BMC Family Practice: highlights of 2017

BMC Family Practice has had another productive year, publishing important research relating to all aspects of primary care, from treatment of chronic conditions and mental health to prescribing habits and multi-disciplinary teams. Here we present four articles worth revisiting from 2017.

Discussing success in support for patient self-management

Given the rising prevalence of long-term health conditions, self-management by patients is seen as crucial to making health care service more effective.  Support for self-management (SSM) by healthcare professionals is an important contributor to patient well-being.  Evaluations of SSM tend to focus on just one or two outcomes and so do not reveal a complete picture of the quality of service provided to patients.

Successful self-management depends on many factors, many of which cannot be influenced by a health professional.

To address this lack from the provider perspective, Owens et al. conducted individual interviews and group discussions with health professionals who worked with patients with diabetes and/or Parkinson’s Disease.  Participants were asked to discuss what they viewed as successful SSM and what factors helped or hindered this.

The descriptions of success were complex and included elements that inter-related and sometimes contradicted each other.  The three main groups of elements of success were related to patient health and quality of life, patient self-management capacity, and provider-patient relationships and communication.  Many of these elements were specific to certain contexts or patients, highlighting the difficulty in developing generic measures of success in SSM.  One challenge that was highlighted was that successful self-management depends on many factors, many of which cannot be influenced by a health professional; meanwhile, outcomes which providers can influence may not be those most important to patients.  Additionally, the definition of “realistic” goals is both individual and subjective.

The discussions of success in SSM in this paper indicate the need for careful consideration of measures of success that take into account the complexity of judgment and many ways to measure quality in this area.

Are Self-Rating Scales an Effective Tool in Primary Care for Depressed Patients?

In Sweden, patients with depression are often treated in primary care. The recommended guidelines for this population suggest that general practitioners regularly administer self-rating scales as a means to monitor depressive symptoms. However, the most commonly used, Montgomery-Asberg Depression Rating Scale (MADRS-S), is specifically designed for a psychiatric setting.

A recent multicenter randomized controlled study conducted by Wikberg et al., sought to address the utility of self-rating scales. The trial assessed the use of pharmacological treatment such as sedatives and antidepressants, patient’s quality of life, psychological wellbeing, sick leave, frequency of care visits, and the severity of depression.

For three months, general practitioners across 22 primary health care centers either administered a self-rating scale monthly along with their usual course of care or proceeded to treat patients as usual.  This study found that participants in both groups had significant improvements in quality of life, depressive symptoms and psychological wellbeing between the start of the study and the three-month follow-up.

Over the course of the study, there were also increases in the percentage of antidepressant use by the three-month mark. At the six-month follow-up, 69% of patients in the intervention group were still on anti-depressants, as compared to 59% of controls.  By the one-year mark, over 50% of patients were still using anti-depressants, with 59% in the intervention and 58% in the control groups.  Additionally, the control group visited psychology health professionals more often than the intervention group, while the intervention group visited primary care centers more than the controls.

Wikberg et al. concluded that while the self-rating scale lead to increases in continued use of anti-depressants, the other variables measured in the study were not significantly impacted by the scales. Furthermore, it is their belief that self-rating scales may be best left to the discretion of the general practitioner and the needs of their patient.

How health care providers’ burnout and empathy affect patient outcomes

High blood pressure (BP) is increasingly prevalent in most populations.  Diagnosis, treatment, and monitoring of high BP regularly take place in primary care settings.  Outcomes are often poor due to a number of factors associated with how primary health care providers manage and interact with patients.

They found that patients had significantly lower blood pressure when in the care of a doctor or nurse with low burnout.

Yuguero et al. investigated how primary care providers’ characteristics, specifically empathy and burnout, affected BP control and management in their patients.  Physician burnout is a measure of emotional exhaustion, depersonalization towards patients, and feelings of competence and success.  They found that patients had significantly lower BP when in the care of a doctor or nurse with low burnout.  They also found a significant association between low burnout and high empathy.

Previous studies have shown high empathy to improve immediate patient outcomes.  This suggests that the improved BP control seen in patients of health care professionals with lower burnout and higher empathy may result from a better physician-patient relationship and better adherence to treatment recommendations.

The findings of this study support recommendations to promote skills that improve empathy and reduce burnout among health care providers, particularly in primary care, to benefit both providers and patients.

Management of Polypharmacy in Primary Care

Polypharmacy refers to the use of multiple medications by an individual patient over their course of treatment. Increasing rates of multi-morbidity and chronic illness, the use of disease-specific evidence-based guidelines, and the lack of guidelines for multi-morbidity, have led to increases in polypharmacy.  This phenomenon is positively associated with disease management and quality of life, but is also associated with increased risk for drug interactions and side-effects.

In order to ensure that polypharmacy is most advantageous for patients, researchers have identified high-risk groups and provided suggestions for primary care physicians.  Researchers found those at highest risk were adults 65 and older, due to higher incidence of multi-morbidity with age, as well as patients in residential health care facilities. Outside of this group, primary care physicians have looked for patients at risk based on the number of medications they were taking.  While the number of medications prescribed to patients with risk of polypharmacy varies, it was recommended that patients taking ten or more medications should be identified.

In an insightful debate article, Molokhia and Majeed suggest that once physicians are aware of what factors are associated with polypharmacy, electronic medical records can be a useful tool to easily filter through patients.  They also suggested improving patient-physician communication regarding risk and benefits.

In conclusion, regularly checking in with patients to ensure that treatment are followed as directed and frequently assessing whether each drug is still necessary can allow physicians to proactively manage polypharmacy.

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