Abstracts In Press

The abstracts below are from articles currently ‘in press’ at the JABFM. Content and publication dates are subject to change during the copy editing process; please check back here for weekly updates.

NOVEMBER / DECEMBER 2019

JANUARY / FEBRUARY 2020 - SPECIAL OPIOID ISSUE

OTHER MANUSCRIPTS ACCEPTED FOR PUBLICATION

COMMENTARY

Community Pharmacists as Partners in Reducing Suicide Risk

Cortney M. Mospan, PharmD, BCACP, BCGP; Chris Gillette, PhD; Jerry McKee, PharmD, MS, BCPP; Stephanie S. Daniel, PhD

Corresponding Author: Cortney M. Mospan, PharmD, BCACP, BCGP; Wingate University Levine College of Health Sciences. Email:  c.mospan@wingate.edu

Publication: November December 2019 (Full article available online for free on November 8, 2019)

DOI: 10.3122/jabfm.2019.06.190021 

Suicidal ideation and death by suicide is a major public health issue in the United States. Over half of patients who die by suicide did not have a previous mental health diagnosis, and only a small proportion of adults are screen for mental health conditions each year. This commentary describes the importance of engaging community pharmacists in mental health screening to address this major public health concern. The commentary will describe potential mental health roles of the community pharmacist, the benefits of primary care provider collaboration with community pharmacists in suicidal ideation screening, and solutions to existing barriers.

POLICY BRIEF

The Declining Presence of Family Physicians in Hospital-Based Care

Anuradha Jetty, MPH; Yalda Jabbarpour, MD; Stephen Petterson, PhD; Aimee Eden, PhD, MPH; Andrew Bazemore, MD MPH

Corresponding Author: Anuradha Jetty, MPH; Robert Graham Center. Email:  ajetty@aafp.org

Publication: November December 2019 (Full article available online for free on November 8, 2019)

DOI: 10.3122/jabfm.2019.06.190152 

Despite training to provide care across the continuum of health delivery settings, the proportion of Family Physicians (FPs) reporting inpatient care has decreased by 26% between 2013 and 2017, leaving approximately 1 in 4 of FPs practicing hospital medicine in 2017. Policymakers, payers, and leaders in medical education should closely track the impact of these trends, given previous evidence associating better cost and utilization outcomes with broader scope of practice.

ORIGINAL RESEARCH

Health Care Utilization and Pain Outcomes Following Early Imaging for Low Back Pain in Older Adults

Adam C. Powell, PhD; Teresa L. Rogstad, MPH; Sarah W. Elliott, PhD; Stephen E. Price, DPT, MBA; James W. Long, BSBA; Uday U. Deshmukh, MD, MPH; M. Hassan Murad, MD, MPH; Mark W. Steffen, MD, MPH

Corresponding Author: Adam C. Powell, PhD; HealthHelp. Email:  powellad@healthhelp.com

Publication: November December 2019 (Full article available online for free on November 8, 2019)

DOI: 10.3122/jabfm.2019.06.190103

Background: Professional societies have provided inconsistent guidance regarding whether older patients should receive early imaging for low back pain, in the absence of clinical indications. Our study assesses the implications of early imaging by evaluating its association with downstream utilization in an elderly population. Methods: Patients were included if they had a Medicare Advantage plan, had claims-based evidence of low back pain in 2014, and lacked conditions justifying early imaging. The outcomes examined were short-term, nonchronic, and chronic opioid use, steroid injections, and spinal surgery in the following 730 days, and persistent low back pain at 180-365 days. Morphine Dose Equivalents (MDEs) of opioid use was used as a measure of intensity. Logistic and Gamma regressions were used to assess the association between imaging in the first six weeks and the outcomes. Results: Among the 57,293 patients meeting inclusion criteria, the mean age was 71.2, and 26,606 (46.4%) received early imaging. Early imaging was associated with increased odds of short-term (OR 1.21; 95% CI: 1.15-1.28), nonchronic (OR 1.78; 95% CI: 1.69-1.88), and chronic (OR 1.13; 95% CI: 1.07-1.18) opioid use, as well as steroid injections (OR 2.55; 95% CI: 2.28-2.85) and spinal surgery (OR 3.40; 95% CI: 2.97-3.90). Patients that received early imaging were more likely to experience persistent pain (OR 1.09; 95% CI: 1.05-1.14) and used significantly more MDEs if they had nonchronic opioid use. Conclusions: Early imaging for low back pain in older individuals was common, and was associated with greater utilization of downstream services and persistent pain.

ORIGINAL RESEARCH

Natural History of Back Pain in Older Adults Over Five Years

Wendelien H. van der Gaag, MD; Wendy T.M. Enthoven, MD, PhD; Pim A.J. Luijsterburg, PhD; Jantine van Rijckevorsel-Scheele, PhD; Sita M.A. Bierma-Zeinstra, PhD; Arthur M. Bohnen, MD, PhD; Maurits W. van Tulder, PhD; Bart W. Koes, PhD

Corresponding Author: Wendelien van der Gaag, MD; Erasmus MC. Email: w.vandergaag@erasmusmc.nl

Publication: November December 2019 (Full article available online for free on November 8, 2019)

DOI: 10.3122/jabfm.2019.06.190041

Introduction: Back pain is a prevalent health problem. Research often focuses on adults. Evidence on the long-term course of back pain in older patients is limited. A prospective cohort study (BACE) was conducted in a primary care setting in the Netherlands. We aim to investigate the five-year course and medical consumption of older adults (>55 years) presenting with back pain in general practice. Methods: Patients aged >55 years, consulting their general practitioner (GP) with a new back pain episode, were included between 2009-2011. Follow-up questionnaires included e.g. pain severity, disability, quality of life, recovery and medical consumption. Results: 675 patients (mean age 66.4 (SD±7.6)) participated, showing a mean back pain reduction from 5.2 (SD±2.7) to 3.6 (SD±2.8; numerical rating scale, 0-10) at three months follow-up; disability decreased from 9.8 (SD±5.8) to 7.8 (SD±6.2; Roland-Morris Disability Questionnaire, 0-24). After six months this remained practically constant over time. Medical consumption was highest in the first months; medication was used by 72% at baseline and approximately one third (25-39%) during follow-up. At five-year follow-up (response rate 58%; n=392), 43% had recovered; a majority reported persistent or recurrent back pain. Conclusion: Clinical relevant improvements in back pain intensity and disability were seen in the first 3-6 months follow-up. A majority of patients does not become pain free within three months; this does not improve over five years. However, most patients stop consulting healthcare professionals during follow-up. Current medical strategies may not be sufficient in older back pain patients, where back pain becomes a recurrent or chronic condition in the majority of patients.

