primary health care

A set of recommendations based upon a systematic literature review for the evaluation of patients presenting with fatigue in primary care. James W. Mold, MD, MPH

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Fatigue is one of the most common presenting complaints in primary care and poses a significant diagnostic challenge due to its multifactorial aetiology. While the majority of cases are benign and self-limiting, fatigue may also represent an early manifestation of serious underlying pathology. This review distinguishes between acute fatigue, typically transient and associated with intercurrent illness or lifestyle factors, and chronic fatigue, defined as fatigue persisting for six or more weeks, which is more likely to be multifactorial in origin.

This narrative review aims to provide a practical and structured diagnostic framework for general practitioners to evaluate and manage fatigue effectively in the primary care setting.

A narrative review of the literature was conducted using PubMed and Google Scholar. Searches were limited to articles published in English from 2010 onwards. Search terms included "fatigue," "primary care," "chronic fatigue," "myalgic encephalomyelitis," "post-viral fatigue," "sleep disorders," and "functional somatic syndromes." Seminal references predating 2010 were retained where no suitable replacement was available. This review did not employ a formal systematic search strategy, and no risk-of-bias assessment was performed, consistent with the narrative review format.

Fatigue arises from a wide range of physical, psychological, and lifestyle-related causes, best understood through a three-tier classification: primary/idiopathic, secondary, and psychosocial. A systematic approach incorporating thorough history-taking, focused clinical examination, and judicious use of investigations is essential. Identification of red flag symptoms is critical to exclude serious conditions, including malignancy and chronic infections.

A structured, patient-centred approach enables general practitioners to manage fatigue effectively while minimising unnecessary investigations and ensuring timely identification of serious disease.

Author/s:

Omar Elbaroumi

Gold 2023: Highlights for Primary Care

Linda Fowler — Wed, 10 Jan 2024 14:21:54 +0000

Date Added:

January 10, 2024

Journal/Publication:

npj Primary Care Respiratory Medicine

Publisher:

npj

Publication Date:

July 31, 2023

Issue:

Volume:

URL:

Gold 2023: Highlights for Primary Care

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

https://doi.org/10.1038/s41533-023-00349-4

Keywords

chronic obstructive pulmonary disease

gold

primary health care

Humans

PMID (1):

37524724

MeSH

pulmonary disease, chronic obstructive

Gold

Humans

primary health care

A summary for primary care clinicians of the 2023 update to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) Guidelines. James W. Mold, MD, MPH

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The Global Initiative for Chronic Obstructive Lung Disease (GOLD) has issued its 2023 annual report1. Compared with former versions, it has been significantly updated. Here, we summarize the most relevant changes for a Primary Care audience. The complete document can be downloaded for free from the GOLD web page (www.goldcopd.org), together with a “pocket guide” and a “teaching slide set”.

Author/s:

Alvar Agustí, Antoni Sisó-Almirall, Miguel Roman, Claus F. Vogelmeier

Amitriptyline at Low-Dose and Titrated for Irritable Bowel Syndrome as Second-Line Treatment in primary care (ATLANTIS): a randomised, double-blind, placebo-controlled, phase 3 trial

Erin Blanchette — Tue, 21 Nov 2023 20:21:34 +0000

Date Added:

November 21, 2023

Journal/Publication:

The Lancet

Publisher:

Elsevier

Publication Date:

November 11, 2023

Issue:

10414

Volume:

402

Pages:

1773-1785

URL:

Amitriptyline at Low-Dose and Titrated for Irritable Bowel Syndrome as Second-Line Treatment in primary care (ATLANTIS): a randomised, double-blind, placebo-controlled, phase 3 trial

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.1016/S0140-6736(23)01523-4

Keywords

amitriptyline

Irritable Bowel Syndrome

primary health care

antidepressive agents

PMID (1):

37858323

MeSH

Irritable Bowel Syndrome* / drug therapy

primary health care

Amitriptyline / adverse effects

antidepressive agents

antidepressive agents, tricyclic

amitriptyline

Irritable Bowel Syndrome

General Practitioners

Low-dose amitriptyline can be an effective and well-tolerated treatment option for patients with irritable bowel syndrome. James W. Mold, MD, MPH

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Background: Most patients with irritable bowel syndrome (IBS) are managed in primary care. When first-line therapies for IBS are ineffective, the UK National Institute for Health and Care Excellence guideline suggests considering low- dose tricyclic antidepressants as second-line treatment, but their effectiveness in primary care is unknown, and they are infrequently prescribed in this setting.

