Must-Read Family Medicine Research—Glucosamine/Chondroitin Supplements and Mortality, Telomere Length and the Doctor-Patient Relationship, Reducing Opioid Use, and More
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* Dean A. Seehusen
* Marjorie A. Bowman

## Abstract

This issue of the *Journal* contains some exceptional research articles. A few are truly “must-reads,” including a fascinating look at the relationship between having a usual source of care and telomere length. Glucosamine/chrondroitin supplementation seems to be helpful for more than just arthritis pain. There is a very practical advice on keeping patients discharged from the emergency department out of the hospital and on reducing patient requests for inappropriate antibiotics. This issue also features 5 articles addressing how family physicians can combat the opioid epidemic. Three articles highlight research on diabetes and another 3 on breast cancer. Payment reform, dermoscopy, and telemedicine are among many other topics covered.

Two potential keys to a longer life? Definitely 2 must reads for family physicians. First, continuity has always been considered foundational to the practice of family medicine and has been associated with many positive health outcomes, including lower mortality. Baltrus et al1 used National Health and Nutrition Examination Survey (NHANES) data to evaluate the relationship between having a usual source of care and leukocyte telomere length (LTL). LTL is associated with chronic stress and aging. This very interesting study provides us with one plausible biological mechanism to explain the well-established benefits of continuity.

Taking their cue from preliminary research on the topic, King and Xiang2 used another large publicly available database to evaluate the effects of glucosamine/chondroitin on overall and cardiovascular mortality. Their results are not only consistent with the preliminary research, the beneficial effects suggested are quite surprising. These findings may make everyone rethink their position on these supplements.

There is growing concern that the COVID-19 pandemic will only make another health care crisis in America—the opioid addiction epidemic—worse.3 It would seem that treating opioid use disorder will continue to grow as a proportion of what family physicians do on a daily basis. Justesen et al4 report on factors associated with patient retention in a medication-assisted treatment program based in a family medicine residency clinic. We also know that opioid prescriptions for acute pain can start patients down the path to long-term opioid use. Onishi et al5 examined which patient characteristics are associated with an expectation that opioids will be prescribed for acute pain. The findings set the stage for future research on interventions that reduce such expectations. In an effort to improve and standardized the opioid prescribing practices within their family medicine clinic, investigators at the University of North Carolina created a Controlled Medication Advisory Board.6 The results over a 4-year time frame are encouraging. The authors provide several excellent tools to facilitate recreating such a board at other institutions. Meanwhile, Lai et al7 are designing an opioid taper tool to help family physicians safely reduce their patients’ morphine milligram equivalents per day in accordance with recent guidelines. Lastly, Boggiano et al8 demonstrate how important receiving high-quality education on the treatment of opioid-use disorder (OUD) during residency is for future practice patterns regarding OUD.

There has been a lot written on the pros and cons of mammography in average-risk women. Less is known about how the ongoing debate surrounding when, and how often, to recommend mammography is viewed by family physicians. A team of researchers from Canada used some novel methodology to explore family physicians’ perspectives on the topic.9 In 2019, The United States Preventive Services Task Force recommended the 7-Question Family History Screening (FHS-7) tool to identify asymptomatic women who should be offered genetic counseling related to *BRCA*-related cancer risk. A surprising percentage of women in one urban academic medical center completing the FHS-7 met referral criteria.10 The results prompt the investigators to question whether the FHS-7 is the right tool for the job. For many reasons, breast cancer survivors have a higher risk of cardiovascular disease than women without a history of breast cancer. Among women followed in primary care at the Medical University of South Carolina, breast cancer survivors were also more likely to be screened and treated for cardiovascular disease risk factors.11 It is likely that these patients’ increased health awareness is part of the reason. It is also likely that having a usual source of care contributes.

As the number of patients family physicians care for with diabetes continues to grow, preventing diabetes complications is becoming a key component of clinical practice. Because diabetes treatment is predicated on lifestyle change, communication between the patient and their family physician is of utmost importance. A team out of the University of Florida explored the prevention of complications and cost savings of 1 strategy.12 It is not news that among patients with diabetes, depression is associated with worse glycemic control. In an ambitious study looking at most patients with diabetes living in Minnesota over the course of 8 years, an interesting interaction with living a rural town was found.13 This study is further evidence that the underlying causes, as well as the best treatments, are linked with patients’ social relationships and support structures. A research team from the University of Maryland–College Park report the results of their internet survey of patients with diabetes, exploring patient knowledge of the relationship between diabetes and periodontal disease.14 This is must-read research if you do not regularly recommend dental appointments to your patients with diabetes.