ORIGINAL RESEARCH

Prevalence and Characterization of Yoga Mentions in the Electronic Health Record

Nadia M. Penrod, PhD; Selah Lynch, MS; Sunil Thomas, MBA; Nithya Seshadri, BS; Jason H. Moore PhD

Corresponding Author: Jason H. Moore PhD; University of Pennsylvania. Email:  jhmoore@upenn.edu

Publication: November December 2019 (Full article available online for free on November 8, 2019)

DOI: 10.3122/jabfm.2019.06.190115

Background: There is a growing patient population using yoga as a therapeutic intervention, but little is known about how yoga interfaces with healthcare in clinical settings Purpose: To characterize how yoga is documented at a large academic medical center and to systematically identify clinician-derived therapeutic use cases of yoga. Methods: We designed a retrospective observational study using a yoga cohort (n=30,976) and a demographically matched control cohort (n=92,919) from the electronic health records at Penn Medicine between 2006 and 2016. We modeled the distribution of yoga notes among patients, clinicians, and clinical service departments, built a multinomial Naïve Bayes classifier to separate the notes by context-dependent use of the word yoga, and modeled associations between clinician recommendations to use yoga and 754 diagnostic codes with Fisher’s exact test, setting an FDR-adjusted p-value < 0.05 (i.e., q-value) as the significance threshold. Results: Yoga mentions in the electronic health record have increased 10.4 fold during the 10 year study period, with 2.6% of patients having at least one mention of yoga in their notes. In total, 30,976 patients, 2,398 clinicians, and 41 clinical service departments were affiliated with yoga notes. The majority of yoga notes are in primary care. Nine diagnoses met the significance criteria for having an association with clinician recommendations to use yoga including: Parkinson’s disease (OR 6.3 [3.7-11.4]; q-value < .001), anxiety (OR 5.8 [3.8-9.0]; q-value < .001), and backache (OR 3.8, [2.4-6.3]; q-value = .001). Conclusions: There is a widespread and growing trend to include yoga as part of the clinical record. In practice, clinicians are recommending yoga as a nonpharmacological intervention for a subset of common chronic diseases. 

ORIGINAL RESEARCH

The Dietary Inflammatory Index Is Associated with Diabetes Severity

Dana E King, MD, MS; Jun Xiang, MS, MA

Corresponding Author: Dana E. King, MD, MS; West Virginia University. Email: kingdana@wvumedicine.org

Publication: November December 2019 (Full article available online for free on November 8, 2019)

DOI: 10.3122/jabfm.2019.06.190092

Objective: The Dietary Inflammatory Index (DII) is a recently developed dietary inflammation assessment tool. The current study examined the association between DII and the presence and severity of diabetes in adults age >20 years. Research Design and Methods: Cross-sectional analysis of 4434 adult participants in the National Health and Nutrition Examination Survey (NHANES 2013-2014). The DII was calculated based on 24-hour dietary recall data. Linear and logistic regression models were used to estimate the relationship and control for possible confounding factors. Results: Among 4434 participants, mean age was 49.4 years, mean BMI was 29.3, and mean DII (higher is more inflammatory) was 0.65 (range -3.41-- +9.05). The mean DII scores in participants with and without diabetes were 0.79 and 0.50 respectively (p=.0098). Participants with HgbA1c > 9% had higher DII scores than those with 6.5%-- 9% HgbA1c (1.37 vs. 0.54, p=0.0002) and those with <6.5% HgbA1c (1.37 vs. 0.50, p<0.0001). With one point increase in the DII score, odds of having diabetes increased by 13% (95% CI = [1.02-1.24]). Among the individuals with diabetes, we also observed a significant association between severity of diabetes and DII scores; with one point increase in DII score, the odds of having hemoglobin A1c higher than 9% increased by 43% (95% CI = [1.21-1.68]). Conclusions: The DII had a significant association with diabetes and a stronger association when HgbA1c > 9%. Further research will help clarify the association between inflammation and diet and the utility of the DII as a tool in risk assessment and management of patients with diabetes.

ORIGINAL RESEARCH

Statin Use in the U.S. for Secondary Prevention of Cardiovascular Disease Remains Suboptimal

Quyen Ngo-Metzger, MD, MPH; Samuel Zuvekas, PhD; Paul Shafer, MA; Howard Tracer, MD; Amanda Borsky, DrPH, MPP; Arlene S. Bierman, MD, MS

Corresponding Author: Quyen Ngo-Metzger, MD, MPH; Agency for Healthcare Research and Quality. Email: Quyen.Ngo-Metzger@ahrq.hhs.gov

Publication: November December 2019 (Full article available online for free on November 8, 2019)

DOI: 10.3122/jabfm.2019.06.180313

Background: Atherosclerotic cardiovascular disease (ASCVD) remains the leading cause of mortality in the US. The purpose of this study is to examine the rates of statin use for secondary prevention of ASCVD events in the United States over the last decade and determine whether disparities in the treatment of ASCVD still persist among women and racial/ethnic minorities. Methods: We conducted a trend analysis using data from 2008 through 2016 to describe age-adjusted trends in the use of statins for secondary prevention using the Medical Expenditure Panel Survey (MEPS). We also conducted a multivariable logistic regression analysis to determine whether sociodemographic characteristics are associated with statin use during the three years that followed the publication of the 2013 ACC/AHA guideline (2014 through 2016). Results: The prevalence of statin use among those with a history of ASCVD remained unchanged from 2008 through 2016. In 2014-16, more than 40% of those aged 40 and older with a history of ASCVD did not use statins, corresponding to approximately 9.5 million Americans. Increasing age and having been diagnosed with high cholesterol (OR: 6.22, p<.001) were associated with higher odds of statin use while being female (OR: 0.65, p<.001) or Hispanic (OR: 0.69, p=.011) were associated with lower odds of statin use. Conclusions:  Our study found there was no increase in the national rates of statin use following the ACC/AHA 2013 secondary prevention guideline and the availability of generic statins. Significant gender and ethnic disparities in ASCVD treatment remained in the U.S.

