Improving Disease Prediction by Incorporating Family Disease History in Risk Prediction Models with Large-Scale Genetic Data.
Gim Jungsoo,Kim Wonji,Kwak Soo Heon,Choi Hosik,Park Changyi,Park Kyong Soo,Kwon Sunghoon,Park Taesung,Won Sungho
Despite the many successes of genome-wide association studies (GWAS), the known susceptibility variants identified by GWAS have modest effect sizes, leading to notable skepticism about the effectiveness of building a risk prediction model from large-scale genetic data. However, in contrast to genetic variants, the family history of diseases has been largely accepted as an important risk factor in clinical diagnosis and risk prediction. Nevertheless, the complicated structures of the family history of diseases have limited their application in clinical practice. Here, we developed a new method that enables incorporation of the general family history of diseases with a liability threshold model, and propose a new analysis strategy for risk prediction with penalized regression analysis that incorporates both large numbers of genetic variants and clinical risk factors. Application of our model to type 2 diabetes in the Korean population (1846 cases and 1846 controls) demonstrated that single-nucleotide polymorphisms accounted for 32.5% of the variation explained by the predicted risk scores in the test data set, and incorporation of family history led to an additional 6.3% improvement in prediction. Our results illustrate that family medical history provides valuable information on the variation of complex diseases and improves prediction performance.
Oseltamivir plus usual care versus usual care for influenza-like illness in primary care: an open-label, pragmatic, randomised controlled trial.
Butler Christopher C,van der Velden Alike W,Bongard Emily,Saville Benjamin R,Holmes Jane,Coenen Samuel,Cook Johanna,Francis Nick A,Lewis Roger J,Godycki-Cwirko Maciek,Llor Carl,Chlabicz Sławomir,Lionis Christos,Seifert Bohumil,Sundvall Pär-Daniel,Colliers Annelies,Aabenhus Rune,Bjerrum Lars,Jonassen Harbin Nicolay,Lindbæk Morten,Glinz Dominik,Bucher Heiner C,Kovács Bernadett,Radzeviciene Jurgute Ruta,Touboul Lundgren Pia,Little Paul,Murphy Andrew W,De Sutter An,Openshaw Peter,de Jong Menno D,Connor Jason T,Matheeussen Veerle,Ieven Margareta,Goossens Herman,Verheij Theo J
Lancet (London, England)
BACKGROUND:Antivirals are infrequently prescribed in European primary care for influenza-like illness, mostly because of perceived ineffectiveness in real world primary care and because individuals who will especially benefit have not been identified in independent trials. We aimed to determine whether adding antiviral treatment to usual primary care for patients with influenza-like illness reduces time to recovery overall and in key subgroups. METHODS:We did an open-label, pragmatic, adaptive, randomised controlled trial of adding oseltamivir to usual care in patients aged 1 year and older presenting with influenza-like illness in primary care. The primary endpoint was time to recovery, defined as return to usual activities, with fever, headache, and muscle ache minor or absent. The trial was designed and powered to assess oseltamivir benefit overall and in 36 prespecified subgroups defined by age, comorbidity, previous symptom duration, and symptom severity, using a Bayesian piece-wise exponential primary analysis model. The trial is registered with the ISRCTN Registry, number ISRCTN 27908921. FINDINGS:Between Jan 15, 2016, and April 12, 2018, we recruited 3266 participants in 15 European countries during three seasonal influenza seasons, allocated 1629 to usual care plus oseltamivir and 1637 to usual care, and ascertained the primary outcome in 1533 (94%) and 1526 (93%). 1590 (52%) of 3059 participants had PCR-confirmed influenza infection. Time to recovery was shorter in participants randomly assigned to oseltamivir (hazard ratio 1·29, 95% Bayesian credible interval [BCrI] 1·20-1·39) overall and in 30 of the 36 prespecified subgroups, with estimated hazard ratios ranging from 1·13 to 1·72. The estimated absolute mean benefit from oseltamivir was 1·02 days (95% [BCrI] 0·74-1·31) overall, and in the prespecified subgroups, ranged from 0·70 (95% BCrI 0·30-1·20) in patients younger than 12 years, with less severe symptoms, no comorbidities, and shorter previous illness duration to 3·20 (95% BCrI 1·00-5·50) in patients aged 65 years or older who had more severe illness, comorbidities, and longer previous illness duration. Regarding harms, an increased burden of vomiting or nausea was observed in the oseltamivir group. INTERPRETATION:Primary care patients with influenza-like illness treated with oseltamivir recovered one day sooner on average than those managed by usual care alone. Older, sicker patients with comorbidities and longer previous symptom duration recovered 2-3 days sooner. FUNDING:European Commission's Seventh Framework Programme.
