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What The Study Did: The outcomes of universal COVID-19 testing following the discovery of new cases in 11 long-term care facilities in the U.S. are evaluated in this observational study.

Authors: Morgan J. Katz, M.D,, M.H.S., of the Johns Hopkins University School of Medicine in Baltimore, is the corresponding author.

To access the embargoed study: Visit our For The Media website at this link https://media.jamanetwork.com/

(doi:10.1001/jamainternmed.2020.3738)

Editor's Note: The article includes conflict of interest disclosures. Please see the article for additional information, including other authors, author contributions and affiliations, conflicts of interest and financial disclosures, and funding and support.

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Washington, DC - July 14, 2020 - As data accumulates on COVID-19 cases and deaths, researchers have observed patterns of peaks and valleys that repeat on a near-weekly basis. But understanding what's driving those patterns has remained an open question.

A study published this week in mSystems reports that those oscillations arise from variations in testing practices and data reporting, rather than from societal practices around how people are infected or treated. The findings suggest that epidemiological models of infectious disease should take problems with diagnosis and reporting into account.

"The practice of acquiring data is as important at times as the data itself," said computational biologist Aviv Bergman, Ph.D., at the Albert Einstein College of Medicine in New York City, and microbiologist Arturo Casadevall, M.D., Ph.D., at the Johns Hopkins Bloomberg School of Public Health in Baltimore, Maryland. Bergman and Casadevall worked on the study with Yehonatan Sella, Ph.D., at Albert Einstein, and physician-scientist Peter Agre, Ph.D., at Johns Hopkins.

The study began when Agre, who co-won the 2003 Nobel Prize in Chemistry, noticed that precise weekly fluctuations in the data were clearly linked to the day of the week. "We became very suspicious," said Bergman.

The researchers collected the total number of daily tests, positive tests, and deaths in U.S. national data over 161 days, from January through the end of June. They also collected New York City-specific data and Los Angeles-specific data from early March through late June. To better understand the oscillating patterns, they conducted a power spectrum analysis, which is a methodology for identifying different frequencies within a signal. (It's often used in signal and image processing, but the authors believe the new work represents the first application to epidemiological data.)

The analysis pointed to a 7-day cycle in the rise and fall of national new cases, and 6.8-day and 6.9-day cycles in New York City and Los Angeles, respectively. Those oscillations are reflected in analyses that have found, for example, that the mortality rate is higher at the end of the week or on the weekend.

Alarmed by the consistency of the signal, the researchers looked for an explanation. They reported that an increase in social gatherings on the weekends was likely not a factor, since the time from exposure to the coronavirus to showing symptoms can range from 4-14 days. Previous analyses have also suggested that patients receive lower-quality care later in the week, but the new analysis didn't support that hypothesis.

The researchers then examined reporting practices. Some areas, like New York City and Los Angeles, report deaths according to when the individual died. But national data publishes deaths according to when the death was reported--not when it occurred. In large datasets that report the date of death, rather than the date of the report, the apparent oscillations vanish. Similar discrepancies in case reporting explained the oscillations found in new case data.

The authors of the new study note that weekend interactions or health care quality may influence outcomes, but these societal factors do not significantly contribute to the repeated patterns.

"These oscillations are a harbinger of problems in the public health response," said Casadevall.

The researchers emphasized that no connection exists between the number of tests and the number of cases, and that unless data reporting practices change, the oscillations will remain. "And as long as there are infected people, these oscillations, due to fluctuations in the number of tests administered and reporting, will always be observed," said Bergman, "even if the number of cases drops."

Preeclampsia is globally a leading cause of illness and deaths among mothers and their babies. This severe pregnancy disorder occurs in up to five percent of all pregnancies.

Preeclampsia is characterized by the elevated blood pressure of the mother, and the baby is often delivered preterm and smaller than usual.

Although preeclampsia is cured by the delivery of the placenta, the mechanism of the disease has still remained unclear.

"It is necessary for a successful pregnancy that the mother's immune system does not react too strongly and reject the fetus, even though half of its genes are from the father and thus foreign," says professor Juha Kere from Karolinska Institutet, Sweden.

Kere coordinated the research to uncover the role of the HLA-G gene in preeclampsia. This gene protects the placenta against mother's immune attack.

The results of the study have now been published in EBiomedicine, a journal published by The Lancet.

"The study reveals mechanisms of preeclampsia. In addition, we showed for the first time in any species that there is a gene directly influencing the balance of boys and girls born," says Dr. Satu Wedenoja, the lead author of the study, from University of Helsinki and Helsinki University Hospital.

Fewer boys are born from preeclamptic pregnancies

The researchers studied 1.79 million births from the Finnish Birth Registry, a national preeclampsia cohort, and a group of stillborn babies. They found that fewer boys than girls were born from preeclamptic pregnancies, especially among babies delivered preterm and smaller than usual for the duration of pregnancy.

According to the results, certain alternative forms of the HLA-G gene are connected to the male-to-female ratio at birth, the survival of the fetuses, and preeclampsia.

The researchers pointed out that natural selection works even today on the HLA-G gene. The oldest forms of the HLA-G gene increase the risk of fetal death and preeclampsia, but might protect the fetus from infections during pregnancy, such as malaria. In placental samples collected from pre-eclamptic pregnancies, the gene expression of HLA-G was low, but in contrast, the expression was highly elevated for interferon-alpha-1, a gene involved in autoimmune disorders and tissue rejection.

"The results show that natural selection works through the fetal HLA-G gene influencing the pregnancy outcome and its complications. The results further strengthen earlier findings of the vulnerability of boys to mother's inflammation, late miscarriages, and preeclampsia," says Wedenoja.

Based on the results, the researchers propose that a well-known drug for autoimmune disorders might be tested to prevent or treat preeclampsia.