ORIGINAL RESEARCH

Translating Team-Based Breastfeeding Support into Primary Care Practice

Ann M. Witt, MD, IBCLC; Rachel Witt; Lauren Lasko, APRN, IBCLC; Sue Flocke, PhD

Corresponding Author: Ann Witt MD, FABM, IBCLC; Breastfeeding Medicine of Northeast Ohio. Email: awitt@bfmedneo.com

Publication: November December 2019 (Full article available online for free on November 8, 2019)

DOI: 10.3122/jabfm.2019.06.190118

Background: Team-based care facilitates efficient, evidence-based, patient-centered practice. An outpatient, integrated lactation consultant (LC) and primary care provider (PCP) model improves breastfeeding support, yet practices need assistance with implementation. Method: Based on experience with team-based breastfeeding support at a suburban practice serving mainly well-educated and privately insured families, we constructed and piloted a 6- step needs assessment which informed implementation of the model at a federally qualified health center (FQHC). Practice assessment included baseline data collection of practice newborn volume, breastfeeding intent, breastfeeding rates, provider survey, and financial variables. Post-implementation outcome measurements included provider satisfaction and visit volume. Results: Analysis using newborn volume, breastfeeding intent, and average insurance reimbursement enabled business calculation which estimated additional 400 visits per year and revenue to cover staff training costs. The baseline provider survey(n=20) assessed knowledge, practice resources and barriers. The main barriers identified to providing lactation support were “Not enough time” (80%) and patients “not receiving adequate help” (80%) with 58% noting “inadequate LC staffing at the clinic.” After team-based LC/PCP implementation, monthly lactation visit volume doubled. Provider post-intervention assessment surveys(n=20) demonstrated a positive response with providers reporting a perception of “providing better breastfeeding support” (100%) and that “patients had a positive breastfeeding support experience” (84%). Conclusion: Team-based LC and PCP healthcare is a promising approach for delivering efficient, patient-centered, face to face counseling and support. Practice assessment informs financial feasibility and confirms provider interest in change. An integrated LC/PCP model can be implemented in a FQHC while enhancing patient breastfeeding support and provider satisfaction. 

ORIGINAL RESEARCH

Use of Advance Care Planning Billing Codes in a Tertiary Care Center Setting

Peter Kim, BS, MPH; Jeanette M. Daly, RN, PhD; Maresi Berry-Stoelzle, MD, PhD; Megan Schmidt, MPH; Barcey T. Levy, PhD, MD

Corresponding Author: Peter Kim, BS, MPH; University of Iowa. Email: peter-kim@uiowa.edu

Publication: November December 2019 (Full article available online for free on November 8, 2019)

DOI: 10.3122/jabfm.2019.06.190121

Introduction: The Centers for Medicare and Medicaid Services released the final payment rules for reimbursement of advance care planning (ACP) effective January 2016. In its first year, 23,000 providers nationwide submitted 624,000 claims using the Current Procedural Terminology (CPT) codes 99497 and 99498. The objectives of our study was to (1) assess the frequency of ACP codes used at a single academic tertiary care center in Iowa; (2) determine when and by whom the codes were used; and (3) summarize ACP clinical notes. Methods: Using the electronic medical record (EMR) data warehouse from a single tertiary teaching hospital and affiliated clinics, date of service, department where service was provided, provider name and type, patient medical record number, date of birth and gender linked to the ACP codes 99497 and 99498 were collected. The content of ACP clinical notes were reviewed and summarized. Study period was from January 1, 2016 through September 19, 2018. Results: During the 21-months, code 99497 was used 17 times and code 99498 was never used. Code 99497 was successfully reimbursed 4 times. Discussion: Charges were not reimbursed if the ACP visits did not meet the minimum time requirement or were conducted by an individual not considered a qualified health professional per Medicare rules. Conclusion: ACP codes 99497 and 99498 were very rarely used at this tertiary care center during the initial 21-months the Medicare rules went into effect. Interventions are needed to promote the use of ACP codes, so the time spent in important ACP discussions are properly compensated. 

ORIGINAL RESEARCH

Features of US Primary Care Physicians and Their Practices Associated with Advance Care Planning Conversations

David Nowels, MD, MPH; Molly A. Nowels, MS, MA; Julia L. Sheffler, PhD; Susan Kunihiro, MD; Hillary D. Lum, MD, PhD

Corresponding Author: David Nowels, MD, MPH; University of Colorado. Email: david.nowels@ucdenver.edu

Publication: November December 2019 (Full article available online for free on November 8, 2019)

DOI: 10.3122/jabfm.2019.06.190017

Introduction: Primary care practices are essential settings for Advance Care Planning (ACP) conversations with patients. We hypothesized that such conversations occur more routinely in Advanced Primary Care/Patient Centered Medical Home (APCP/PCMH) Practices utilizing practice transformation strategies. Methods: We analyzed characteristics of physician respondents and their practices associated with ACP discussions in older and sicker patients using US data from the 2015 Commonwealth Fund International Survey of Primary Care Physicians in 10 Nations. The primary outcome was how routinely these ACP conversations are reported. We developed an index of APCP/PCMH features as a practice covariable. Results: 60% of respondents (N=1001) were male; 73% were ≥ 45 years. Multivariable analyses showed that suburban practice location was associated with fewer ACP conversations; working in a practice commonly seeing patients with multiple chronic conditions or who having palliative care needs, and working in a practice from which home visits are made was associated with more ACP conversations. Physicians compensated in part by capitation were more likely to report ACP conversations. No association was found between a single item asking if the practice was an APCP/PCMH and having ACP conversations. However, higher scores on an index of APCP/PCMH features was associated with more ACP conversations. Conclusions: Abstract In this sample of US primary care physicians, the types of patients seen, practice location, and physician compensation influenced whether physicians routinely discuss ACP with patients who are older and sicker. Practices demonstrating more features of APCP/PCMH models of primary care are also associated with ACP discussions. 