Facilitators and Barriers to Interdisciplinary Communication between Providers in Primary Care and Palliative Care.
Dudley Nancy,Ritchie Christine S,Rehm Roberta S,Chapman Susan A,Wallhagen Margaret I
Journal of palliative medicine
BACKGROUND:Community-based palliative care (CBPC) plays an integral role in addressing the complex care needs of older adults with serious chronic illnesses, but is premised on effective communication and collaboration between primary care providers (PCPs) and the providers of specialty palliative care (SPC). Optimal strategies to achieve the goal of coordinated care are ill-defined. OBJECTIVE:The objective of this study was to understand the facilitators and barriers to optimal, coordinated interdisciplinary provision of CBPC. METHODS:This was a qualitative study using a constructivist grounded theory approach. Thirty semistructured interviews were conducted with primary and palliative care interdisciplinary team members in academic and community settings. RESULTS:Major categories emerging from the data that positively or negatively influence optimal provision of coordinated care included feedback loops and interactions; clarity of roles; knowledge of palliative care, and workforce and structural constraints. Facilitators were frequent in-person, e-mail, or electronic medical record-based communication; defined role boundaries; and education of PCPs to distinguish elements of generalist palliative care (GPC) and more complex elements or situations requiring SPC. Barriers included inadequate communication that prevented a shared understanding of patients' needs and goals of care, limited time in primary care to provide GPC, and limited workforce in SPC. CONCLUSIONS:Our findings suggest that processes are needed that promote communication, including structured communication strategies between PCPs and SPC providers, clarification of role boundaries, enrichment of nonspecialty providers' competence in GPC, and enhanced access to CBPC.
Interdisciplinary Practice Models for Older Adults With Back Pain: A Qualitative Evaluation.
Salsbury Stacie A,Goertz Christine M,Vining Robert D,Hondras Maria A,Andresen Andrew A,Long Cynthia R,Lyons Kevin J,Killinger Lisa Z,Wallace Robert B
Purpose:Older adults seek health care for low back pain from multiple providers who may not coordinate their treatments. This study evaluated the perceived feasibility of a patient-centered practice model for back pain, including facilitators for interprofessional collaboration between family medicine physicians and doctors of chiropractic. Design and Methods:This qualitative evaluation was a component of a randomized controlled trial of 3 interdisciplinary models for back pain management: usual medical care; concurrent medical and chiropractic care; and collaborative medical and chiropractic care with interprofessional education, clinical record exchange, and team-based case management. Data collection included clinician interviews, chart abstractions, and fieldnotes analyzed with qualitative content analysis. An organizational-level framework for dissemination of health care interventions identified norms/attitudes, organizational structures and processes, resources, networks-linkages, and change agents that supported model implementation. Results:Clinicians interviewed included 13 family medicine residents and 6 chiropractors. Clinicians were receptive to interprofessional education, noting the experience introduced them to new colleagues and the treatment approaches of the cooperating profession. Clinicians exchanged high volumes of clinical records, but found the logistics cumbersome. Team-based case management enhanced information flow, social support, and interaction between individual patients and the collaborating providers. Older patients were viewed positively as change agents for interprofessional collaboration between these provider groups. Implications:Family medicine residents and doctors of chiropractic viewed collaborative care as a useful practice model for older adults with back pain. Health care organizations adopting medical and chiropractic collaboration can tailor this general model to their specific setting to support implementation.
A multimethod analysis of shared decision-making in hospice interdisciplinary team meetings including family caregivers.
