debt.

Methods: Responses were analyzed from the American Association of Colleges of Osteopathic Medicine survey of pending medical school graduates from 2007 through 2016 regarding indebtedness and specialty selection.

Results: The percentage of graduating osteopathic medical students who chose a primary care specialty increased from 28.1% (676 students) in 2007 to 33.2% (1377 students) in 2016. Among graduates, those above the 75th percentile of debt had a general move toward more non–primary care positions, with a value of 74.4% in 2007 and 79.9% in 2016. Graduates below the 25th percentile had a gradual increase in primary care representation, moving from 24.6% in 2007 to 29.4% in 2016. In 2007, graduates with a loan forgiveness/repayment program were more likely to choose primary care over graduates without such a program (OR, 0.681 [95% CI, 0.505-0.920]; P=.02). Analysis of subsequent years showed a declining OR with increasing significance.

Conclusions: Results of this analysis indicated that increased educational debt loan directly influenced physician practice choice. Graduates with high debt burden were more likely to enter primary care fields and use loan forgiveness/repayment programs. Graduates with high debt burden who did not use loan forgiveness/repayment programs were more likely to enter non–primary care specialty fields, with this trend increasing as mean medical school debt increased. This association has implications for policies that could affect choice of primary care. However, further research is needed to fully understand the primary care choice by graduates of colleges of osteopathic medicine.

Hot Topics: Current Patient Engagement Measures Fall Short

jackiewe Family Medicine, Hot Topics in Research, Uncategorized
How do healthcare professionals working in accountable care organisations understand patient activation and engagement? Qualitative interviews across two time points

Mishra MK, Saunders CH, Rodriguez HP, Shortell SM, Fisher E, Elwyn G. How do healthcare professionals working in accountable care organisations understand patient activation and engagement? Qualitative interviews across two time points. BMJ Open. 2018;8(10). http://dx.doi.org/10.1136/bmjopen-2018-023068

Objective If patient engagement is the new ‘blockbuster drug’ why are we not seeing spectacular effects? Studies have shown that activated patients have improved health outcomes, and patient engagement has become an integral component of value-based payment and delivery models, including accountable care organisations (ACO). Yet the extent to which clinicians and managers at ACOs understand and reliably execute patient engagement in clinical encounters remains unknown. We assessed the use and understanding of patient engagement approaches among frontline clinicians and managers at ACO-affiliated practices.

Design Qualitative study; 103 in-depth, semi-structured interviews.

Participants Sixty clinicians and eight managers were interviewed at two established ACOs.

Approach We interviewed healthcare professionals about their awareness, attitudes, understanding and experiences of implementing three key approaches to patient engagement and activation: 1) goal-setting, 2) motivational interviewing and 3) shared decision making. Of the 60 clinicians, 33 were interviewed twice leading to 93 clinician interviews. Of the 8 managers, 2 were interviewed twice leading to 10 manager interviews. We used a thematic analysis approach to the data.

Key results Interviewees recognised the term ‘patient activation and engagement’ and had favourable attitudes about the utility of the associated skills. However, in-depth probing revealed that although interviewees reported that they used these patient activation and engagement approaches, they have limited understanding of these approaches.

Conclusions Without understanding the concept of patient activation and the associated approaches of shared decision making and motivational interviewing, effective implementation in routine care seems like a distant goal. Clinical teams in the ACO model would benefit from specificity defining key terms pertaining to the principles of patient activation and engagement. Measuring the degree of understanding with reward that are better-aligned for behaviour change will minimise the notion that these techniques are already being used and help fulfil the potential of patient-centred care.