ORIGINAL RESEARCH

End of Life Services for Persons Experiencing Homelessness by Health and Social Service Providers

Meredith MacKenzie, MD, BSc, CCFP (AM), FCFP; Eva Purkey, MD, MPH, CCFP, FCFP

Corresponding Author: Eva Purkey, MD, MPH, CCFP, FCFP;  Queen’s University. Email: eva.purkey@dfm.queensu.ca

Publication: November December 2019 (Full article available online for free on November 8, 2019)

DOI: 10.3122/jabfm.2019.06.190066

Background: People experiencing homelessness have significantly shorter life expectancies, higher rates of morbidity and mortality than the general population. Many barriers have been identified to providing palliative care to this population. This study examines health and social service providers’ experiences providing end of life care to people experiencing homelessness, seeking recommendations to improve both patient and provider experience. Methods: Qualitative study using phenomenological approach. Qualitative and quantitative surveys with 136 health and social service providers in Ontario’s South East Local Health Integration Network, in depth interview with 10 key informants. Findings: Participants approached the end of life care of people experiencing homelessness from a framework of dignity and respect. Themes included barriers to end of life care internal to the healthcare system; care avoidance; the experience of stigma for this population when accessing end of life care; lack of provider information and awareness on how to provide care for marginalized groups, how to provide care in the context of substance use, and how to assist clients in accessing the formal palliative care system; and the need for harm reduction approaches to end of life care for persons experiencing homelessness. Discussion: Focusing on harm reduction, and using the framework of Equity Oriented Health Care to make systemic, cultural and policy changes to develop a palliative care system for persons experiencing homelessness may improve care experience for both patients and providers.

ORIGINAL RESEARCH

Experiences of Palliative Health Care for Homeless and Vulnerably Housed Individuals 

Eva Purkey, MD, MPH, CCFP, FCFP; Meredith MacKenzie, MD, BSc, CCFP (AM), FCFP

Corresponding Author: Eva Purkey, MD, MPH, CCFP, FCFP;  Queen’s University. Email: eva.purkey@dfm.queensu.ca

Publication: November December 2019 (Full article available online for free on November 8, 2019)

DOI: 10.3122/jabfm.2019.06.190093

Background: Thirty-five thousand Canadians are homeless on any given night, and mortality rates are much higher than for the general population. Studies have identified barriers to accessing end of life care among the homeless, including logistical barriers and experiences of stigma. This study seeks to explore the experience, goals, fears, and hopes surrounding death in the setting of homelessness or vulnerable housing. Methods: Qualitative phenomenological study involving focus groups and in-depth interviews with 31 people with lived experience of homelessness. Additional sociodemographic data collected from participants. Findings: Themes included extensive experience with death and dying, relationship with mortality, ideas for a good death, and desires for end of life care. Participants presented suggestions for improving end of life care including care that was delivered by people with lived experience of homelessness and substance use; care that was provided either as outreach or in a welcoming, flexible institutional environment; care that minimized stigma and enhanced dignity; and care that respected people’s desires to use substances at the end of life. Discussion: Participants with lived experience of homelessness were articulate in their desires and needs for end of life care. They have extensive exposure to mortality and feel that their needs are not met by the current palliative care system. Recommendations for system change that include harm reduction and equity-oriented healthcare, as well as a combination of outreach and inpatient services, are necessary before palliative care services will be accessible for this population.

ORIGINAL RESEARCH

Prevalence and Factors Associated with Family Physicians Providing E-Visits

Michael R. Peabody, PhD; Mingliang Dai, PhD; Kea Turner, PhD, MPH, MA; Lars E. Peterson, MD, PhD; Arch G. Mainous III, PhD

Corresponding Author: Michael R. Peabody, PhD; The American Board of Family Medicine. Email: mpeabody@theabfm.org

Publication: November December 2019 (Full article available online for free on November 8, 2019)

DOI: 10.3122/jabfm.2019.06.190081

Purpose: The use of telemedicine has grown in recent years. Asa subset of telemedicine, e-visits typically involve the evaluation and management of a patient by a physician or other clinician through a web-based or electronic communication system. The national prevalence of e-visits by primary care physicians is unclear as is what factors influence adoption. The purpose of this study was to examine the prevalence of family physicians providing e-visits and associated factors. Methods: A national, cross-sectional practice demographic questionnaire for 7580 practicing family physicians was utilized.  Bivariate statistics were calculated and logistic regression was conducted examining both physician level and practice level factors associated with offering e-visits. Results: The overall prevalence of offering e-visits was 9.3% (n=702).  Compared to private practice physicians, other physicians were more likely to offer e-visits if their primary practice was an academic health center / faculty practice (OR=1.73, CI=1.03-2.91), managed care / HMO practice (OR=9.79, CI=7.05-13.58), hospital-/health system-owned medical practice (not including managed care or HMO) (OR=2.50, CI=1.83-3.41), workplace clinic (OR=2.28, CI=1.43-3.63), or federal (military, Veterans Administration/Department of Defense) (OR=4.49, CI=2.93-6.89). Physicians with no official ownership stake (OR=0.44, CI=0.28-0.68) or other ownership arrangement (OR=0.29, CI=0.12-0.71) had lower odds of offering e-visits compared to sole owners. Conclusion: Fewer than 10% of family physicians provided e-visits.  Physicians in HMO and VA settings (i.e., capitated versus non-capitated models) were more likely to provide e-visits which suggests that reimbursement may be a major barrier.

ORIGINAL RESEARCH

Validating the Test Plan Specifications for the American Board of Family Medicine’s Certification Examination

Thomas R. O’Neill, PhD; Michael R. Peabody, PhD; Keith L. Stelter, MD, MMM; James C. Puffer, MD; John E. Brady, MD

Corresponding Author: Thomas R. O’Neill, PhD; The American Board of Family Medicine. Email: toneill@theabfm.org

Publication: November December 2019 (Full article available online for free on November 8, 2019)

DOI: 10.3122/jabfm.2019.06.190088

Purpose: To demonstrate the degree to which the American Board of Family Medicine’s certification examination is representative of family physician practice with regard to frequency of diagnoses encounter and the criticality of the diagnoses. Methods: Data from 2012 National Ambulatory Medical Care Survey was used to assess the frequency of diagnoses encountered by family physicians nationally. These diagnoses were also rated by a panel of content experts for how critical it was to diagnose and treat the condition correctly and then assign the condition to 1 of the 16 content categories used on the ABFM examination. These ratings of frequency and criticality were used to create seven different new schemas to compute percentages for the content categories. Results: The content category percentages for the 7 different schemas correlated with the 2006- 2016 test plan percentages from 0.50 to 0.90 with the frequency conditions being more highly correlated and the criticality conditions being less correlated. Conclusions: This study supports the continued use of the current FMCE content specifications as being representative of current family medicine practice; however small adjustments might be warranted to permit better representation of the criticality of the topics.