Washington Karla T,Oliver Debra Parker,Gage L Ashley,Albright David L,Demiris George
BACKGROUND:Much of the existing research on shared decision-making in hospice and palliative care focuses on the provider-patient dyad; little is known about shared decision-making that is inclusive of family members of patients with advanced disease. AIM:We sought to describe shared decision-making as it occurred in hospice interdisciplinary team meetings that included family caregivers as participants using video-conferencing technology. DESIGN:We conducted a multimethod study in which we used content and thematic analysis techniques to analyze video-recordings of hospice interdisciplinary team meetings (n = 100), individual interviews of family caregivers (n = 73) and hospice staff members (n = 78), and research field notes. SETTING/PARTICIPANTS:Participants in the original studies from which data for this analysis were drawn were hospice family caregivers and staff members employed by one of five different community-based hospice agencies located in the Midwestern United States. RESULTS:Shared decision-making occurred infrequently in hospice interdisciplinary team meetings that included family caregivers. Barriers to shared decision-making included time constraints, communication skill deficits, unaddressed emotional needs, staff absences, and unclear role expectations. The hospice philosophy of care, current trends in healthcare delivery, the interdisciplinary nature of hospice teams, and the designation of a team leader/facilitator supported shared decision-making. CONCLUSION:The involvement of family caregivers in hospice interdisciplinary team meetings using video-conferencing technology creates a useful platform for shared decision-making; however, steps must be taken to transform family caregivers from meeting attendees to shared decision-makers.
What research agenda could be generated from the European General Practice Research Network concept of Multimorbidity in Family Practice?
Le Reste J Y,Nabbe P,Lingner H,Kasuba Lazic D,Assenova R,Munoz M,Sowinska A,Lygidakis C,Doerr C,Czachowski S,Argyriadou S,Valderas J,Le Floch B,Deriennic J,Jan T,Melot E,Barraine P,Odorico M,Lietard C,Van Royen P,Van Marwijk H
BMC family practice
BACKGROUND:Multimorbidity is an intuitively appealing, yet challenging, concept for Family Medicine (FM). An EGPRN working group has published a comprehensive definition of the concept based on a systematic review of the literature which is closely linked to patient complexity and to the biopsychosocial model. This concept was identified by European Family Physicians (FPs) throughout Europe using 13 qualitative surveys. To further our understanding of the issues around multimorbidity, we needed to do innovative research to clarify this concept. The research question for this survey was: what research agenda could be generated for Family Medicine from the EGPRN concept of Multimorbidity? METHODS:Nominal group design with a purposive panel of experts in the field of multimorbidity. The nominal group worked through four phases: ideas generation phase, ideas recording phase, evaluation and analysis phase and a prioritization phase. RESULTS:Fifteen international experts participated. A research agenda was established, featuring 6 topics and 11 themes with their corresponding study designs. The highest priorities were given to the following topics: measuring multimorbidity and the impact of multimorbidity. In addition the experts stressed that the concept should be simplified. This would be best achieved by working in reverse: starting with the outcomes and working back to find the useful variables within the concept. CONCLUSION:The highest priority for future research on multimorbidity should be given to measuring multimorbidity and to simplifying the EGPRN model, using a pragmatic approach to determine the useful variables within the concept from its outcomes.
Interdisciplinary teaching in family medicine teaching units: the residents' points of view.
Dallaire Louis-François,Rhéaume Caroline,Vézina Lucie
Canadian medical education journal
BACKGROUND:Interdisciplinary teaching (IDT) is the norm in Canadian family medicine residency programs. Literature on IDT reports many academic, collaborative and organizational benefits, but little is known about family medicine residents' own perspectives of IDT. The purpose of this study was to explore family medicine residents' points of view on IDT in family medicine teaching units (FMTU). METHODS:A mixed methods design combined interviews and self-completed online questionnaires to explore participants' perceptions of IDT during residency. Content analysis was conducted on the qualitative data and univariate analysis statistical tests on means and proportions were conducted on the quantitative survey questions. RESULTS:A total of 125 family medicine residents from 12 FMTU affiliated with Université Laval (Quebec City) participated in the study (11 interviews and 114 online questionnaires). Participants perceived significant benefits of IDT, including clinical knowledge, complementary perspectives and interprofessional collaboration skills. However, they believe that IDT works best when the educators adapt their teaching to the specific needs of residents in family medicine. CONCLUSION:These findings support those of previous IDT research and highlight the positive impacts of interdisciplinary education in family medicine residency, especially on interprofessional collaboration. IDT should remain an essential component of the family medicine curricula.
Impact of Collaborative Shared Medical Appointments on Diabetes Outcomes in a Family Medicine Clinic.
