Does Family Medicine Research Contribute to Improving Peoples Health

1
Does Family Medicine Research Contribute to
Improving Peoples Health?

• East Tennessee State Department of Family
  Medicine
• Walter Rosser
• Professor and Head
• Department of Family Medicine
• Queens University
• Kingston, Ontario, Canada

2
Plan

• What is Family medicine research and why is it
  different?
• Examples of contributions
• Is there a role for community based family
  physicians in FM research?
• Conclusion

3
Defining Family Medicine Research

• Family Medicine research is defined as research
  carried out in the context of Family Medicine.
• One could ask why does the context for conducting
  research make any difference?
• Most research that we use in our practices is
  conducted in large teaching hospitals.

4
Defining FM Research

• Although randomized controlled trials (RCTS) may
  be the gold standard required to provide evidence
  supporting a new therapy, the results of most
  RCTS cannot be applied in most primary care
  settings. (1)
• The trials have small numbers of participants.
• Trials are usually conducted in highly selected
  populations. Trial participants are usually
  people referred to a teaching center, who have
  only one problem.

5
Defining FM Research

• Trials (particularly new drugs) are usually run
  over a very short time, missing the adverse
  effects of long term use.
• Very often the question asked is not the most
  important question that you need answered in your
  practice.
• An example of the benefits of doing a trial in
  family practice are illustrated by a study done
  in Italian family practice in the late1990s. (2)

6
Defining FM Research

• The question answered was Does low dose ASA
  prevent adverse cardiovascular events in persons
  with one cardiovascular risk factor in Family
  Practice?
• Unlike most trials, the study population was more
  than 4,495 persons, drawn from approximately 350
  family practices and hospital outpatient clinics.

7
Defining FM Research

• The entry criteria was basically anyone over the
  age of 45 with one cardiovascular risk factor.
  There was no exclusion criteria so that
  participants had multiple problems and were
  similar to the patients in our own practices.
• The average age of participants was 64.4

8
Defining FM Research

• The intervention group received 100 mgms of
  coated ASA daily while the control group did not.
• The trial had to be stopped after 3 ½ years for
  ethical reasons (was to run for 5 years).
• The results were that anyone over 45, with normal
  or controlled blood pressure, had a reduced risk
  of death from stroke or heart attack by 40
  (RR.56) and risk of all cardiovascular events by
  25 (RR.77)

9
Defining FM Research

• The risk of stroke was eliminated by having
  persons with controlled or normal blood pressure.
• The EC ASA, combined with the low dose (100 mgms
  in Europe 82 mgms in North America) reduced the
  GI bleed rate and the benefit far outweighed the
  risk.
• You and I can have great confidence in the
  results of this study since it was done in our
  context

10
Defining FM Research

• If you accept that much of the research that we
  apply in our practices may not be relevant, then
  what is?
• I want to provide you with examples of research
  done in the context of Family Medicine to see if
  you agree that this work overcomes many of the
  weaknesses of most of the research information
  that we routinely use.

11
Pharyngitis

• A group of family physicians at the University of
  Toronto tested out a sore throat scoring system
  in a teaching family practice at Mount Sinai
  Hospital as well as a group of Family Physicians
  in a small community in Stratford, Ontario.
• They used an already developed scoring system as
  a predictor of those with or without positive
  streptococcus cultures from the pharynx. (3)(4)

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Adult Pharyngitis Scoring

• 1)Sore throat
• 1)Tender glands in the anterior neck below the
  mandible.
• 1)Fever greater than 39C (102F)
• 1)White exudates on the pharynx
• Absence of Cough

13
Pharyngitis

• 45 of people presenting to the practices had
  only a sore throat and no other symptoms.
  Cultures found only 7 of these people positive
  for streptococcus.
• The recommendation was topical treatment.
• 45 of people had 2 or 3 of the findings.
  Cultures found 25 percent positive for
  streptococcus. A two or three score justified a
  throat swab. (a rapid strep test is more
  sensitive and specific than the standard swab.)

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Pharyngitis

• The remaining 10 of people presenting to their
  FP had all four signs. More than 60 of these
  cultures were positive for strep. They should be
  treated with Penicillin-V with no culture needed.
• Use of the sore throat score reduces antibiotic
  use by up to 75.
• Widespread use of the sore throat score will
  contribute to addressing the problem of bacterial
  resistance.

15
Hypertension

• A group of Family Medicine researchers at
  Queens Center for Studies in Primary Care (CSPC)
  has been carrying out studies on managing
  hypertension in a research network of 50-80
  practices over the past 5 years. (5)
• Findings include the fact that 24 hour
  measurement of blood pressure reduces the number
  of people diagnosed as hypertensive
  significantly.
• It has also been found that there is no benefit
  to 3 month, when compared to 6 month follow up of
  people diagnosed with hypertension.

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Hypertension

• A family practice residents project produced the
  study titled A comparison of 24 hr BP vs BP true
  machine assessment of labile hypertension.
• This study confirmed the value of both methods in
  assessing labile BP.