ORIGINAL RESEARCH

Prevalence of Preexisting Conditions Among Community Health Center Patients Before and After the Affordabe Care Act

Nathalie Huguet, PhD; Heather Angier, PhD, MPH; Megan J. Hoopes, MPH; Miguel Marino, PhD; John Heintzman, MD, MPH; Teresa Schmidt, MS; Jennifer E. DeVoe, MD, DPhil

Corresponding Author: Nathalie Huguet, PhD; Oregon Health & Science University. Email: huguetn@ohsu.edu

Publication: November December 2019 (Full article available online for free on November 8, 2019)

DOI: 10.3122/jabfm.2019.06.190087

Objective: To assess the prevalence of pre-existing conditions for community health center (CHC) patients who gained insurance coverage post-Affordable Care Act (ACA). Methods: We analyzed electronic health record data from 78,059 patients aged 19-64 uninsured at their last visit pre-ACA from 386 CHCs in 19 states. We compared the prevalence and types of pre-existing conditions pre-ACA (2012-2013) and post-ACA (2014-2015), by insurance status and race/ethnicity. Results: Pre-ACA, >50% of patients in the cohort had ≥1 pre-existing condition. Post-ACA, >70% of those who gained insurance coverage had ≥1 condition. Post-ACA, all racial/ethnic subgroups showed an increase in the number of pre-existing conditions, with non-Hispanic black and Hispanic patients experiencing the largest increases (adjusted prevalence difference =18.9, 95% CI: 18.2, 19.6 and 18.3, 95% CI: 17.8, 18.7, respectively). The most common conditions post-ACA were mental health disorders with the highest prevalence among patients who gained Medicaid (45.6%) and lowest among those who gained private coverage (30.5%). Conclusions: This study emphasizes the high prevalence of pre-existing conditions among CHC patients and the large increase in the proportion of patients with at least one of these diagnoses post-ACA. Given how common these conditions are, repealing pre-existing condition protections could be extremely harmful to millions of patients and would likely exacerbate healthcare and health disparities.

ORIGINAL RESEARCH

Neighborhood Socioeconomic and Housing Characteristics Associations with Hospitalization of Veterans

Elham Hatef, MD, MPH; Hadi Kharrazi, MD, PhD; Karin Nelson, MD, MSHS; Philip Sylling, MA; Xiaomeng Ma, MS; Elyse C. Lasser, MS; Kelly M. Searle, PhD; Zachary Predmore, AB; Adam J. Batten, BA; Idamay Curtis, BA; Stephan Fihn, MD, MPH; Jonathan P. Weiner, DrPH

Corresponding Author: Elham Hatef, MD, MPH; Johns Hopkins Bloomberg School of Public Health. Email: ehatef1@jhu.edu

Publication: November December 2019 (Full article available online for free on November 8, 2019)

DOI: 10.3122/jabfm.2019.06.190138

Background: Social determinants of health (SDOH) have an inextricable impact on health. If remained unaddressed poor SDOH can contribute to increased healthcare utilization and costs. We aimed to determine if geographically-derived neighborhood level SDOH had an impact on hospitalization rates of patients receiving care at the Veterans Health Administration’s (VHA) primary care clinics. Methods: In a one-year observational cohort of veterans enrolled in VHA’s primary care medical home program during 2015 we abstracted data on individual veterans (age, sex, race, Gagne comorbidity score) from the VHA Corporate Data Warehouse and linked those data to data on neighborhood socioeconomic status (NSES) and housing characteristics from the U.S. Census Bureau on census tract level. We used generalized estimating equation (GEE) modeling and spatial-based analysis to assess the potential impact of patient-level demographic and clinical factors, NSES, and local housing stock (i.e., housing instability, home vacancy rate, % of houses with no plumbing, and % of houses with no heating) on hospitalization. We defined hospitalization as an overnight stay in a VHA hospital only and reported the risk of hospitalization for veterans enrolled in the VHA’s primary care medical home clinics, both across the nation and within one specific case study region of the country: King County, WA. Results: Nationally 6.63% of our veteran population was hospitalized within the VHA system. After accounting for patient-level characteristics, veterans residing in census tracts with a higher NSES index had decreased odds of hospitalization. After controlling all other factors, veterans residing in census tracts with higher percentage of houses Abstract Clean without heating had 9% (Odds Ratio: 1.09 and 95% Confidence Interval: 1.04, 1.14) increase in the likelihood of hospitalization in our regional Washington State analysis, though not our national level analyses. Conclusions: Our results present the impact of neighborhood characteristics such as NSES and lack of proper heating system on the likelihood of hospitalization. The application of placed-based data at the geographic level is a powerful tool for identification of patients at high risk of healthcare utilization. 

ORIGINAL RESEARCH

Different Depression Treatment Recommendations and Adherence for Spanish and English Speaking Patients

Jacquelyn Stephenson, PhD, MSW; Brian Distelberg, PhD, MA; Kelly R. Morton, PhD, MA; Larry Ortiz, PhD, MSW; Susanne B Montgomery, PhD, MPH, MS

Corresponding Author: Jacquelyn Stephenson, PhD, MSW; Inland Empire Health Plan. Email: jstephenson@llu.edu

Publication: November December 2019 (Full article available online for free on November 8, 2019)

DOI: 10.3122/jabfm.2019.06.180323

Introduction: National guidelines recommend primary care providers (PCPs) screen patients for depression with a standardized tool and address positive screenings. However, depression prevalence is lower in Latinos (8-15%, with Spanish speakers at 8%) than non-Latino whites (22%).  As a result of these prevalence differences, PCPs may use ethnicity and language of the patient to determine depression screening behaviors. This study examined standard of care depression (SoC) treatment recommendations by ethnicity and language for patients who screened positive for major depression during a medical visit. Methods: 275 patients scored >10 on the PHQ-9 screening; a chart review assessed treatment referrals, followed by semi-structured interviews with 18 patients and 7 PCPs regarding depression treatment behaviors. Results: 138 patients (50%) received SoC treatment recommendations. After controlling for age, gender, and race, a binary logistic regression was performed to determine language and ethnicity effects on SoC depression treatment recommendations (psychotherapy/pharmacotherapy vs. other).  Spanish-speaking Latinos were 72% less likely to receive SoC recommendations than English-speakers (OR=.39). Interviews with Spanish-speaking patients confirmed that negative perceptions about medications, patient non-compliance, and a shortage of bilingual behavioral health providers within the clinic impacted SoC recommendations and uptake. Conclusions: Spanish-speaking Latinos did not receive or follow through with SoC recommendations as often as English-speakers regardless of ethnicity. Future studies should explore reasons why language is a barrier to SoC recommendations for Latinos and explore culturally and linguistically sensitive methods to effectively treat Spanish-speakers for depression during a medical visit.