"The mother's immune system affects the survival of the fetus. This generally safe drug can also be used during pregnancy and it modulates immune reactivity, thus potentially preventing preeclampsia," says Wedenoja.

Philadelphia, July 14, 2020 - In a retrospective study, investigators from New York University Langone Health found that the quantity of SARS-CoV-2 (viral load) collected from patients in the emergency department is significantly higher in patients with fewer or milder symptoms who did not require hospitalization--the opposite of what might be expected. Reporting in The American Journal of Pathology, published by Elsevier, they also found that a patient's history of cancer and cardiovascular disease is associated with higher viral loads even after adjusting for age.

The study was designed to determine possible associations between the viral load measured in patients positive for SARS-CoV-2 and their clinical parameters including severity of symptoms, hospital admission vs direct discharge, length of hospitalization, admission to the intensive care unit, length of need for oxygen support, and overall survival.

"It appears that the viral load peaks in the early stages of the disease. Although it is not associated with the duration of symptoms, their severity or outcome, it appears that the viral load is an important epidemiological surrogate marker of infectivity in mildly symptomatic and asymptomatic non-hospitalized patients, explained co-lead investigator Paolo Cotzia, MD, Assistant Professor, Department of Pathology, and Assistant Director, Center for Biospecimen Research and Development, NYU Langone Health, New York City, NY, USA.

"Whether the viral load in these patients stays the same or changes in later stages of the disease remains to be investigated and could provide further insights on the dynamics of viral replication."

Two hundred and five patients who visited the emergency department at a New York City tertiary care center with confirmed COVID-19 were included in the study. Nasopharyngeal samples were taken at the time of diagnosis. One hundred and sixty-five patients were discharged from the emergency department, and 40 patients were hospitalized. Non-hospitalized patients were younger overall, and other characteristics were similar across the group. The median duration from symptom onset to sample collection for the hospitalized group was five days compared with three days for the discharged patients.

Investigators found that the initial viral load was significantly lower in patients who required hospitalization compared to those who were discharged. The association remained significant even after adjustment for age, sex, race, body mass index, and other existing medical conditions. They also found that a higher viral load was associated with shorter duration of symptoms in all patients and was not associated with disease severity.

Co-lead investigator George Jour, MD, Assistant Professor, Department of Pathology and Department of Dermatology, Associate Director Molecular Pathology, NYU Langone Health, New York City, NY, USA, observed, "Another important finding of our study is that the initial nasopharyngeal viral load reflects the time from onset of symptoms and duration of symptoms. We found that higher viral loads are seen in mild rather than in severe disease because they appear to reflect the time lapsed from the onset of infection. Furthermore, higher viral loads correlate with the presence of cancer or cardiovascular diseases."

Although diagnostic viral load seems to have no prognostic utility for predicting outcomes from COVID-19, the investigators say it may be an important surrogate marker in mildly symptomatic, non-hospitalized patients. Their results support the concept that such patients may represent important sources of the virus. "Our study should increase awareness and should prompt the adherence to strict recommendation of social distancing and mask usage to avoid transmission," the investigators concluded.

Scientists have identified an oncogene (a cancer-causing gene) responsible for glioblastoma, the deadliest brain tumor. The discovery offers a promising new treatment target for a cancer that is always fatal.

The researchers say the oncogene is essential to the survival of the cancer cells. Without it, the cancer cells die. Scientists have already developed many targeted therapies for other cancers with a similar "oncogene addiction."

"Glioblastoma is one of the most deadly cancers. Unfortunately, there is no effective treatment option for the disease. The current standard option, radiation plus temozolomide, which displayed a 2.5-month better survival rate, was hailed as a great success. Clearly, better understanding and new therapeutic targets are urgently needed," said researcher Hui Li, PhD, of the University of Virginia School of Medicine and the UVA Cancer Center. "The novel oncogene we discovered promises to be an Achilles' heel of glioblastoma, with its specific targeting potentially an effective approach for the treatment of the disease."

Targeting Glioblastoma

Oncogenes are naturally occurring genes that spiral out of control and cause cancer. The oncogene Li and his colleagues identified, AVIL, normally helps cells maintain their size and shape. But the gene can be shifted into overdrive by a variety of factors, the researchers found. This causes cancer cells to form and spread.

Blocking the gene's activity completed destroyed glioblastoma cells in lab mice but had no effect on healthy cells. This suggests targeting the gene could be an effective treatment option.

"AVIL is overexpressed in 100% of glioblastoma cells and clinical samples, and is expressed at even higher level in so called glioblastoma stem cells, but hardly expressed in normal cells and tissues," said Li, of UVA's Department of Pathology. "Silencing the gene wiped out glioblastoma cells in culture and prevented animal xenografts, while having no effect on normal control cells. Clinically, high AVIL expression correlates with worse patient outcome. These findings and classic transformation assays proved AVIL being a bona fide oncogene."

Identifying Oncogenes

Identifying an oncogene, as Li and his colleagues have done, is an important step toward developing a treatment. But identifying oncogenes is very difficult. The environment inside cells is so complex that it's hard to determine cause-and-effect.

Li and his team weren't even working on glioblastoma when they first caught the scent that led to the discovery. Instead, they were studying a rare childhood cancer called rhabdomyosarcoma. (Childhood cancers typically are easier to understand and involve fewer mutations than adult cancers.)

During their research, the scientists discovered an abnormality in the AVIL gene. That prompted them to examine adult cancers to see if the gene could be contributing there. And it was. The researchers concluded the gene plays a "critical role" in glioblastoma, they report in a new scientific paper outlining their findings.

Li and his team believe their approach can be used to discover other oncogenes - hopefully leading to new treatments for a variety of cancers.

"In this day and age, many people thought that all the significant oncogenes have been discovered, Here we uncovered a novel powerful oncogene, and elucidated its signaling pathways, all starting from studying a structure variant in a pediatric cancer. In the past, numerous significant discoveries in cancer also stemmed from studying pediatric tumors" Li said. "We believe this is a strategy can be applied to find novel players in other adult cancers."

