Many Family Medicine Successful Interventions and Clinical Reviews for Common Illnesses

Screening for Social Determinants of Health

We have 2 commentaries related to screening for social determinants of health (SDH).^1⇓–3 We know that multiple social determinants affect health, and there has been a strong move toward SDH screening in health settings. But do patients want SDH screening? Should “fixing” the SDH be the work for individuals, from a small but dedicated group such as an individual practice, or does it take a whole society to impact SDH?⁴ Read the commentaries that go into depth on the subject.

Improving Diabetes Care and Prevention

Here is an amazing success story: Figueroa et al⁵ reported that 7 family medicine residency programs used systematic prenatal counseling for >1500 patients, leading to lower pregnancy weight gain and a reduced incidence of prenatal diabetes! This success resulted from providers implementing the recommendations of the National Academy of Medicine (previously named the Institute of Medicine).

Some may not be familiar with “psychological insulin resistance,” a term used when a patient is psychologically opposed to initiating insulin. Many clinicians will be familiar with patients who resist starting insulin therapy. I (MB) once had a patient with very high hemoglobin A1c values associated with adult onset diabetes who repeatedly refused insulin because he so feared injections (in spite of office demonstrations). There was a solution: with his permission, his wife gave him the insulin while he was asleep. By the next visit, he was giving himself the injections and said, “Well, I never woke up when she gave me the shots and my sugars were better.” Tanga et al⁶ reported on additional physician strategies that did and did not work to overcome psychological insulin resistance.

Careyva et al⁷ specified the methodology for creating a prediabetes shared decision aid that both patients and physicians found helpful. See the 2-page visual decision aid in the appendix. Thankfully, the involved physicians also did not believe it prolonged visits. In a qualitative study from the Military Primary Care Research Network, Ledford et al⁸ identified various turning points for patients with type 2 diabetes, examining how patients make needed changes.

Improving Patient Outcomes

In another success story, Davis et al⁹ showed the advantage of repeated attempts to improve care with various interventions rolled out over time. This case study is from a single practice that monitored their outcomes over time as they successively implemented home visits, same-day urgent care, more care coordination, and in-office laboratory blood draws. The numbers show impressive success, with the same-day urgent care appearing to have made the most difference in lowering hospitalization rates.

Jiang et al¹⁰ considered the various influences on preventive service guideline uptake and found a complex interplay of factors, including the patient, clinicians, the practice, the health system, the environment, and the guidelines themselves. Sweeney et al¹¹ reported on a project using practice facilitation for quality improvement. The Agency for Healthcare Research and Quality funded 7 Cooperatives, each of which worked with over 200 primary care practices to rapidly disseminate and implement multiple targeted improvements in cardiovascular preventive care. Much has been learned from this large project, but a specific learning point is that it takes substantial infrastructure and dedicated staff to create significant and sustainable practice change.

Drug Advertising

Few physicians will be surprised by the study results reported by Jung and Fugh-Berman¹²: in spite of Food and Drug Administration rules, many of the marketing messages found in continuing medical education materials for binge eating disorder are disconcerting and do not follow the rules. Sullivan et al¹³ also found that patients are influenced by advertising. This interesting report of a nationwide FDA survey investigated patient responses to drug company direct-to-consumer advertising. Although many people would ask a physician for a specific medication brand, a sizeable minority would change clinicians if their request was refused.

Overuse Related to Endocrinology Issues

Rozario et al¹⁴ successfully intervened to decrease the overuse of vitamin D screening through primary care clinician education plus electronic health record interventions, saving 1 healthcare system more than 1 million dollars. Thyroid hormone use in the United States has skyrocketed,¹⁵ with expenditures tripling. The authors’ explanation is enlightening.

Review Articles

This issue includes 3 informative clinical reviews. Kaplan¹⁶ addressed when to use, or to attempt withdrawal of, inhaled steroids for chronic obstructive pulmonary disease. McCormick et al¹⁷ reviewed cervical spondylotic myelopathy, including many hints and pictures on physical examination methods to assist with diagnosis. With an increasing recognition of the needs of transgender patients, Radix¹⁸ provided much clinical information and practice management tips to support clinician care. In addition, Kim et al¹⁹ provided a scoping review on advance care planning prognostic indices with potential use in primary care for determining whom should receive advance care planning discussions.

Personal Reflections

“Crashing Out of a Career”²⁰ is a heartfelt reflection on an unexpected career at an Indian Health Service site, with illness eventually creating an early retirement. This essay will resonate with many clinicians who have established relationships with patients.