17
Hypertension

• Martin Dawes has conducted long term follow up in
  Oxford in the UK of people whos blood pressure
  was determined by 24 hr monitoring.
• The preliminary findings are that 24 hr
  monitoring is a much better predictor of adverse
  outcomes (stroke, heart attack, cardiovascular
  events) than office blood pressure readings
• .

18
Hypertension

• The Queens group are now assessing if home self
  monitoring using BP true daily readings
  provides similar results to 24 hr BP monitoring.
• These findings have the potential to rewrite text
  books on diagnosing hypertension, to reduce
  unnecessary treatment of many individuals thought
  to have hypertension, and have greater benefit
  for those receiving treatment for hypertension.

19
Episiotomy

• Family Medicine researcher Michael Klein, who has
  had a very strong interest in obstetrics, became
  convinced in the 1980s that an episiotomy during
  delivery was not helpful and may cause more harm
  than good. (6)(7)
• He designed a series of trials to test his
  hypothesis and found that midline episiotomies
  consistently produced more pain and more damage
  to the perineum than natural tears.

20
Episiotomy

• His studies further demonstrated that
  medio-lateral episiotomy and its extensions,
  although less traumatic than the midline,
  produced significantly more pain and
  complications for up to six months after birth
  than did natural tears.
• Since these studies were published in the early
  1990s, the episiotomy rate has declined around
  the world and the unnecessary suffering of
  millions of women has been avoided.

21
Patient Centered Method

• For more than 20 years, an interdisciplinary
  group of researchers in the Department of Family
  Medicine at the University of Western Ontario
  have been developing and evaluating the Patient
  Centered Clinical Method. (8)(9)
• This method provides an approach to interviewing
  and determining what the patients problems are
  from their viewpoint and provides a strategy to
  find common ground in determining management.

22
Patient Centered Method

• Extensive evaluation of this approach using
  community based family physicians in a network
  has found significantly higher levels of patient
  satisfaction, higher levels of patients following
  physician advise, and significantly better
  patient outcomes when physicians follow this
  approach.
• Better outcomes include lower blood pressure,
  less pain and discomfort, improved sense of well
  being, lowered levels of anxiety.
• Methods of measuring the patient centeredness of
  any physician patient encounter have been
  developed.

23
Patient Centered Method

• Family Medicine has incorporated this method of
  diagnostic interviewing into to patient care in
  many countries around the World.
• Specialists have adopted the patient centered
  strategy for their patient encounters.
• Now many medical schools teach the Patient
  Centered Method as the preferred approach to
  physician patient encounters.

24
Otitis Media

• In the early 1980s, Dutch general practitioners
  conducted a large study on more than 10,000
  children under the age of 5 who were diagnosed
  with acute otitis media. (10)
• They found that for children over 2 years of age,
  waiting for up to 72 hours after onset of pain or
  fever saw between 75 and 80 of episodes
  resolving spontaneously
• The watchful waiting strategy for otitis media
  was in Holland during the late 1980s and early
  1990s

25
Otitis Media

• An international collaboration of American,
  Canadian, British, Dutch and Israeli family
  physicians conducted a study and found that in
  North America, 95 of children with the diagnosis
  of otitis media received 10 days of antibiotics,
  in the UK 95 of children received 5 days of
  antibiotics and in Holland about 20 of children
  received antibiotics. Outcome measures with 3 to
  6 months follow up found no significant
  differences between the three strategies. (11)

26
Otitis Media

• Meta analysis of many studies in the late 1990s
  found that the watchful waiting used
  judiciously was safe, generally acceptable to
  parents and had a major impact on reducing
  antibiotic use. (12)
• Patients over 2 are monitored for up to 72 hours
  before antibiotic use.
• Between 20 and 25 require antibiotics.
• This strategy reduces antibiotic use between 50
  and 75 with major impact on antibiotic
  resistance

27
Otitis Media

• There have been no documented increase in
  mastoiditis or any other serious complications.
• Pain in those who need antibiotics after the
  wait is prolonged on average for less than 1
  day
• The critical aspect for this strategy is use of
  adequate pain control (frequent full doses of
  acetaminophen or NSAIDS) and saline or
  decongestants to open the eustation tube

28
Cystitis

• Warren McIsaac, a family physician researcher
  at the University of Toronto recently published
  work on cystitis based on his previous sore
  throat studies.(12)
• The objective was to determine the value of
  empirical treatment of cystitis when compared to
  obtaining a culture and sensitivity of the urine.
  
• His urban rural group assessed 231 women with
  cystitis to determine if testing their urine for
  white blood cells and nitrites would identify
  accurately those needing antibiotics

29
Cystitis

• .
• Testing the urine of women complaining of
  symptoms of cystitis for WBC and nitrites by
  dipstick provided an accurate predictor for
  urinary tract infection .
• Treating only those with both WBC and Nitrites
  present reduced antibiotic use in cystitis by
  27.5 (from 91.8 to 66.4) .
• Women who suffer frequent cystitis can do the
  test themselves.

30
Exercise

• Dr. R. Petrella is a family physician researcher
  with a PhD in physical education. He recruited
  241 active patients over 65 years of age from
  family practices. (13)
• He randomly allocated these folks to receive or
  not a STEP exercise program.
• This is a simple exercise routine that can be
  prescribed in a busy family practice.
• All participants were followed for one year.