A Majority of U.S. Men Want Their Doctors to Ask About Intimate Partner Violence

Nine out of 10 U.S. men ages 18 to 35 support health care providers asking about intimate partner violence, according to new survey analysis. Data from a 2014 nationally representative survey showed that while most men support health care-based intimate partner violence screenings, only about 10 percent reported being asked by their doctor. Men who reported lower levels of education were most likely to be asked, but support for screenings varied by race and past experience with such violence. Black non-Hispanic men were less likely to think doctors should ask. Victims of intimate partner violence were more likely to support screening. The study notes that overall, about 17 percent of the 916 respondents reported experiences of physical violence with their partners, and a majority of men--56 percent--said they had been both a victim and perpetrator. Authors note that, "When young men seek health care with their primary care physician, those health care encounters offer opportunities to identify intimate partner violence." Understanding the attitudes and experiences of men may help primary care clinicians tailor their conversations, support and referrals.

Prevalence of Intimate Partner Violence and Beliefs About Partner Violence Screening Among Young Men
Tova B. Walsh, PhD, et al
University of Wisconsin-Madison, School of Social Work, Madison, Wisconsin
https://www.annfammed.org/content/18/4/303

LGBT-Friendly Primary Care Practices Improve STD and HIV Screening Rates for Vulnerable Populations

This report--describing the first national quality improvement collaborative focused on providing culturally affirming care for LGBT people--finds that making primary care practices more LGBT-friendly and inclusive may improve STD and HIV screening rates among this vulnerable population. The goal of the Transforming LGBT Care program was to help highly motivated community health centers implement LGBT-affirming care by providing infrastructure for training, collaboration, knowledge sharing, leadership buy-in and practice change. Ten federally qualified health centers were selected to participate in the year-long program. Small care teams were formed at each site, and those teams received coaching, training and facilitation from the program's staff, much of which was conducted virtually. By the end of the program, estimated HIV screening of LGBT patients at eight of the reporting sites rose from 14.8 percent to 30.5 percent, with increases in STD screenings as well. Most participating centers had improved their electronic health record system to allow for sexual orientation and gender identity documentation, but very few reported improvements in documenting the sexual histories of LGBT patients. The authors of the program's quality improvement study note, "Ultimately, federally qualified health centers and other primary care organizations have an opportunity and a responsibility to provide equitable care to people of all sexual orientations and gender identities. Even small changes to health care practices may make a large difference for people burdened by health disparities and discrimination."

Transforming Primary Care for Lesbian, Gay, Bisexual, and Transgender People: A Collaborative Quality Improvement Initiative
Bruce W. Furness, MD, MPH, et al
Centers for Disease Control and Prevention, Atlanta, Georgia
https://www.annfammed.org/content/18/4/292

New Prescribing Rules in France Result in Decreased Prescribing of One Type of Sedative-Hypnotic Drug for Insomnia

In France, the implementation of new prescribing rules for the sedative-hypnotic drug zolpidem led to an important and immediate decrease in use. This decline was partially compensated for by a rise in the use of a nonbenzodiazepine drug called zopiclone. In 2017, French health authorities made it mandatory to use a secure prescribing form for zolpidem, which is a popular insomnia drug in France and one of the drugs most involved in falsified prescribing and diversion. A time-series analysis of national prescription drug reimbursement records from 2015 to 2018 shows the positive impact of France's regulations, with prescribing of zolpidem cut in half when comparing rates before and after the policy change. Nearly equal and opposite increases in zopiclone were seen during this same time period. The change in prescribing policies resulted in a shift to the alternative drug zopiclone--a trend that has been seen amongst prescribing restriction efforts, including restrictions on benzodiazepines.

Impact of Secured Prescription Implementation for Zolpidem on Hypnotics Use in France: A Time-Series Analysis on National Data
Nicolas Rousselot, MD, MSc, et al
University of Bordeaux, Department of General Practice, Bordeaux, France
https://www.annfammed.org/content/18/4/345

Machine Learning Accurately Predicts Who's Who in the Health Care Workforce

Until recently, economists, policy makers and workforce experts have relied on outdated and inaccurate snapshots of the U.S. physician workforce, making it especially difficult to predict the need and availability of health care services across the country. Data about each physician's area of specialty is collected at the beginning of their career and is rarely updated, increasing the potential for outdated information about who is providing care for our nation's population. In this study, Wingrove et al examine how machine learning algorithms may allow for more real-time, accurate descriptions of the medical workforce, including professions that do not formally collect specialty data like physician assistants and nurse practitioners. Algorithms also can identify physicians in new and evolving interdisciplinary positions. One such learning model from the Robert Graham Center and the University of Pittsburgh was trained to identify a majority of medical specialties with 95 percent accuracy. The model was fed data from clinical encounters in the form of procedures and prescriptions billed by Medicare from 2014 to 2016. The models were less accurate at predicting some specialties, like neurosurgery and physical medicine and rehabilitation. But overall, the model correctly predicted 70 percent of physician's practice type within five percentage points of their actual count, including primary care and specialties such as emergency medicine, cardiology, gastroenterology and radiology.

Using Machine Learning To Predict Primary Care and Advance Workforce Research
Peter Wingrove, et al
University of Pittsburgh, School of Medicine, Pittsburgh, Pennsylvania and the Robert Graham Center for Policy Studies in Family Medicine and Primary Care, Washington, DC
https://www.annfammed.org/content/18/4/334

COVID-19 Makes Clear the Need to Address Social Determinants of Health

In this editorial, University of Michigan public health experts Julia Wolfson and Cindy Leung argue that the COVID-19 pandemic has made glaringly apparent the structural conditions that underlie inequities in our nation's health. Race and ethnicity, housing, income, occupation and chronic health conditions are all key factors that influence one's ability to safely weather highly infectious disease pandemics like COVID-19. Unlike the novel coronavirus strain, these social, economic and structural factors are not new. The authors argue, "An opportunity exists to use the unfolding crisis to advocate for structural changes to a system that has long perpetuated disparities." Wolfson and Leung draw together four articles in the July-August 2020 issue of the Annals of Family Medicine that emphasize social determinants of health and highlight the calls to action for primary care.