Hartzler Melody L,Shenk McKenzie,Williams Julie,Schoen James,Dunn Thomas,Anderson Douglas
The Diabetes educator
Purpose The purpose of this study is to evaluate the impact of a collaborative diabetes shared medical appointment on patient outcomes in an urban family medicine practice. Methods Fifty-nine patients were enrolled to participate in multiple shared medical appointments (SMAs) over 12 months. Baseline data included hemoglobin (A1C), lipids, systolic blood pressure (SBP), weight, adherence to American Diabetes Association (ADA) guidelines, and surveys, including the Problem Areas in Diabetes (PAID-2) scale and the Spoken Knowledge in Low Literacy in Diabetes Scale (SKILLD). A1C and SBP were evaluated at each visit. Lipid control was assessed at baseline and at 6 and 12 months. Adherence to ADA guidelines, SKILLD and PAID-2 survey scores, and number of antihyperglycemic and antihypertensive medications were also evaluated at 12 months. Results Thirty-eight patients completed the study. Compared with baseline, A1C and low-density lipoprotein cholesterol (LDL-C) levels decreased significantly over 12 months ( P < .001 and P = .004, respectively). More patients became compliant with the ADA guidelines throughout the course of the study. Specifically, more patients achieved the LDL-C goal of ≤100 mg/dL (2.59 mmol/L; P < .001), were prescribed appropriate antihypertensive medications ( P < .001) and aspirin ( P < .001), and received the pneumonia vaccine ( P < .001). PAID-2 and SKILLD survey scores also significantly improved over the course of the study ( P ≤ .001 and P = .003, respectively). Conclusion Short-term interdisciplinary SMAs decreased A1C and LDL-C, improved patient adherence to ADA guidelines, improved emotional distress related to diabetes, and increased knowledge of diabetes.
Addressing Family Medicine's Capacity to Improve Health Equity Through Collaboration, Accountability and Coalition-Building.
Martinez-Bianchi Viviana,Frank Brian,Edgoose Jennifer,Michener Lloyd,Rodriguez Michael,Gottlieb Laura,Reddick Bonzo,Kelly Christina,Yu Kim,Davis Sarah,Carr Jewell,Lee Jay W,Smith Karen L,New Ronna D,Weida Jane
Achieving health equity requires an evaluation of social, economic, environmental, and other factors that impede optimal health for all. Family medicine has long valued an ecological perspective of health, partnering with families and communities. However, both the quantity and degree of continued health disparities requires that family medicine intentionally work toward improvement in health equity. In recognition of this, Family Medicine for America's Health (FMAHealth) formed a Health Equity Tactic Team (HETT). The team's charge was to address primary care's capacity to improve health equity by developing action-oriented approaches accessible to all family physicians. The HETT has produced a number of projects. These include the Starfield II Summit, the focus of which was "Primary Care's Role in Achieving Health Equity." Multidisciplinary thought leaders shared their work around health equity, and actionable interventions were developed. These formed the basis of subsequent work by the HETT. This includes the Health Equity Toolkit, designed for a broad interdisciplinary audience of learners to learn to improve care systems, reduce disparities, and improve patient outcomes. The HETT is also building a business case for health equity. This has focused efforts on demonstrating to the private sector an economic argument for health equity. The HETT has formed a close partnership with the American Academy of Family Physicians' (AAFP's) Center for Diversity and Health Equity (CDHE), collaborating on numerous efforts to increase awareness of health equity. The team has also focused on engaging leadership in all eight US national family medicine organizations to participate in its activities and to ensure that health equity remains a top priority in its leadership. Looking ahead, family medicine will be required to continuously engage with government and nongovernment agencies, academic centers, and the private sector to create partnerships to systematically tackle health inequities.
Development of an application for mobile phones (App) based on the collaboration between the Spanish Society of Rheumatology and Spanish Society of Family Medicine for the referral of systemic autoimmune diseases from primary care to rheumatology.
Urruticoechea-Arana Ana,León-Vázquez Fernando,Giner-Ruiz Vicente,Andréu-Sánchez José Luis,Olivé-Marqués Alejandro,Freire-González Mercedes,Pego-Reigosa José María,Muñoz-Fernández Santiago,Román-Ivorra José A,Alegre-Sancho Juan José,Vargas-Negrín Francisco,Medina-Abellán María,Cobo-Ibáñez Tatiana,Mas-Garriga Xavier,Calvo-Alén Jaime,Costa-Ribas Carmen,Blanco-Vela Ricardo,Pérez-Martín Álvaro,Beltrán-Catalán Emma,Forcada-Gisbert Jordi,Hernández-Miguel María Victoria,Hermosa-Hernán Juan Carlos,Narváez-García Javier,Nieto-Pol Enrique,Rúa-Figueroa Íñigo
Management of systemic autoimmune diseases is challenging for physicians in their clinical practice. Although not common, they affect thousands of patients in Spain. The family doctor faces patients with symptoms and non-specific cutaneous, mucous, joint, vascular signs or abnormal laboratory findings at the start of the disease process and has to determine when to refer patients to the specialist. To aid in disease detection and better referral, the Spanish Society of Rheumatology and the Spanish Society of Family Medicine has created a group of experts who selected 26 symptoms, key signs and abnormal laboratory findings which were organized by organ and apparatus. Family doctors and rheumatologists with an interest in autoimmune systemic diseases were selected and formed mixed groups of two that then elaborated algorithms for diagnostic guidelines and referral. The algorithms were then reviewed, homogenized and adapted to the algorithm format and application for cell phone (apps) download. The result is the current Referral document of systemic autoimmune diseases for the family doctor in paper format and app (download). It contains easy-to-use algorithms using data from anamnesis, physical examination and laboratory results usually available to primary care, that help diagnose and refer patients to rheumatology or other specialties if needed.