Methods: This randomised, double-blind, placebo-controlled trial (Amitriptyline at Low-Dose and Titrated for Irritable Bowel Syndrome as Second-Line Treatment [ATLANTIS]) was conducted at 55 general practices in England. Eligible participants were aged 18 years or older, with Rome IV IBS of any subtype, and ongoing symptoms (IBS Severity Scoring System [IBS-SSS] score ≥75 points) despite dietary changes and first-line therapies, a normal full blood count and C-reactive protein, negative coeliac serology, and no evidence of suicidal ideation. Participants were randomly assigned (1:1) to low-dose oral amitriptyline (10 mg once daily) or placebo for 6 months, with dose titration over 3 weeks (up to 30 mg once daily), according to symptoms and tolerability. Participants, their general practitioners, investigators, and the analysis team were all masked to allocation throughout the trial. The primary outcome was the IBS-SSS score at 6 months. Effectiveness analyses were according to intention-to-treat; safety analyses were on all participants who took at least one dose of the trial medication. This trial is registered with the ISRCTN Registry (ISRCTN48075063) and is closed to new participants.

Findings: Between Oct 18, 2019, and April 11, 2022, 463 participants (mean age 48·5 years [SD 16·1], 315 [68%] female to 148 [32%] male) were randomly allocated to receive low-dose amitriptyline (232) or placebo (231). Intention-to-treat analysis of the primary outcome showed a significant difference in favour of low-dose amitriptyline in IBS-SSS score between groups at 6 months (-27·0, 95% CI -46·9 to -7·10; p=0·0079). 46 (20%) participants discontinued low-dose amitriptyline (30 [13%] due to adverse events), and 59 (26%) discontinued placebo (20 [9%] due to adverse events) before 6 months. There were five serious adverse reactions (two in the amitriptyline group and three in the placebo group), and five serious adverse events unrelated to trial medication.

Interpretation: To our knowledge, this is the largest trial of a tricyclic antidepressant in IBS ever conducted. Titrated low-dose amitriptyline was superior to placebo as a second-line treatment for IBS in primary care across multiple outcomes, and was safe and well tolerated. General practitioners should offer low-dose amitriptyline to patients with IBS whose symptoms do not improve with first-line therapies, with appropriate support to guide patient-led dose titration, such as the self-titration document developed for this trial.

Funding: National Institute for Health and Care Research Health Technology Assessment Programme (grant reference 16/162/01).

Author/s:

Alexander C Ford, Alexandra Wright-Hughes, Sarah L Alderson, Pei-Loo Ow, Matthew J Ridd, Robbie Foy, Gina Bianco, Felicity L Bishop, Matthew Chaddock, Heather Cook, Deborah Cooper, Catherine Fernandez, Elspeth A Guthrie, Suzanne Hartley, Amy Herbert, Daniel Howdon, Delia P Muir, Taposhi Nath, Sonia Newman, Thomas Smith, Christopher A Taylor, Emma J Teasdale, Ruth Thornton, Amanda J Farrin, Hazel A Everitt, ATLANTIS trialists

Approach to atrial fibrillation: Essentials for primary care

Aubrey Delammermore — Sat, 22 Apr 2023 05:00:00 +0000

Date Added:

April 22, 2023

Journal/Publication:

Canadian Family Physician

Publisher:

College of Family Physicians of Canada

Publication Date:

April 1, 2023

Issue:

Volume:

Pages:

245-256

URL:

Approach to atrial fibrillation: Essentials for primary care

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.46747/cfp.6904245

Keywords

PMID (1):

37072207

MeSH

Anticoagulants / therapeutic use

Atrial Fibrillation* / diagnosis

chronic disease

Stroke* / etiology

primary health care

A very nice summary of current knowledge and recommendations regarding the prevention and management of atrial fibrillation. James W. Mold, MD, MPH

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Objective: To support family physicians in preventing atrial fibrillation (AF) in patients at risk and in identifying and managing those with established AF; and to summarize key recommendations for ideal screening and care of patients.