Patients with Down Syndrome are living longer so family physicians see this population as older adults. Fitzpatrick et al15 used a large national database of patients with Down Syndrome to conduct a retrospective cohort study spanning 20 years. Their findings related to cardiovascular risk factors and heart disease in patients with Down Syndrome are quite interesting and challenge prevailing perceptions. Adults with communications difficulties are another population known to have worse health outcomes. Stransky et al16 examined over 33,000 responses to another national survey (the National Health Interview Survey Voice, Speech, and Language Supplement) to identify behavioral health symptoms and diagnoses associated with communication difficulties.

Family medicine leaders have been calling for payment reform for a long time. The Medicare Access and CHIP Reauthorization Act (MACRA) is one government answer to those calls. How well are practices planning for the changes required by MACRA? In particular, how are smaller practices doing? A qualitative study of small and medium practices in Virginia highlights some unintended consequences of such reform measures.17

Keeping low-acuity patients out of the hospital is more important now than ever. Close, reliable followup after Emergency Department visits can help prevent avoidable hospitalization. Nanavati et al.18 report on a novel, low-tech, low-cost method that worked for them. This method, or a variation of it, could work in almost any family medicine clinic. While electronic medical records have not fulfilled all the expectations many had 20 years ago, there are many ways in which this technology can improve clinical care. Mulhem19 adds to that list with a well-conducted study of a Hepatitis C screening reminder embedded in the electronic medical record. Patient portals also help provide care outside of the traditional clinic visit. El-Toukhy et al.20 explored factors associated with use, or lack of use, of patient portals and their various functions.

Family physicians are frequently faced with requests for antibiotics for inappropriate indications. What types of messages about the harms of prescribing nonindicated medications are most effective at reducing such requests? The messages in typical antibiotic stewardship campaigns may need to change.21 Making a strong argument for team-based care, investigators in West Virginia report on an analysis of a chronic obstructive pulmonary disease clinic staffed by an interdisciplinary team.22

Most practicing family physicians are providing care for children, but it seems that the percentage is falling. The Robert Graham Center used data from family physicians registering to take the American Board of Family Medicine Certification Examination to quantify the trend in the years 2014 to 2018.23

In recent years, dermoscopy has been shown to be an easy to use and effective tool for the detection of skin cancer when put in the hands of family physicians.24 What has the uptake of this tool been and how do family physicians feel about using dermoscopy in their clinics?25 Randall26 provides an update on the current indications for tonsillectomy and adenoidectomy.

Fenton et al27 analyzed the inter-rater reliability of the peer review ratings of abstracts to 2 large academic family medicine conferences. The results were disappointing, but perhaps not surprising. Considering these conferences are important events for the development of junior faculty and the sharing of new information in the specialty, this is a real problem. Hopefully, these findings will trigger some creative rethinking of how abstracts are selected. The authors have generously started this process.

## Notes

*   *Conflict of interest:* The authors are editors of the *JABFM*.

*   To see this article online, please go to: [http://jabfm.org/content/33/6/823.full](http://jabfm.org/content/33/6/823.full).

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    [Abstract/FREE Full Text](http://www.jabfm.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NToiamFiZnAiO3M6NToicmVzaWQiO3M6ODoiMzMvNi85OTgiO3M6NDoiYXRvbSI7czoyMDoiL2phYmZwLzMzLzYvODIzLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

9.  9.Siedlikowski S, Grad R, Bartlett-Esquilant G, Ells C. Physician perspectives on mammography screening for average-risk women: “like a double-edged sword”. J Am Board Fam Med 2020;33:871–884.
    
    [Abstract/FREE Full Text](http://www.jabfm.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NToiamFiZnAiO3M6NToicmVzaWQiO3M6ODoiMzMvNi84NzEiO3M6NDoiYXRvbSI7czoyMDoiL2phYmZwLzMzLzYvODIzLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

10. 10.Parente DJ. *BRCA*-related cancer genetic counseling is indicated in many women seeking primary care. J Am Board Fam Med 2020;33:885–893.
    
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11. 11.Price S, Mims LD, Player MS, et al. Cardiovascular screening and lipid management in breast cancer survivors. J Am Board Fam Med 2020;33:894–902.
    
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12. 12.Hong YR, Huo J, Jo A, Cardel M, Mainous AG. Association of patient-provider teach-back communication with diabetic outcomes: a cohort study. J Am Board Fam Med 2020;33:903–912.
    
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13. 13.Fu HNC, Skolnick VG, Carlin C, Solberg L, Raiter AM, Peterson KA. The effect of depression and rurality on diabetes control. J Am Board Fam Med 2020;33:913–922.
    