Assessing collaboration between family medicine residents and pharmacy residents during an interprofessional paired visit.
Lounsbery Jody L,Moon Jean,Prasad Shailendra
BACKGROUND AND OBJECTIVES:As health care embraces an interprofessional team approach toward care delivery, examples quantifying team members' collaboration in care delivery are limited. Our study objective was to determine the type of and satisfaction with collaboration that occurs between family medicine residents and pharmacy residents during an interprofessional paired visit. METHODS:For 1 half day a week for 10 months, residents were paired to see patients together and complete an evaluation tool. The tool asked participants to rank the contribution of each team member on medication-related patient care tasks and to evaluate the interprofessional pairs' skills on four interprofessional competencies for collaborative practice (values and ethics for interprofessional practice, roles and responsibilities, interprofessional communication, and team and teamwork). Residents participated in focus groups 2 months after the conclusion of the paired visits, and responses were analyzed for common themes. RESULTS:There were 38 half days of paired visits over the 10 months. Shared contribution was found on all tasks, both for self-assessment and of the interprofessional partner. Resident evaluation of the pairs' skills on four interprofessional competencies averaged in the 4 range of the scale (good skills, above average ability). Themes from the focus groups focused on provider experience, perceived impact on patient care, and considerations for ongoing use of paired visits. CONCLUSIONS:Participants of the interprofessional paired visits were able to identify mutual contributions to patient care tasks at the point of care. Focus groups identified potential benefits, impact on patient care, and areas for improvement of paired visits.
An integrated, collaborative healthcare model for the early diagnosis and management of dementia: Preliminary audit results from the first transdisciplinary service integrating family medicine and geriatric psychiatry services to the heart of patients' homes.
Lai Shan Hui,Tsoi Tung,Tang Chao Tian,Hui Richard Jor Yeong,Tan Kim Kiat,Yeo Yehudi Wee Shung,Kua Ee Heok
BACKGROUND:The number of dementia cases is expected to rise exponentially over the years in many parts of the world. Collaborative healthcare partnerships are envisaged as a solution to this problem. Primary care physicians form the vanguard of early detection of dementia and influence clinical care that these patients receive. However, evidence suggests that they will benefit from closer support from specialist services in dementia care. An interdisciplinary, collaborative memory clinic was established in 2012 as a collaborative effort between a large family medicine based service and a specialist geriatric psychiatry service in Singapore. It is the first service in the world that integrates a family medicine based service with geriatric psychiatry expertise in conjunction with community-based partnerships in an effort to provide holistic, integrated care right into the heart of patients' homes as well as training in dementia care for family medicine physicians. We describe our model of care and the preliminary findings of our audit on the results of this new model of care. METHODS:This was a retrospective audit done on the electronic medical records of all patients seen at the Memory Clinic in Choa Chu Kang Polyclinic from August 2013 to March 2016. The information collected included gender, referral source, patient trajectories, presence of behavioural and psychological symptoms of dementia and percentage of caregivers found to be in need of support. A detailed outline of the service workflow and processes were described. RESULTS:A majority (93.5%) of the patients had their memory problems managed at the memory clinic without escalation to other specialist services. 22.7% of patients presented with behavioural and psychological symptoms of dementia. When initially assessed, a majority (82.2%) of patients' caregivers were found to be in need of support with 99.5% of such caregivers' needs addressed with memory clinic services. CONCLUSION:Our model of care has the potential to shape future dementia care in Singapore and other countries with a similar healthcare setting. Redesigning and evolving healthcare services to promote close collaboration between primary care practitioners and specialist services for dementia care can facilitate seamless delivery of care for the benefit of patients.