Sources of information: The 2020 Canadian Cardiovascular Society and Canadian Heart Rhythm Society comprehensive guidelines for the management of AF, based on current evidence and clinical experience related to AF.

Main message: Atrial fibrillation, which is estimated to affect at least 500,000 Canadians, is associated with high risks of stroke, heart failure, and death. Primary care clinicians occupy a central role in the management of this chronic condition, focusing on the challenges of preventing AF and identifying, diagnosing, treating, and following patients with AF. Evidence-based guidelines that provide optimal management strategies have been published by the Canadian Cardiovascular Society and Canadian Heart Rhythm Society to assist in these tasks. Messages critical to primary care are offered to support effective knowledge translation.

Conclusion: Most patients with AF can be managed effectively in primary care. Family physicians not only play an important role in ensuring patients with AF receive timely diagnoses, but they are also key to providing initial and ongoing care, especially in patients with comorbid conditions.

Author/s:

Bell, A., Andrade, J. G., Macle, L., Connelly, K. A., LaBine, L., Singer, A. G.

Penicillin allergy delabelling of patients at risk of sexually transmitted infections in primary care

Aubrey Delammermore — Thu, 30 Mar 2023 05:00:00 +0000

Date Added:

March 30, 2023

Journal/Publication:

Canadian Medical Association Journal

Publisher:

CMA Impact

Publication Date:

March 27, 2023

Issue:

Volume:

195

Pages:

E449-E451

URL:

Penicillin allergy delabelling of patients at risk of sexually transmitted infections in primary care

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1503/cmaj.221266

Keywords

Penicillins

Anti-Bacterial Agents

primary health care

sexually transmitted diseases

hypersensitivity

PMID (1):

36972911

MeSH

Anti-Bacterial Agents / adverse effects

Drug Hypersensitivity* / epidemiology

Penicillins / adverse effects

Sexually Transmitted Diseases* / epidemiology

Hypersensitivity*

A concise review and algorithm for evaluating and delabelling "penicillin-allergic"
patients. James W. Mold, MD, MPH

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KEY POINTS
Most patients who report a penicillin allergy do not have a serious allergy.

Penicillin allergy delabelling enables patients to receive penicillin and β-lactam antibiotics when indicated.

A simple algorithm allows for stratification of allergy risk for patients.

Patients at low risk of a serious allergic reaction can undergo an oral penicillin challenge in sexual health clinics and other primary care settings.

Author/s:

Wittmer, R., Vincent-Boulay, O., Barrios, J. L.

Practical Management of Lumps and Bumps of the Fingers, Hand, and Wrist

Aubrey Delammermore — Sat, 07 Jan 2023 06:00:00 +0000

Date Added:

January 7, 2023

Journal/Publication:

Journal of the American Board of Family Medicine

Publisher:

American Board of Family Medicine

Publication Date:

December 23, 2022

Issue:

Volume:

Pages:

1194-1203

URL:

Practical Management of Lumps and Bumps of the Fingers, Hand, and Wrist

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.3122/jabfm.2022.220028R2

Keywords

Dupuytren’s Contracture

Epidermal Inclusion Cysts

Fingers, Ganglion Cysts

Giant Cell Tumors

plastic surgery

primary health care

PMID (1):

36564195

MeSH

Dupuytren Contracture* / diagnosis

Dupuytren Contracture* / pathology

Dupuytren Contracture* / surgery

Hand / pathology

Wrist*

A review of some common abnormalities of the hand and wrist. James W. Mold, MD, MPH

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Background: Primary care physicians encounter many patients who present with lumps and bumps on their fingers, hands, and wrists. Some benign lesions including ganglion cysts, epidermal inclusion cysts, and giant cell tumors of the tendon sheath that are benign and can be managed by primary care clinicians most of the time in an outpatient setting.

Methods: We conducted a narrative of review of literature on the clinical presentation, diagnosis, prognosis, and management of common types of lumps and bumps found on the fingers, hand, and wrist.

Conclusions: Based on the literature review and our clinical practice, we provide indications for referral to plastic surgeons or other specialists for these lesions.

Author/s:

Ho Gung, J., Mehrzad, R., Bhatt, R. A.