An Opportunity to Emphasize Equity, Social Determinants, and Prevention in Primary Care
Julia A. Wolfson, PhD MPP, et al
University of Michigan, School of Public Health, Departments of Health Management and Policy and Nutritional Sciences, Ann Arbor, Michigan
https://www.annfammed.org/content/18/4/290

The Five Phases of Pandemic Care for Primary Care

The authors present a roadmap for necessary primary care practice transformations to care for patients and communities during the COVID-19 pandemic. Changes to U.S. primary health care will occur in five phases, according to the authors. The first three phases describe the transformation of primary care to accommodate COVID-19 testing and triage, as well as virtual visits and targeted outreach to patients with chronic conditions that put them at greater risk of COVID-19 complications. Many U.S. communities are grappling with the fourth phase, recovery after acute care, as primary care provides rehabilitation and recovery services to COVID-19-positive patients after hospital discharge. The fifth phase of the authors' model addresses the indirect consequences of this pandemic, including worsening mental health, substance misuse, delay of patient's traditional care, as well as social and environmental health risks like domestic violence, housing, and food and financial insecurity. The paper provides a framework and strategies to spur long-term change and evolution of the U.S. health care system.

Redesigning Primary Care to Address the COVID-19 Pandemic in the Midst of the Pandemic
Alex H. Krist, MD, MPH, et al
Virginia Commonwealth University, Department of Family Medicine and Population Health, Richmond, Virginia
https://www.annfammed.org/content/18/4/349

A New Measure of Social Determinants of Health May Improve Cardiovascular Health Assessment at the County Level

The authors of this study developed a single risk score derived from multiple social determinants of health that predicts county-level cardiovascular disease mortality. Using data culled from government resources, they identified U.S. counties with a high risk of CVD based on a three-year average mortality rate. They used a 50 percent random sample of 3,026 counties to develop a risk score based on seven social determinants of health factors: proportion of non-white population, poverty rate, proportion of population without high school diploma, grocery store ratio, fast-food restaurant ratio, after-tax soda price and primary care physician supply. The remaining 50 percent of the counties served to validate the measure. The resulting index had better predictive performance for CVD burden than common single-measure area-level indexes (e.g., only measuring poverty). The authors conclude that their multivariable SDoH risk score can identify counties with high CVD risk and has the potential to improve CVD risk prediction and interventions for vulnerable populations at the county level.

Development and Validation of a County-Level Social Determinants of Health Risk Assessment Tool for Cardiovascular Disease
Young-Rock Hong, PhD, MPH, et al
University of Florida, College of Public Health and Health Professions, Department of Health Services Research, Management and Policy, Gainesville, Florida
https://www.annfammed.org/content/18/4/318

International Conference on Social Determinants of Health in Primary Care Identified Actions for Change

In November 2019, clinicians, health administrators, educators and researchers from around the world gathered in Toronto to discuss how to best address social determinants of health from a primary care perspective. Participants developed starting points for accessible and feasible actions to improve health equity in their own primary care setting. They emphasized strategies to incorporate community members, especially those with lived experiences of discrimination, in the health care design team. Additionally, they highlighted the need to address structural determinants of health, including racism, capitalism and colonialism.

Improving Equity Through Primary Care: Proceedings of the 2019 Toronto International Conference on Quality in Primary Care
Tara Kiran, MD, MSc, CCFP, et al
University of Toronto and St. Michael's Hospital, Department of Family and Community Medicine, Toronto, Ontario, Canada
https://www.annfammed.org/content/18/4/364

Participants in CPC+ Are Diverse But Not Representative of All Primary Care Practices

This study analyzes patterns of participation in the Comprehensive Primary Care Plus initiative which is the largest voluntary primary care payment and delivery reform model tested to date. Of the nearly 20,000 primary care practices within the 18 regions selected by the Centers for Medicare and Medicaid Services for CPC+ implementation, 22 percent applied to participate. CMS accepted all applicants that met their minimum criteria, reflecting 15 percent of all primary care practices in the regions. Participation rates varied across the 18 regions from 2 percent to 34 percent. The Mathematica research team found that applicant practices, while diverse, were more likely to be larger, to be owned by a hospital or health system, to have experience with transformation efforts, and to be located in urban areas than practices that did not apply. Applicants also generally served slightly healthier and more advantaged Medicare fee-for-service beneficiaries. Overall, participating practices were not necessarily representative of all primary care practices in their region, underscoring the need to further engage practices that are small, independent, in rural areas, and lack experience with practice and payment transformation models, and the need to extrapolate evaluation results carefully.

Participation in the Comprehensive Primary Care Plus Initiative
Pragya Singh, PhD, et al
Mathematica, Princeton, New Jersey
https://www.annfammed.org/content/18/4/309

Graduates of Family Medicine Residencies Are Likely to Enter and Remain in Family Medicine Practice

This study provides an overview of the characteristics of physicians who completed family medicine residency training from 1994 to 2017. It serves to update the only previous comprehensive national review of this kind, conducted in 1996, which covered family medicine graduates from 1969 through 1993. With only 10.9 percent of medical students entering family medicine residency training in 2016, and in light of the continuing shortage of family physicians, one goal of the new study was to determine whether family medicine residency graduates continue to practice in the field after residency. The study yielded moderately encouraging findings suggesting that family medicine residents are likely to remain in the primary care workforce.