31
Exercise

• In the study, a series of factors including BMI,
  pulmonary function, blood pressure and confidence
  in exercising ability were all significantly
  improved in the intervention group compared to
  the control group who received normal exercise
  advise.
• He concluded that simple exercise interventions
  prescribed by family physicians for elderly (over
  65) patients significantly improved their health
  and well being.

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Summary

• Seven examples of research in the context of
  family medicine have been provided.
• In all of this work, the results can be applied
  with confidence in your practice, knowing that
  you can expect similar results in your patients.
• I would like to persuade you that widespread
  adoption of the results from these studies would
  significantly improve health in Tennessee.
• An extension of this argument is that Family
  Medicine Research is essential to improving
  health globally (14)

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Is there a role for you in FM research?

• Many family practitioners believe that most
  research should be carried out by specialists as
  they know more about specific conditions than
  most family physicians.
• Family Medicine Research has a very low profile
  in universities, medical schools and the
  community.
• Surveys have found that most community
  practitioners are unaware of any family medicine
  research that they use.

34
Is there a role for you in FM research?

• There is strong evidence supporting the fact that
  the strength of the primary care health care
  delivery system predicts the health status of the
  countries population as well as the cost
  effectiveness of the health care system of a
  country. (15)
• Because of the different factors influencing
  health beliefs of individuals in every country,
  the evolution of the primary health care system
  is unique in each country.

35
Is there a role for you in FM research?

• Research questions from family medicine are
  unique in each country.
• The methods used to answer these questions
  require adaptation to the context.
• Each country requires their own strategy to gain
  adoption of widespread change in both physician
  and patient behavior to reach the full potential
  of improving population health.

36
Is there a role for you in FM research?

• If you agree that there is a large gap between
  the perception of the existence and value of
  Family Medicine Research and the reality, then
  what can be done to narrow this gap?
• Your first role is to become aware of FM research
  and the reasons why it is important and discuss
  these ideas with colleagues.
• Your attendance at this meeting today is
  important in awareness raising.

37
Is there a role for you in FM research?

• Increasing your awareness of the many yet
  unanswered questions in Family Practice and their
  relative importance to the whole populations
  health is another step.
• In 2000, the Ontario College of Family Physicians
  attempted to assist family physicians by
  providing the opportunity to learn how to answer
  a research question that arose from their
  clinical practice.

38
Is there a role for you in FM research?

• Nine community based family physicians from
  across Ontario participated in a five weekend
  program over a one year period to learn how to
  answer their questions.
• Participants committed the time in return for
  three years worth of CME study credits.
• The other objective was for family physicians to
  gain a better understanding of research methods.

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Is there a role for you in FM research?

• Each weekend consisted of
• Friday afternoon, each participant providing
  feedback about their work over the two months
  preceding the meeting.
• All day Saturday devoted to learning new skills
  (refining the question, doing a literature
  search, quantitative and qualitative methods,
  writing a grant application and presenting the
  work)
• Sunday morning debriefing the weekend and
  developing a plan for the next two months of
  gap work.

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Is there a role for you in FM research?

• A second round was run in 2003-4 to test out new
  strategies and to develop a manual for
  facilitators of the program.
• In the next two weeks, a grant will allow
  starting two five weekend programs for 10
  participants each at 7 sites in the Province.
• 140 family physicians will have an opportunity to
  participate over the next two years.
• You may wish to convince Fred or others here to
  run such a program.

41
Is there a role for you in FM research?

• One of the most effective ways to involve
  practicing family physicians in research is
  through Practice Based Research Networks (PBRNs)
• Networks of family physicians have the power to
  answer major research questions.
• Networks were used in the ASA trial, pharyngitis
  trials, otitis media trials, in developing the
  patient centered method, exercise studies,
  hypertension studies and the cystitis trials.

42
Is there a role for you in FM research?

• The AHRQ has been sponsoring the development of
  PBRNS across the U.S. with more than 100 in
  existence.
• You have a network here. Participation is an
  excellent way to learn as well as contribute to
  better understanding the work you are doing.
• Trials done in networks are relevant to practice
  unlike trials done in hospital settings.
• Each region of a country has its own
  characteristics so that the best way to answer
  your questions is through your network.

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Summary of the role you can play in FM research

• Continuing to use your critical appraisal skills
• Joining a PBRN when in practice
• Considering a five weekend program
• Considering resurrecting research training you
  had in the past or taking some in the future.
• Talking to colleagues about the contributions to
  improved patient care from Family Medicine
  research.

44
Conclusion

• The low profile of Family Medicine Research is
  inappropriate given the contributions that have
  been made by family medicine research to improve
  the health of the population.
• Because we deal with common problems, the impact
  on the population of our research is very
  substantial
• A number of strategies to improve knowledge about
  research as well as participation in research by
  family physicians have been discussed.

45
Conclusion

• East Tennessee clearly has the potential of
  making major contributions in the context of
  family medicine that can improve the health of
  the population.