Integrating Physical Therapists Into Primary Care Within A Large Health Care System

Saige Blanchard — Fri, 06 Aug 2021 05:00:00 +0000

Date Added:

August 6, 2021

Journal/Publication:

Journal of the American Board of Family Medicine

Publisher:

JABMF

Publication Date:

July 26, 2021

Issue:

Volume:

Pages:

866-870

URL:

Integrating Physical Therapists Into Primary Care Within A Large Health Care System

Type:

Best Local Practices, Practice Management Research Results

Format:

Article

DOI (1):

https://doi.org/10.3122/jabfm.2021.04.200432

Keywords

PMID (1):

34312283

MeSH

COVID-19

Patient Satisfaction

Fee-for-Service Plans

Patient Handoff

Physical Therapists

referral and consultation

A description of one health care system’s experience integrating physical therapists into primary care teams. James W. Mold, MD, MPH

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Background: Bellin Health in Wisconsin has pioneered the colocation and integration of physical therapists into primary care pods.

Methods: This is an observational study based on one in-person visit and several interviews.

Results: For patients with musculoskeletal complaints, providers make warm handoffs to the physical therapist, who is a few steps away. The physical therapist performs most of the visit, providing diagnosis, treatment, and patient education. Research studies show that-compared with physician management-appropriate patients managed by physical therapists have better outcomes, lower costs, and higher patient satisfaction. In a fee-for-service environment, the business case for this innovation requires an increased number of follow-up referrals to the physical therapy department. In the Coronavirus disease 2019 (COVID-19) era, physical therapists can provide video visits with equal quality compared with in-person visits.

Conclusion: The Bellin Health program is a blueprint for other primary care practices to integrate physical therapists into primary care teams.

Author/s:

Bodenheimer, T., Kucksdorf, J., Torn, A., Jerzak, J.

Challenges and Approaches to Population Management of Long-Term Opioid Therapy Patients

Devin Evans — Wed, 03 Mar 2021 06:00:00 +0000

Date Added:

March 3, 2021

Journal/Publication:

Journal of the American Board of Family Medicine

Publication Date:

February 1, 2021

Issue:

Volume:

Pages:

89-98

URL:

Challenges and Approaches to Population Management of Long-Term Opioid Therapy Patients

Type:

Best Local Practices, Practice Management Research Results

Format:

Article

DOI (1):

10.3122/jabfm.2021.01.190100

Keywords

PMID (1):

33452086

MeSH

analgesics, opioid

Focus Groups

Capacity Building

Medication Therapy Management

chronic pain

opioid-related disorders

drug overdose

prescriptions

Useful tips from a multi-practice initiative to improve management of opioids in primary care. James W. Mold, MD, MPH

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Purpose: Primary care is challenged with safely prescribing opioids for patients with chronic noncancer pain (CNCP), specifically to address risks for overdose, opioid use disorder, and death. We identify sociotechnical challenges, approaches, and recommendations in primary care to effectively track and monitor patients on long-term opioid therapy, a key component for supporting adoption of opioid prescribing guidelines.

Methods: We examined qualitative data (field notes and postintervention interview and focus group transcripts) from 6 rural and rural-serving primary care organizations with 20 clinic locations enrolled in a study evaluating a practice redesign program to improve opioid medication management for CNCP patients. Two independent researchers used content analysis to categorize data into key themes to develop an understanding of sociotechnical factors critical to creating and implementing an approach to tracking and monitoring of patients on long-term opioid therapy in primary care practices.

Results: Four factors were critical to developing a tracking and monitoring system. For each we describe common challenges and approaches used by the clinics to overcome then. The first factor, buy-in and participation, was essential for accomplishing the other 3. The other factors occurred sequentially: 1) cohort identification-finding the right patients, 2) data collection and extraction-tracking the right data, and 3) data use-monitoring patients and adjusting care processes.

Conclusions: We identified common challenges and approaches to tracking and monitoring patients using long-term opioid therapy for CNCP in primary care. Based on these findings we provide recommendations to build capacity for tracking and monitoring for organizations that are engaged in improving safe opioid-prescribing practices for CNCP in primary care.