ORIGINAL RESEARCH

Accountable Care Organizations Serving Deprived Communities Are Less Likely To Share in Savings

Alex R. Webb, BS; Winston Liaw, MD, MPH; YoonKyung Chung, PhD; Stephen Petterson, PhD; Andrew Bazemore, MD, MPH

Corresponding Author: Alex R. Webb, BS; Georgetown University School of Medicine. Email: Arw96@georgetown.edu

Publication: November December 2019 (Full article available online for free on November 8, 2019)

DOI: 10.3122/jabfm.2019.06.190004

Purpose: Primary care physicians are increasingly participating in accountable care organizations (ACOs). While prior studies have identified ACO and patient characteristics associated with savings, none have examined characteristics of the communities served by ACOs. Our objective was to assess the relationship between an ACO’s service area characteristics and its savings rate. Methods: In this cross-sectional study, we used the CMS 2014 Medicare Shared Savings Program (MSSP) ACO Provider and Beneficiary, and Public Use Files to identify ACO and beneficiary characteristics. We used the American Community Survey to measure community deprivation at the ACO service area-level by using the social deprivation index.  The outcome of interest was the ACO savings rate. We conducted bivariate analyses and regressions, adjusting for ACO organization and beneficiary characteristics. Results: Our sample consisted of 320 ACOs participating in the Shared Savings Plan. The savings rate for ACOs serving the most deprived communities was 1.19% compared to 1.14% for those serving the least deprived.  Adjusting for ACO and beneficiary characteristics, however, ACOs serving the most deprived had a savings rate that was 2.3 percentage points lower than those serving the least deprived. Conclusions: ACOs serving deprived communities generate less savings. These findings are important to primary care practices, payers, and policymakers anticipating continued ACO expansion, if population health is to be achieved equitably.

BRIEF REPORT

Abnormally Low Hemoglobin A1c as Harbinger of Hemoglobinopathy

Joshua St. Louis, MD, MPH; Anthony Valdini, MD, MS, MPH

Corresponding Author: Joshua St. Louis, MD, MPH; Tufts University School of Medicine. Email: joshua.stlouis@glfhc.org  

Publication: November December 2019 (Full article available online for free on November 8, 2019)

DOI: 10.3122/jabfm.2019.06.190124

Hemoglobin A1c is frequently used in primary care to screen for and monitor disorders of glucose metabolism. A number of clinical syndromes may impact the accuracy of this laboratory value. This report describes a case of abnormally low hemoglobin A1c that was the result of an asymptomatic compound hemoglobinopathy (homozygous hemoglobin S disease and hereditary persistence of fetal hemoglobin) that had gone previously undiagnosed. Primary care physicians must be aware of such pitfalls in the use of this laboratory value and be prepared to use other values to monitor for and assess disorders of glucose metabolism. 

BRIEF REPORT

Use of an Ambulatory Patient Portal for Advance Care Planning Engagement

Adreanne Brungardt, MM, MT-BC; Andrea E. Daddato MS; Bennett Parnes MD; Hillary D. Lum MD, PhD

Corresponding Author: Hillary D. Lum, MD, PhD; University of Colorado School of Medicine. Email: Hillary.Lum@ucdenver.edu

Publication: November December 2019 (Full article available online for free on November 8, 2019)

DOI: 10.3122/jabfm.2019.06.190016

Background: Primary care clinics need sustainable, population-based approaches to engage patients in advance care planning (ACP). Patient portal-based ACP tools may provide an option for patient engagement. Objective: To increase ACP outcomes by engaging older adults through portal-based ACP tools, including an electronic Medical Durable Power of Attorney (MDPOA) form. Methods: Geriatric clinic pilot of a multi-modal population-based outreach strategy for portalbased ACP tools. Outreach was to patients (n=105) who were 65 years and older with an active portal account, no cognitive impairment, and no MDPOA on file. Patients received a motivational message via the portal and, if not read within two weeks, a mailed postcard about the portal-based ACP tools. Primary outcome was composite of any ACP action at 1-year including 1) new advance directive (AD) in the electronic health record, 2) use of portal-based ACP tools or 3) documented ACP discussion with a provider. Results: Sixty-five older adults read the electronic message at 12 months. Seventeen (16%) engaged in at least one ACP action. Fourteen of 17 engaged by adding an AD to their record. More patients completed an AD on paper or brought a previously completed AD to clinic, compared to choosing to complete an electronic MDPOA via the portal. Conclusions: Brief motivational messages about ACP via a patient portal is feasible and may increase ACP outcomes for older adults in primary care. Future studies should evaluate population-based portal outreach strategies in combination with team-based workflows to enhance patient engagement in ACP.

SPECIAL COMMUNICATION

The Potential Emergence of Disease-Modifying Treatments for Alzheimer’s Disease: The Role of Primary Care in Managing the Patient Journey

Jenny Lam, MD, MAS; Jakub Hlávka, PhD; Soeren Mattke, MD, DSc

Corresponding Author: Soeren Mattke, MD, DSc; University of Southern California. Email: mattke@usc.edu

Publication: November December 2019 (Full article available online for free on November 8, 2019)

DOI: 10.3122/jabfm.2019.06.180328

Despite recent setbacks, disease-modifying treatments (DMTs) for Alzheimer’s disease (AD) might become available within a few years. These DMTs are likely to be used in the early stages of AD to avoid the progression to manifest dementia, which implies that a large reservoir of prevalent cases would need to be evaluated when DMTs first become available. Primary care providers (PCPs) would play a vital role in managing the patient flow to specialty care. We review the literature on diagnostic tests that could be used by PCPs and estimate the impact of different testing approaches on demand for specialty care. While many tests have been evaluated, only the Mini-Mental State Exam (MMSE) and the Montreal Cognitive Assessment (MoCA) perform acceptably for detection of early-stage cognitive decline with sensitivities and specificities of 55-82% and 72-84%, respectively, for the MMSE, and 77-96% and 73- 95%, respectively, for the MoCA. However, neither test is sufficiently specific for the AD pathology and would result in four to five false positives for each true positive. Blood-based tests for AD biomarkers may soon become available for clinical use. A plasma amyloid-beta (Aβ) test has been shown to have a sensitivity of up to 97% and specificity of up to 81%. Adding this test to the MMSE or MoCA could reduce false positives by approximately 80%. These findings suggest a combination of brief cognitive tests and blood-based biomarker tests will allow PCPs to identify patients with potential early stage AD efficiently and triage them for further evaluation.