Characteristics of Family Medicine Residency Graduates, 1994-2017: An Update
Mingliang Dai, PhD, et al
American Board of Family Medicine, Lexington, Kentucky
https://www.annfammed.org/content/18/4/370

Antibiotic Allergy Reporting May Lead to Antibiotic Resistance, Higher Costs and Decreased Patient Safety

Antibiotics are among the most commonly prescribed medications, but in determining the most appropriate prescription for a patient, doctors and pharmacists often rely on inaccurate records of the patient's antibiotic allergies. Many records are incomplete, unclear or incorrect. They may have originated with a patient's previous physician, or incompatible electronic medical record systems may have introduced errors. In turn, this may contribute to the development of antibiotic resistance, higher health care costs and decreased patient safety. This qualitative study by researchers in the Netherlands identifies problems with the antibiotic allergy reporting process that may point toward interventions for improving registration accuracy. Based on focus group discussions, the researchers suggest that developing a training module and primary care guidelines regarding the registration process, cleaning up existing records, and fostering better communication, both human and electronic, as potential ways to improve antibiotic allergy registrations.

Inappropriate Antibiotic Allergy Documentation in Health Records: A Qualitative Study on Family Physicians' and Pharmacists' Experiences
Eefje G.P.M. de Bont, MD, PhD, et al
Maastricht University, Department of Family Medicine, Maastricht, The Netherlands
https://www.annfammed.org/content/18/4/326

Gender Disparities Identified in Robert Graham Center's Published Research: First Steps Towards Gender Parity in Academic Authorship

Researchers affiliated with the Robert Graham Center for Policy Studies in Family Medicine and Primary Care conducted a descriptive bibliometric analysis to determine the gender ratio of scholarly authorship on publications by its researchers between 2008 and 2018. While the average gender ratio of RGC researchers across this period was 46.3 percent female to 56.4 percent male, gender disparities in authorship were much starker. For example, roughly two-thirds of 229 publications listed a male first author, and almost all had at least one male author. While the RGC team recognizes the limitations of a single-case study, their intention is to broaden the discussion about gender parity in authorship among academic medical researchers.

Trends in the Gender Ratio of Authorship at the Robert Graham Center
Elizabeth Wilkinson, et al
Robert Graham Center for Policy Studies in Family Medicine and Primary Care, Washington, DC
https://www.annfammed.org/content/18/4/341

What Encourages--or Impedes--Primary Care Team Collaboration through Case Management?

While multiple recent studies have provided evidence of the benefits of case management, primary care teams have struggled to implement and sustain its use in their clinical practices. In this systematic review, researchers examine barriers to case management, as well as factors facilitating its implementation. Researchers conducted a comprehensive literature review of studies that address comprehensive case management from a primary care perspective. A thematic analysis revealed nine barriers and/or facilitators that emerge across different studies, representing the perspectives of diverse health care professionals across six countries. The nine categories are family context; policy and available resources; physician buy-in and understanding of the case manager role; relationship building; team communication practices; autonomy of case manager; training in technology; relationships with patients; and time pressure and workload. Moreover, the framework situates these barriers and facilitators relative to each other. The authors believe their results may be of interest to policymakers, health care professionals and researchers who may use this study as a starting point for further investigation.

Understanding Barriers to and Facilitators of Case Management in Primary Care: A Systematic Review and Thematic Synthesis
Catherine Hudon, MSc, MD, PhD, et al
University of Sherbrooke, Faculty of Medicine, Department of Family Medicine, Sherbrooke, Quebec, Canada
https://www.annfammed.org/content/18/4/355

Innovations in Primary Care

Innovations in Primary Care are brief one-page articles that describe novel innovations from health care's front lines. In this issue:

Population Mapping for Quality Improvement in a Neighborhood Health Center--Neighborhood Health Centers of the Lehigh Valley Federally Qualified Health Center uses HealthLandscape's Population Health Profiler, a population-health mapping tool developed by the American Academy of Family Physicians, to better understand health disparities in their service area, to target resources for care in their community, and to conduct comparative research to improve health outcomes for their patients.
https://www.annfammed.org/content/18/4/374

Neuropsychologist Consultations in a Primary Care Setting--A collaborative care model in which a neuropsychologist works closely with clinicians in a primary care setting improves patient access to cognitive assessments, allows patients to centralize their care, and reduces the burden on primary care clinicians as they manage patients with cognitive impairment.
https://www.annfammed.org/content/18/4/375

The authors present a roadmap for necessary primary care practice transformations to care for
patients and communities during the COVID-19 pandemic. Changes to U.S. primary health care will occur in five phases, according to the authors. The first three phases describe the transformation of primary care to accommodate COVID-19 testing and triage, as well as virtual visits and targeted outreach to patients with chronic conditions that put them at greater risk of COVID-19 complications. Many U.S. communities are grappling with the fourth phase, recovery after acute care, as primary care provides rehabilitation and recovery services to COVID-19-positive patients after hospital discharge. The fifth phase of the authors' model addresses the indirect consequences of this pandemic, including worsening mental health, substance misuse, delay of patient's traditional care, as well as social and environmental health risks like domestic violence, housing, and food and financial insecurity. The paper provides a framework and strategies to spur long-term change and evolution of the U.S. health care system.