Author/s:

Stephens, Kari A., Ike, Brooke, Baldwin, Laura-Mae, Packer, Christine, Parchman, Michael

Sudden Sensorineural Hearing Loss: A Diagnostic and Therapeutic Emergency

Devin Evans — Fri, 26 Feb 2021 06:00:00 +0000

Date Added:

February 26, 2021

Journal/Publication:

Journal of the American Board of Family Medicine

Publication Date:

January 31, 2021

Issue:

Volume:

Pages:

216-223

URL:

Sudden Sensorineural Hearing Loss: A Diagnostic and Therapeutic Emergency

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.3122/jabfm.2021.01.200199

Keywords

Audiology

clinical decision-making

Conductive Hearing Loss

PMID (1):

33452100

MeSH

physicians, family

Hearing Loss, Sudden

Hearing Loss, Sensorineural

Otolaryngology

Medicine

primary health care

A summary for primary care clinicians of the recently updated ENT guidelines for evaluation and management of sudden acute hearing loss. James W. Mold, MD, MPH

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The family physician's role in recognizing and managing sudden sensorineural hearing loss (SSNHL) is crucial. A recently updated otolaryngologic clinical practice guideline has been released for this emergency syndrome, but dissemination is limited to a specialty journal. As a result, the guidelines may not be widely available in the primary care setting where patients often present. We provide this focused review to clarify and disseminate SSNHL guidelines for the frontline family physician.

Author/s:

Prince, Andrew D.P., Stucken, Emily Z.

Characteristics of Case Management in Primary Care Associated With Positive Outcomes for Frequent Users of Health Care: A Systematic Review

John Bayhi — Fri, 27 Sep 2019 16:56:05 +0000

Date Added:

September 27, 2019

Journal/Publication:

Annals of Family Medicine

Publisher:

Annals of Family Medicine, Inc.

Publication Date:

September 17, 2019

Issue:

Volume:

Pages:

448-458

URL:

Characteristics of Case Management in Primary Care Associated With Positive Outcomes for Frequent Users of Health Care: A Systematic Review

Type:

Practice Management Research Results

Format:

Article

DOI (1):

10.1370/afm.2419

Keywords

PMID (1):

31501208

MeSH

Outcome Assessment (Health Care)

The results of this study should be of interest and helpful to practices that provide care management services. James W. Mold, MD, MPH

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PURPOSE:

Case management (CM) interventions are effective for frequent users of health care services, but little is known about which intervention characteristics lead to positive outcomes. We sought to identify characteristics of CM that yield positive outcomes among frequent users with chronic disease in primary care.

METHODS:

For this systematic review of both quantitative and qualitative studies, we searched MEDLINE, CINAHL, Embase, and PsycINFO (1996 to September 2017) and included articles meeting the following criteria: (1)population: adult frequent users with chronic disease, (2)intervention: CM in a primary care setting with a postintervention evaluation, and (3)primary outcomes: integration of services, health care system use, cost, and patient outcome measures. Independent reviewers screened abstracts, read full texts, appraised methodologic quality (Mixed Methods Appraisal Tool), and extracted data from the included studies. Sufficient and necessary CM intervention characteristics were identified using configurational comparative methods.

RESULTS:

Of the 10,687 records retrieved, 20 studies were included; 17 quantitative, 2 qualitative, and 1 mixed methods study. Analyses revealed that it is necessary to identify patients most likely to benefit from a CM intervention for CM to produce positive outcomes. High-intensity intervention or the presence of a multidisciplinary/interorganizational care plan was also associated with positive outcomes.

CONCLUSIONS:

Policy makers and clinicians should focus on their case-finding processes because this is the essential characteristic of CM effectiveness. In addition, value should be placed on high-intensity CM interventions and developing care plans with multiple types of care providers to help improve patient outcomes.

Author/s:

Hudon, C, Chouinard, MC, Pluye, P, El Sherif, R, Bush, PL, Rihoux, B, Poitras, ME, Lambert, M, Zomahoun, HTV, Legare, F

Ten tips for advancing a culture of improvement in primary care

Brian Desmarais — Thu, 20 Jun 2019 13:12:16 +0000

Date Added:

June 20, 2019

Journal/Publication:

BMJ Quality and Safety

Publication Date:

October 31, 2018

URL:

Ten tips for advancing a culture of improvement in primary care

Type:

Practice Management Research Results

Format:

Article

DOI (1):

10.1136/bmjqs-2018-008451

Keywords

MeSH

Personal Satisfaction

Based upon their successful improvement efforts, this academic family practice identified 10 keys to success. James W. Mold, MD, MPH

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Embracing practice-based quality improvement (QI) represents one way for clinicians to improve the care they provide to patients while also improving their own professional satisfaction. But engaging in care redesign is challenging for clinicians. In this article, we describe our experience over the last 7 years transforming the care delivered in our large primary care practice. We reflect on our journey and offer 10 tipsto healthcare leaders seeking to advance a culture of improvement. Our organisation has developed a cadre of QI leaders, tracks a range of performance measures and has demonstrated sustained improvements in important areas of patient care. Success has required deep engagement with both patients and clinicians, a long-term vision, and requisite patience.