RESEARCH LETTER

Accuracy of Reporting Primary Care Specialty Status in Medical Research

Andrea M. Diep; Harish S. Thoppe; Angela Yang; Abhinav S. Agnani; William R. Phillips, MD, MPH

Corresponding Author: William R. Phillips, MD, MPH;  University of Washington. Email: wphllps@uw.edu

Publication: November December 2019 (Full article available online for free on November 8, 2019)

DOI: 10.3122/jabfm.2019.06.190141

Introduction: Family physicians (FPs) are specialty trained and certified and provide most primary care (PC) services in the US. General practitioners (GPs), a separate group without specialty PC training, are commonly confused with FPs despite differences in demographic characteristics, professional qualifications and clinical services. Our study documents how often research in major medical journals distinguishes between these two groups or combines GPs and FPs together. Methods: We selected 23 US journals on impact factor and relevance to PC. Using a MEDLINE search, we identified all reports published in 2016-17 that met inclusion criteria: original research; done in US; studying FPs, GPs and/or PC physicians. Two researchers reviewed each article to determine inclusion and whether it lumped or split FPs and GPs. Results: Search retrieved 409 total studies, with 88 (21.5%) meeting inclusion criteria. Among these, 35 (39.8%) included FPs only, leaving 53 (60.2%) that also included GPs. Among these studies, only 3 (5.7%) separated GPs from FPs. Another 21 (39.6%) combined GPs and FPs together. In 29 (54.7%), the classification of GPs, FPs and others was not described. Conclusions: Most PC research reports combine GPs and FPs into a single group, masking differences between these distinct groups. Most research reports fail to explain how they classify PC clinicians. Research reports need to improve classification of FPs and primary care clinicians.

RESEARCH LETTER

Primary Care Provider Understanding of Hair Care Maintenance as a Barrier to Physical Activity in African American Women

Sophia O. Tolliver, MD, MPH; Jennifer L. Hefner, PhD, MPH; Starling D. Tolliver, MS; Leon McDougle, MD, MPH

Corresponding Author: Sophia O. Tolliver, MD, MPH; The Ohio State University. Email: sophia.tolliver@osumc.edu

Publication: November December 2019 (Full article available online for free on November 8, 2019)

DOI: 10.3122/jabfm.2019.06.190168

Introduction: African American (AA) women have reported hair maintenance as a barrier to regular exercise, however, to our knowledge, this study is the first to identify primary care provider thoughts, attitudes, beliefs, and knowledge regarding hair as a barrier to increased physical activity amongst AA females. Methods: A 13-question electronic survey was sent via email to 151 clinicians working within a Department of Family Medicine’s 8 ambulatory clinics within a large urban academic medical center. Results:  62 primary care clinicians completed the survey; a response rate of 41%. The vast majority of respondents (95%) sometimes/often engage in discussions with AA female patients regarding physical activity. However, 76% of respondents have never included a hairstyling or maintenance assessment in that discussion and only 34% noted being comfortable discussing this topic. Among a list of potential barriers to exercise, hair maintenance/scalp perspiration was rarely endorsed as important by clinicians. Discussion: This study highlights a need for increased education among primary care providers regarding AA hair care and maintenance practices as a barrier to increased physical activity in AA women. If specific barriers to increasing healthy habits amongst AA women are to be addressed, there must be a baseline knowledge of hair care and maintenance barriers, an understanding of the strong influence of cultural norms and practices as it relates to physical activity and exercise, and an increased comfortability when engaging in difficult cross-cultural conversation to ultimately improve health outcomes in AA females. 

FAMILY MEDICINE AND THE HEALTH CARE SYSTEM

What is the AAFP’s Political Action Committee Fighting For?

Joshua J. Fenton, MD, MPH

Corresponding Author: Joshua J. Fenton, MD, MPH; University of California, Davis. Email: jjfenton@ucdavis.edu

Publication: November December 2019 (Full article available online for free on November 8, 2019)

DOI: 10.3122/jabfm.2019.06.190111

In this essay, the author analyzes contributions from the American Academy of Family Physician’s (AAFP’s) political action committee – FamMedPAC – during the 2018 election cycle. The author highlights discrepancies between explicit AAFP legislative priorities and the voting records and public positions of Congressional members who received FamMedPAC support during the election cycle. The analysis raises questions about FamMedPAC’s decision-making process for allocating support to candidates. The author posits that consistency between AAFP positions and those of candidates receiving FamMedPAC contributions is essential to preserve both public trust in family physicians and family physicians’ trust in the AAFP.

POLICY BRIEF

Family Medicine Response to Opioid Epidemic Driven by Early Career and Graduating Physicians

Lars E. Peterson, MD, PhD; Zachary J. Morgan, MS; Aimee R. Eden, PhD, MPH

Corresponding Author: Lars E. Peterson, MD, PhD; American Board of Family Medicine. Email: lpeterson@theabfm.org

Publication: January February 2020 (Full article available online for free on January 3, 2020)

DOI: 10.3122/jabfm.2020.01.190230

Using data from 2016 to 2018, we demonstrate a sharp increase in graduating family medicine residents and early career family physicians who intend to or actually prescribe buprenorphine with no change in mid to late career physicians.  Family physicians are responding to the opioid crisis but, growing the family medicine workforce to treat opioid use disorder will require a larger response from mid to late career physicians.