Redesigning Primary Care to Address the COVID-19 Pandemic in the Midst of the Pandemic
Alex H. Krist, MD, MPH, et al
Virginia Commonwealth University, Department of Family Medicine and Population Health, Richmond, Virginia
https://www.annfammed.org/content/18/4/349

This report--describing the first national quality improvement collaborative focused on providing culturally affirming care for LGBT people--finds that making primary care practices more LGBT-friendly and inclusive may improve STD and HIV screening rates among this vulnerable population. The goal of the Transforming LGBT Care program was to help highly motivated community health centers implement LGBT-affirming care by providing infrastructure for training, collaboration, knowledge sharing, leadership buy-in and practice change. Ten federally qualified health centers were selected to participate in the year-long program. Small care teams were formed at each site, and those teams received coaching, training and facilitation from the program's staff, much of which was conducted virtually. By the end of the program, estimated HIV screening of LGBT patients at eight of the reporting sites rose from 14.8 percent to 30.5 percent, with increases in STD screenings as well. Most participating centers had improved their electronic health record system to allow for sexual orientation and gender identity documentation, but very few reported improvements in documenting the sexual histories of LGBT patients. The authors of the program's quality improvement study note, "Ultimately, federally qualified health centers and other primary care organizations have an opportunity and a responsibility to provide equitable care to people of all sexual orientations and gender identities. Even small changes to health care practices may make a large difference for people burdened by health disparities and discrimination."

This study provides an overview of the characteristics of physicians who completed family medicine residency training from 1994 to 2017. It serves to update the only previous comprehensive national review of this kind, conducted in 1996, which covered family medicine graduates from 1969 through 1993. With only 10.9 percent of medical students entering family medicine residency training in 2016, and in light of the continuing shortage of family physicians, one goal of the new study was to determine whether family medicine residency graduates continue to practice in the field after residency. The study yielded moderately encouraging findings suggesting that family medicine residents are likely to remain in the primary care workforce.

Antibiotics are among the most commonly prescribed medications, but in determining the most appropriate prescription for a patient, doctors and pharmacists often rely on inaccurate records of the patient's antibiotic allergies. Many records are incomplete, unclear or incorrect. They may have originated with a patient's previous physician, or incompatible electronic medical record systems may have introduced errors. In turn, this may contribute to the development of antibiotic resistance, higher health care costs and decreased patient safety. This qualitative study by researchers in the Netherlands identifies problems with the antibiotic allergy reporting process that may point toward interventions for improving registration accuracy. Based on focus group discussions, the researchers suggest that developing a training module and primary care guidelines regarding the registration process, cleaning up existing records, and fostering better communication, both human and electronic, as potential ways to improve antibiotic allergy registrations.

PHILADELPHIA (July 14, 2020) - As a rapid influx of patients overwhelmed health systems during the coronavirus pandemic, palliative nurses played dual roles supporting patients, patient families, and colleagues. Two researchers at the University of Pennsylvania School of Nursing (Penn Nursing) are among those detailing the important role palliative care has in responding during the COVID-19 pandemic and in future public health crises.

Advancing Palliative Care During COVID-19 Pandemic

As history proves, nursing science and scholarship have consistently improved patient care and outcomes throughout history's most daunting times. Today, nurse scientists and scholars have a unique opportunity to translate lessons learned about the shortcomings of health care during COVID-19 into strategic actions and investigations that reflect the needs of a rapidly changing society.

"Investing in the global culture of palliative care scholarship for nurses and health professionals across practice domains is one of the most accessible approaches to ensuring health care reflects a person-centered and value concordant ethos in the face of a future public health crisis," write William E. Rosa, PhD, MBE, NP-BC, FAANP, FAAN, a Robert Wood Johnson Foundation Future of Nursing Scholar and Salimah H. Meghani, PhD, MBE, RN, FAAN, Professor of Nursing & Term Chair of Palliative Care and Associate Director of the NewCourtland Center for Transitions and Health. They are two of the co-authors of a guest editorial in the Journal of Nursing Scholarship.

Their editorial provides a palliative care perspective on advancing patient care globally during COVID-19 and beyond. It provides recommendations to develop a research agenda rooted in a palliative care philosophy and ethos to meet the current global population health needs and anticipated future health crises.

The editorial, "Opportunities for Nursing Science to Advance Patient Care in the Time of COVID-19:A Palliative Care Perspective" is available online. Co-authors of the editorial include Patricia W. Stone, PhD, RN, FAAN, CIC of the Columbia University School of Nursing; and Betty R. Ferrell, PhD, RN, FAAN, FPCN, of the City of Hope Medical Center.

Optimizing the Palliative Nursing Role

Palliative nurses play a primary and significant role in supporting the broader health care system. As the pandemic continues to evolve, it has become clear that the work of the palliative nurse is indispensable as issues surrounding serious illness, dying, and death are no longer taboo but have become continuous threads of daily mainstream media, politics, and policy-making.

"This crisis offers an opportunity to reimagine the benefits of full palliative care integration to mitigate the effects of this and future health crises for patients, families, and communities," write Rosa and Meghani, two of the co-authors of an article in the Journal of Hospice & Palliative Nursing.

The authors share how best to leverage and integrate the palliative nursing role throughout health care settings. The article has implications for clinical nurses, nurse practitioners, clinical nurse specialists, and multidisciplinary stakeholders and includes resources for self-care and education.

BOSTON - New research shows that people with chronic low back pain (cLBP) have better results from yoga and physical therapy compared to reading evidence-based self-help materials. While this finding was consistent across many patient characteristics, a much larger effect was observed among those already taking pain medication to treat their condition and those who did not fear that exercise would make their back pain worse. Led by researchers at Boston Medical Center and published in Pain Medicine, the findings also showed that individuals who expected to do well with yoga were more likely to have a meaningful improvement in their function if they received yoga compared to receiving physical therapy.

Studying a population of predominately non-white and low-income patients, the results from this clinical trial show that overall, 39 percent of participants responded to one of the three treatment options with a greater response to yoga-or-physical therapy (42 percent) than the self-care group (23 percent). There was not a significant difference in proportion of people responding to yoga versus physical therapy - both showed similar improvements in back-related physical function. Among the study participants that were also using pain medication to treat chronic lower back pain, a large effect was observed among more participants in yoga (42 percent) or physical therapy (34 percent) compared with self-care (11 percent).