Author/s:

Kiran, T., 'Ramji, N.', Derocher, M.B., Girdhari, R., Davie, S., Lam-Antoniades M.

Integrating Community Health Workers Into Health Care Teams Without Coopting Them

Tracy Ashby — Mon, 13 May 2019 05:00:00 +0000

Date Added:

May 13, 2019

Journal/Publication:

Health Affairs

Publisher:

Project HOPE: The People-to-People Health Foundation, Inc.

Publication Date:

May 10, 2019

URL:

Integrating Community Health Workers Into Health Care Teams Without Coopting Them

Type:

Community-Based Research Results

Format:

Article

DOI (1):

10.1377/hblog20190507.746358

Keywords

community health workers

primary health care

MeSH

community health workers

public health

delivery of health care

patient care team

An interesting article about community health workers and primary care practices. James W. Mold, MD, MPH

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Community health workers (CHWs) are trusted laypeople who help their communities achieve health and well-being. For generations, they’ve worked in church basements, shelters, and food pantries to address a variety of health and social needs. In recent years, this workforce has captured the attention of health care organizations looking to hit value-based payment targets that are heavily influenced by the social determinants of health. As a result, they increasingly are transitioning from their grassroots, community-based origins to become integrated members of health care teams. The marriage of community health and formal health care is powerful, but it’s also tricky. If CHWs lose their identity and become medicalized, their effectiveness in the community is lessened. Health care leaders must grapple with a fundamental question: How do we integrate a grassroots workforce into health care without totally coopting it? We explore this tension and offer guidance for health care leaders, based on our experience with developing the IMPaCT CHW model, which has served 10,000 patients in greater Philadelphia and provides tools and technical assistance to more than 1,000 health care organizations across the country.

The challenges facing CHWs as they become part of health care teams can be thought of as falling into four categories: agenda, identity, scope of work, and integration.

Author/s:

Garfield, Cheryl, Kangovi, Shreya

Submit a Suggestion for a New Evidence Review

Tracy Ashby — Mon, 06 May 2019 05:00:00 +0000

Date Added:

May 6, 2019

Journal/Publication:

AHRQ

Publisher:

U. S. Department of Health & Human Services

URL:

Submit a Suggestion for a New Evidence Review

Type:

Notifications and Opportunities

Format:

Web Page

Keywords

primary health care

evidence-based medicine

MeSH

primary health care

delivery of health care

United States Agency for Healthcare Research and Quality

evidence-based practice

Here’s your opportunity to suggest a topic for an AHRQ evidence review, but you have to do it by June 7. James W. Mold, MD, MPH

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What health care decisions are you struggling with? Would a review of the scientific evidence help inform this decision? Share your ideas with the Agency for Healthcare Research and Quality's (AHRQ) Evidence-based Practice Center (EPC) Program. AHRQ will use these ideas to determine the focus of its evidence reports for next fiscal year (i.e., AHRQ can provide an evidence report at no cost). Your input is important!

Propose your evidence report topics by June 7.

The 10 Building Blocks of High-Performing Primary Care

Tracy Ashby — Tue, 09 Apr 2019 05:00:00 +0000

Date Added:

April 9, 2019

Journal/Publication:

Annals of Family Medicine

Publisher:

American Academy of Family Physicians

Publication Date:

March 1, 2014

Issue:

Volume:

Pages:

166-171

URL:

The 10 building blocks of high-performing primary care.

Type:

Practice Management Reviews and Guidelines

Format:

Article

DOI (1):

10.1370/afm.1616.