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15. 15.Fitzpatrick V, Rivelli A, Bria K, Chicoine B. Heart disease in adults with Down syndrome between 1996 and 2016. J Am Board Fam Med 2020;33:923–931.
    
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16. 16.Stransky ML, Oshita JY, Morris MA. Prevalence of behavioral health problems among adults with and without communication disabilities. J Am Board Fam Med 2020;33:932–941.
    
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17. 17.Soylu TG, Goldberg DG, Cuellar AE, Kuzel AJ. Medicare access and CHIP Reauthorization Act in small to medium-sized primary care practices. J Am Board Fam Med 2020;33:942–952.
    
    [Abstract/FREE Full Text](http://www.jabfm.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NToiamFiZnAiO3M6NToicmVzaWQiO3M6ODoiMzMvNi85NDIiO3M6NDoiYXRvbSI7czoyMDoiL2phYmZwLzMzLzYvODIzLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

18. 18.Nanavati M, Saenz S, Swayne K, Carek P. The golden letter: innovation collaboration to reduce avoidable hospital admissions. J Am Board Fam Med 2020;33:1011–1015.
    
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19. 19.Mulhem E, Brown I, Song K. Electronic health record reminder effect on hepatitis C antibody screening. J Am Board Fam Med 2020;33:1016–1019.
    
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20. 20.El-Toukhy S, Méndez A, Collins S, Pérez Stable EJ. Barriers to patient portal access and use: evidence from the Health Information National Trends Survey. J Am Board Fam Med 2020;33:953–968.
    
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21. 21.Miller BJ, Carson KA, Keller S. Educating patients on unnecessary antibiotics: personalizing potential harm aids patient understanding. J Am Board Fam Med 2020;33:969–977.
    
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22. 22.Peckens S, Adelman MM, Ashcraft AM, Xiang J, Sheppard B, King DE. Improving chronic obstructive pulmonary disease (COPD) symptoms using a team-based approach. J Am Board Fam Med 2020;33:978–985.
    
    [Abstract/FREE Full Text](http://www.jabfm.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NToiamFiZnAiO3M6NToicmVzaWQiO3M6ODoiMzMvNi85NzgiO3M6NDoiYXRvbSI7czoyMDoiL2phYmZwLzMzLzYvODIzLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

23. 23.Eden AR, Morgan ZJ, Jetty A, Peterson LE. Proportion of family physicians caring for children is declining. J Am Board Fam Med 2020;33:830–831.
    
    [Abstract/FREE Full Text](http://www.jabfm.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NToiamFiZnAiO3M6NToicmVzaWQiO3M6ODoiMzMvNi84MzAiO3M6NDoiYXRvbSI7czoyMDoiL2phYmZwLzMzLzYvODIzLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

24. 24.Seiverling EV, Ahrns HT, Greene A, et al. Teaching benign skin lesions as a strategy to improve the Triage Amalgamated Dermoscopic Algorithm (TADA). J Am Board Fam Med 2019;32:96–102.
    
    [Abstract/FREE Full Text](http://www.jabfm.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NToiamFiZnAiO3M6NToicmVzaWQiO3M6NzoiMzIvMS85NiI7czo0OiJhdG9tIjtzOjIwOiIvamFiZnAvMzMvNi84MjMuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

25. 25.Williams NA, Marghoob AA, Seiverling E, Usatine R, Tsang D, Jaimes N. Perspectives on dermoscopy in the primary care setting. J Am Board Fam Med 2020;33:1022–1024.
    
    [Abstract/FREE Full Text](http://www.jabfm.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NToiamFiZnAiO3M6NToicmVzaWQiO3M6OToiMzMvNi8xMDIyIjtzOjQ6ImF0b20iO3M6MjA6Ii9qYWJmcC8zMy82LzgyMy5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

26. 26.Randall DA. Current indications for tonsillectomy and adenoidectomy. J Am Board Fam Med 2020;33:1025–1030.
    
    [Abstract/FREE Full Text](http://www.jabfm.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NToiamFiZnAiO3M6NToicmVzaWQiO3M6OToiMzMvNi8xMDI1IjtzOjQ6ImF0b20iO3M6MjA6Ii9qYWJmcC8zMy82LzgyMy5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

27. 27.Fenton JJ, Tapp H, Thakur NM, Pfeifle AL. Reliability of peer review of abstracts submitted to academic family medicine meetings. J Am Board Fam Med 2020;33:986–991.
    
    [Abstract/FREE Full Text](http://www.jabfm.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NToiamFiZnAiO3M6NToicmVzaWQiO3M6ODoiMzMvNi85ODYiO3M6NDoiYXRvbSI7czoyMDoiL2phYmZwLzMzLzYvODIzLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==)