This study highlights the effect that fear can have on patient outcomes. Among the participants identified to have less fear around physical activity, 53 percent were more likely to respond to yoga and 42 percent were more likely to respond to physical therapy than self-care (13 percent). In contrast, among participants who started out with high fear avoidance around taking part in physical activity, the proportions of responders to the three treatment options showed no additional effect in response to treatment.

"Adults living with chronic low back pain could benefit from a multi-disciplinary approach to treatment including yoga or physical therapy, especially when they are already using pain medication,' said Eric Roseen, DC, MSc, a chiropractic physician at Boston Medical Center.

The yoga intervention consisted of 12 group-based weekly 75-minute hatha yoga classes incorporating poses, relaxation and meditation exercises, yoga breathing and yoga philosophy. Thirty minutes of daily home practice was encouraged and supported with at-home yoga supplies. The physical therapy intervention consisted of 15 one-on-one 60-minute appointments over 12 weeks. During each appointment, the physical therapist utilized the Treatment-Based Classification Method and supervised aerobic exercise, while providing written instructions and supplies to continue exercises at home. The self-care intervention consisted of reading from a copy of The Back Pain Handbook, a comprehensive resource describing evidence-based self-management strategies for chronic lower back pain including stretching, strengthening, and the role of psychological and social factors. Participants received check-in calls regarding the reading every three weeks.

The study involved 299 participants with chronic lower back pain at a safety net hospital and seven federally qualified community health centers, across 12 weeks of treatment. An exploratory analysis was performed identifying patient-level characteristics that predicted large improvements in physical function and/or modified the effectiveness of yoga, physical therapy, or self-care. The characteristics that were studied as predictors of improvement or treatment effect modifiers were from the domains of sociodemographic, general health, back-related, psychological, and treatment expectations data.

"Focusing on a diverse population with an average income well below the US median, this research adds important data for an understudied and often underserved population," said Roseen, also an assistant professor of family medicine at Boston University School of Medicine. "Our findings of predictors are consistent with existing research, also showing that lower socioeconomic status, multiple comorbidities, depression, and smoking are all associated with poor response to treatment."

You don't have to be an experienced trailblazer to know that if you choose to hike in the heat, you better be hydrated. Yet scientific literature on the subject reports that roughly 25% of heat-related illness cases are a result of a fluid imbalance, rather than heat exposure alone.

New research out of Arizona State University seeks to understand exactly what is going on in the body as it responds to heat stress, looking in particular at hydration levels, core temperature and sweat loss, in the hopes of developing interventions and best practices for those whose mountainous wanderlust just can't be quenched.

The findings of one such related study, recently published in the International Journal of Environmental Research and Public Health, show that compared to moderate weather conditions, hikers' performance during hot weather conditions was indeed impaired, resulting in slower hiking speeds and prolonged exposure to the elements, thus increasing their risk of heat-related illness.

Perhaps most telling, though, the research team found that most hikers did not bring enough fluid with them on their hike to compensate for their sweat loss. They also found that less aerobically fit participants were most negatively affected by heat stress and performed worse overall compared to their more aerobically fit counterparts.

"The current guidelines for hikers in general are very broad and geared more toward safety than quantifying the adequate amount of fluid they need," said ASU College of Health Solutions Assistant Professor Floris Wardenaar, corresponding author on the paper. "The guidelines also do not take into account fitness levels or the importance of incremental exposure to the heat, which can be affected by acclimatization to specific environments and weather conditions."

Former College of Health Solutions master's degree students Joshua Linsell and Emily Pelham are the first and second authors of the paper, followed by School of Geographical Sciences and Urban Planning Assistant Professor David Hondula and Wardenaar.

In their study, 12 participants -- seven women and five men in their 20s -- were asked to hike "A" Mountain on a moderate day (68 degrees Fahrenheit) and then again on a hot day (105 degrees Fahrenheit). They were told to prepare as they normally would, bringing however much fluid they thought they would need, and were asked to hike as quickly as possible without becoming uncomfortable. Each time, they hiked up and down the mountain four times, which adds up to roughly the same distance and incline as Camelback Mountain, one of the most popular hiking destinations in the Phoenix area that sees its fair share of heat-related illness cases.

Before their trek, participants' resting metabolism was recorded to estimate their energy production during the hike. Their weight, heart rate, core temperature and hydration status were measured before and after the hike, and their drinking behavior - how much or how little fluid they consumed - was monitored throughout.

Using that data, researchers were able to calculate participants' rate of sweat loss through their bodyweight reduction, which averaged out to about 1%, whether conditions were hot or moderate.

"The 1% bodyweight reduction had different reasons," Wardenaar said. "During hot conditions, participants' sweat rates were higher while drinking more, often resulting in consuming all of the fluid brought, whereas during moderate conditions, sweat rates were lower, but participants drank less. A 1% bodyweight loss is considered manageable and not likely to result in detrimental performance decline. My concern is that when people hike longer than 80 to 90 minutes in hot conditions that they will not bring enough fluid, resulting in larger bodyweight losses."

Overall, compared to moderate conditions, hot conditions significantly impaired hiking performance by 11%, reduced aerobic capacity by 7%, increased rate of perceived exertion by 19% and elevated core temperature. On average, participants took about 20 minutes longer to complete the hike during hot conditions than during moderate conditions, which theoretically could exponentially increase the chance of developing heat-related illness.

"Heat slows you down," Wardenaar explained. "This means that what you normally can hike in 75 minutes under moderate conditions may take up to 95 minutes in the heat. That is something that people should take into account, especially when their hike will substantially exceed the 90 minute cut-off."

Based on their findings, Wardenaar suggests preparing for a hike by familiarizing yourself with your personal hydration needs. You can do so by multiplying your weight before the hike by .01, then subtracting your weight after your hike from your starting weight. If the difference between your starting weight and your ending weight is greater than the product of your starting weight multiplied by .01, you need to be drinking more fluid during your hike.