Keywords

medical

physician’s practice patterns

practice management

primary health care

PMID (1):

24615313

MeSH

primary health care

leadership

continuity of patient care

forecasting

These 10 building blocks of primary care were derived from evaluations of a number of high-functioning primary care practices throughout the country. James W. Mold, MD, MPH

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Our experiences studying exemplar primary care practices, and our work assisting other practices to become more patient centered, led to a formulation of the essential elements of primary care, which we call the 10 building blocks of high-performing primary care. The building blocks include 4 foundational elements-engaged leadership, data-driven improvement, empanelment, and team-based care-that assist the implementation of the other 6 building blocks-patient-team partnership, population management, continuity of care, prompt access to care, comprehensiveness and care coordination, and a template of the future. The building blocks, which represent a synthesis of the innovative thinking that is transforming primary care in the United States, are both a description of existing high-performing practices and a model for improvement.

Author/s:

Bodenheimer, Thomas, Ghorob, Amireh, Willard-Grace, Rachel, Grumbach, Kevin

Brief physician advice for problem alcohol drinkers. A randomized controlled trial in community-based primary care practices

Jeffrey Wilson — Wed, 02 Jan 2019 14:31:45 +0000

Date Added:

January 2, 2019

Journal/Publication:

JAMA

Publisher:

American Medical Association

Publication Date:

April 1, 1997

Issue:

Volume:

277

Pages:

1039-1045

URL:

Brief physician advice for problem alcohol drinkers. A randomized controlled trial in community-based primary care practices

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.1001/jama.1997.03540370029032

Keywords

PMID (1):

9091691

MeSH

In this RCT conducted in primary care settings, two 10- to 15-minute counseling visits delivered by physicians using a scripted workbook that included advice, education, and contracting information was sufficient to reduce 7-day alcohol use from 19.1 to 11.5 at 12 months in the experimental group vs 18.9 at baseline to 15.5 at 12 months in controls (P<.001); episodes of binge drinking from 5.7 at baseline to 3.1 at 12 months in the experimental group vs 5.3 at baseline to 4.2 at 12 months in controls (P<.001), and percentage drinking excessively in previous 7 days from 47.5% at baseline to 17.8% at 12 months in the experimental group vs 48.1% at baseline to 32.5% at 12 months in controls (P<.001) at one year.

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OBJECTIVE:

Project TrEAT (Trial for Early Alcohol Treatment) was designed to test the efficacy of brief physician advice in reducing alcohol use and health care utilization in problem drinkers.

DESIGN:

Randomized controlled clinical trial with 12-month follow-up.

SETTING:

A total of 17 community-based primary care practices (64 physicians) located in 10 Wisconsin counties.

PARTICIPANTS:

Of the 17695 patients screened for problem drinking, 482 men and 292 women met inclusion criteria and were randomized into a control (n=382) or an experimental (n=392) group. A total of 723 subjects (93%) participated in the 12-month follow-up procedures.

INTERVENTION:

The intervention consisted of two 10- to 15-minute counseling visits delivered by physicians using a scripted workbook that included advice, education, and contracting information.

MAIN OUTCOME MEASURES:

Alcohol use measures, emergency department visits, and hospital days.

RESULTS:

There were no significant differences between groups at baseline on alcohol use, age, socioeconomic status, smoking status, rates of depression or anxiety, frequency of conduct disorders, lifetime drug use, or health care utilization. At the time of the 12-month follow-up, there were significant reductions in 7-day alcohol use (mean number of drinks in previous 7 days decreased from 19.1 at baseline to 11.5 at 12 months for the experimental group vs 18.9 at baseline to 15.5 at 12 months for controls; t=4.33; P<.001), episodes of binge drinking (mean number of binge drinking episodes during previous 30 days decreased from 5.7 at baseline to 3.1 at 12 months for the experimental group vs 5.3 at baseline to 4.2 at 12 months for controls; t=2.81; P<.001), and frequency of excessive drinking (percentage drinking excessively in previous 7 days decreased from 47.5% at baseline to 17.8% at 12 months for the experimental group vs 48.1% at baseline to 32.5% at 12 months for controls; t=4.53; P<.001). The chi2 test of independence revealed a significant relationship between group status and length of hospitalization over the study period for men (P<.01).

CONCLUSIONS:

This study provides the first direct evidence that physician intervention with problem drinkers decreases alcohol use and health resource utilization in the US health care system.

Author/s:

Fleming, Michael F., Barry, Kristen L., Manwell, Linda B., Johnson, Kristen, London, Richard