It's also important to be well-hydrated before you even get out on the trail, Wardenaar said. And avoid alcohol, as it can contribute to dehydration.

CHICAGO --- Losing weight during the COVID-19 pandemic has increasing urgency because obesity increases the risk of severe disease and death. Two-thirds of U.S. adults are overweight or obese, according to the Centers for Disease Control and Prevention.

A new Northwestern Medicine remote weight-loss program, called Opt-IN, provides maximum weight loss for the lowest cost and with much less hassle than the gold-standard National Diabetes Prevention Program (DPP), the most successful behavioral non-drug treatment currently available. According to a new study, the Opt-IN program helped participants in a clinical trial lose 11 to 13 pounds, which is equivalent to the DPP's success rate.

The study findings were published today (July 14) in the journal Obesity, the primary obesity publication.  

"This matches the gold standard, so it's as good as it gets," said senior study author Bonnie Spring, director of the Institute for Public Health and Medicine's Center for Behavior and Health at Northwestern University Feinberg School of Medicine.  "What's novel is how participants get there."

Compared to the DPP treatment - a year-long program costing around $1,500 that requires weekly 90-minute in-person meetings with highly trained and paid medical professionals - the Opt-IN program is cheaper and much less burdensome, Spring said. Opt-IN is fully remote and costs participants between $324 and $427, depending on their package.

Spring said while there has been a lot of effort made in the U.S. to try to make the DPP treatment more accessible and affordable, like offering it in YMCAs, uptake has been minimal. She cited reasons such as users having a hard time getting to the in-person meetings because of childcare or transportation challenges.

"All these traditional treatments have not been scalable because they're not accessible," said Spring, who also is the chief of behavioral medicine in the department of preventive medicine at Feinberg.  "And they're expensive and burdensome. The direction we've gone in with Opt-IN is to meet people where they are, and these days - especially during the COVID-19 pandemic - that means in their homes.

The higher rate of severe cases of COVID-19 among young adults in the U.S. than other countries like China, Spain and Italy seems to be because obesity is much more common here, Spring said.

"To tackle the obesity behemoth, we are going to need to make obesity treatment much more accessible and affordable," Spring said. "The Opt-IN study demonstrates how we could do that."

The study had 562 Chicago-area adult participants who were overweight or obese begin a bare-minimum "core" program to achieve weight loss: goals, online lessons and a custom-designed weight-loss intervention app. Similar to commercial weight-loss apps on the market, this app helps users predetermine how many calories are in a food before they eat it and helps track their caloric intake and exercise throughout the day. Unlike other apps, however, this one sends the user's data directly to their coach, which Spring said helps keep users accountable.

Spring and her team then layered on and tested other treatment components added to the basic core program. The most cost-effective treatment package included 12 health-coaching calls, progress reports sent to the person's primary care physician and a "buddy" who was trained to help support weight loss. 

The study tested more expensive treatment components, like 24 coaching calls instead of 12 and meal replacement products, but they were left out of the final Opt-IN program, because results showed that they didn't increase weight loss.  

How much weight did they lose?

At $427 per person, the Opt-IN method produced an average weight loss of 13.4 pounds after six months, with 51.8% of the sample losing 7% of their initial body weight. The comparable DPP treatment also produces weight loss of 7% of initial body weight in 50% of enrollees, but at a much greater burden and cost. 

A cheaper treatment package for $324 that includes only the core app and online lessons plus 12 coaching calls resulted in an estimated 11.5-pound average weight loss, or at least 5% weight loss for more than 50% of participants over six months.

"Not fixing our national obesity problem invites the oncoming tsunami of diabetes, heart disease, some cancers and other chronic diseases for which obesity heightens risk, yet preventive services, including obesity treatment, are woefully lacking from our current health care delivery system," Spring said. "We hope our study helps to convince payers to cover, employers to offer and individuals to engage in preventive care."

Research published today has found that Australians strongly believe paramedics deserve a work environment free from the threat of physical harm, but when it comes to the risk of infectious disease, it's complicated.

Edith Cowan University (ECU) PhD candidate and paramedic Cameron Anderson investigated community attitudes regarding the professional obligation of paramedics to respond during pandemics.

The research showed that, pandemic or not, Australians expected an ambulance to arrive if children were involved, if there was adequate protective equipment and if it involved our immediate families.

"Community members felt strongly that paramedics deserve a work environment free from physical harm, but very much expect their paramedics to attend to infectious patients in a pandemic, particularly if there were children involved," Mr Anderson said.

No PPE is a deal-breaker

Access to PPE (personal protective equipment) has been an issue globally during COVID-19. Previous ECU research found 86 per cent of Australian doctors reported feeling anxious about the level of PPE provided to them during the pandemic.

"It is likely that paramedics on the frontline would hold similar concerns if services had difficulty providing a ready supply of PPE. And these concerns, it appears, are valid according to many of the participants in this research," Mr Anderson said.

"Respondents said if PPE was not available it became above and beyond the call of duty for paramedics to respond to an infectious disease case if they were not appropriately protected."

One participant offered the following reflection:

"If they have PPE, then yes, I expect them to be responding in a pandemic, but if not, it's a hard one. Because we still need them to be out there in the community helping people, but not if it means they are at high risk of getting sick themselves and then taking it home to their own families."

Attitudes change when it involves children

Mr Anderson said the community has a great appreciation for the important role of paramedics in the health system and believe there is a moral obligation for paramedics to attend work and respond to whatever cases they are assigned to during their shifts.

"There are, however, a few notable exceptions - pregnant women, single parents and families where both parents are dual responders were felt to have a greater moral 'right to refuse' risky cases, but not to the point where the broader health system is compromised," he said.

"Significantly, participants were united on one point: where the wellbeing of sick children is at risk, there is a strong and consistent community expectation that paramedics will accept additional risks to help."