ORIGINAL RESEARCH

Satisfaction with Health Care among Prescription Opioid Recipients: A U.S. National Study

Anthony Jerant, MD; Alicia Agnoli, MD, MPH, MHS; Peter Franks, MD

Corresponding Author: Anthony Jerant, MD; University of California, Davis. Email: afjerant@ucdavis.edu

Publication: January February 2020 (Full article available online for free on January 3, 2020)

DOI: 10.3122/jabfm.2020.01.190090

Background: Prior studies examining the association of opioid prescriptions with satisfaction with care involved limited, selected samples with mixed findings. We examined this issue, of relevance to reducing discretionary opioid prescribing, in a U.S. representative sample. Methods: Observational study of adults (N=69,985) enrolled in the 2005-2015 U.S. Medical Expenditure Panel Surveys. We examined the association of high (top quartile) satisfaction with receipt of 0, 1-5 or >6 opioid prescriptions per year. The base model adjusted for demographics and year; the full model added adjustment for health status (12-item Short Form Survey). A sensitivity analysis further adjusted for outpatient visits. Results: In the base model, respondents who received 1-5 or >6 opioid prescriptions were each less likely to have high satisfaction than those who received no opioid prescriptions (AORs [95% CIs] 0.83 [0.79-0.88] and 0.70 [0.63-0.79], respectively). After adding health status adjustment, compared with respondents receiving no opioid prescriptions, those receiving 1-5 were similarly likely and those reporting >6 were more likely to have high satisfaction (AORs [95% CIs] 1.00 [0.94-1.06] and 1.44 [1.27-1.63] respectively). The findings were not substantively affected by further adjustment for outpatient visits. Discussion: In a U.S. national sample, individuals who received >6 opioid prescriptions in a year were more likely to have top quartile satisfaction than those receiving fewer or no opioid prescriptions after accounting for health status. Whether the high satisfaction among such individuals was driven by the prescriptions themselves or by other personal characteristics requires study, as do the effects of de-prescribing.

ORIGINAL RESEARCH

Medical and Non-Medical Use of Stimulant Medications by Young Adults: Knowledge, Beliefs, Attitudes and Practice Patterns of Health Professionals

N Loskutova; J Waterman; E Callen; E.W. Staton; E Bullard; J Shields

Corresponding Author: Natalia Y. Loskutova, MD, PhD; American Academy of Family Physicians National Research Network. Email: nloskutova@hotmail.com

Publication: January February 2020 (Full article available online for free on January 3, 2020)

DOI: 10.3122/jabfm.2020.01.190071

Background: The role of family physicians and college health professionals in stimulant treatment and non-medical use of stimulants is not clear. Objective: To investigate the current practices, concerns, needs, beliefs, barriers, and facilitators to appropriate pharmacological treatment of teens and young adults with ADHD and prevention of non-medical use and diversion. Methods: A cross-sectional survey developed by the project team and experts in the field, delivered to national sample of family physicians (FPs) and college health professionals (CHPs). Results: 794 completed surveys were analyzed. The average age of respondents was 51.6±10.3 years; 50.6% of the respondents were female. The majority of CHPs (80.6%) reported they spend 75-100% of their time with patients age 17-24 years and 74.0% of FPs reported they spend less than 25% of their time with this age group. The majority (91.7%) of the respondents indicated that untreated ADHD affects quality of life, and 76.4% indicated untreated ADHD is often associated with risky behaviors. More CHPs than FPs always refer out for ADHD diagnosis (70.7% vs 52.1%, p<0.001). Most respondents (81.2%) were concerned with ADHD medication diversion, and 84.2% believed that diversion or abuse is a problem overall. Respondents indicated they are unprepared to provide patient education on decisions about pharmacotherapy or behavioral therapy choices for adult ADHD. Conclusion: There is an opportunity to enhance safety and effectiveness of ADHD management in young adults. Additional resources and interventions are needed to improve medication management, reduce misuse, and ensure safe and appropriate use of stimulants.

BRIEF REPORT

A Financial Model for Team-Based Opioid Use Disorder Treatment in Family Medicine

Mackenzie Farrar, PharmD; Zach White, LCSW, LCAS; Stephen Hulkower, MD; E. Blake Fagan, MD; Courtenay Gilmore Wilson, PharmD, BCACP, CPP

Corresponding Author: Courtenay Gilmore Wilson, PharmD, BCACP, CPP; University of North Carolina. Email: Courtenay.wilson@mahec.net

Publication: January February 2020 (Full article available online for free on January 3, 2020)

DOI: 10.3122/jabfm.2020.01.190228

Introduction: Opioid Use Disorder (OUD) affects two million Americans, yet many patients do not receive treatment. Lack of team-based care is a common barrier for Office-Based Opioid Treatment (OBOT). In 2015, we started OBOT in a Family Medicine practice. Based on our experiences, we developed a financial model for hiring a team member to provide non-billable OBOT services through revenue from increased patient volume. Methods: We completed a retrospective chart review from July 2015 to December 2016 to determine the average difference in medical visits per patient per month pre-OBOT versus post-OBOT. Secondary outcomes were the percentage of visits coded as a Level 3, Level 4, and Level 5 and the percentage of patients with Medicaid, private insurance, or self-pay. With this information, we extrapolated to build a financial model to hire a team member to support OBOT. Results: Twenty-three patients received OBOT during the study period. There was a net increase of 1.93 visits per patient per month (p<0.001). Fourteen patients were insured by Medicaid, seven had private insurance, and two were self-pay. Twenty-three percent of OBOT visits were Level 3, 69% were Level 4, and 8% were Level 5. Assuming all visits were reimbursed by Medicaid and accounting for 20% Cost of Business, treating one existing patient for one year would generate $1,439. Treating one new patient would generate $1,677. Conclusions: In a fee-for-service model, the revenue generated from increased medical visits can offset the cost of hiring a team member to support non-billable OBOT services.

ORIGINAL RESEARCH

Prescribing Patterns and use of Risk Reduction Tools after Implementing an Opioid Prescribing Protocol in a Family Medicine Residency

Matthew A. Breeden; Christine K. Jacobs; Matthew Witthaus; Joanne Salas; Kelly Everard; Eric Penton; Jeffrey F. Scherrer

Corresponding Author: Matthew Breeden, MD; Saint Louis University. Email: Matthew.Breeden@health.slu.edu

Publication: January February 2020 (Full article available online for free on January 3, 2020)

DOI: 10.3122/jabfm.2020.01.190247

Background: The literature on results from primary care based opioid prescribing protocols is small and results have been mixed. To advance this field, we evaluated whether opioid prescribing changed after a comprehensive protocol was implemented and whether change was associated with the number and type of risk reduction tools adopted. Methods: Electronic medical record data were obtained for 2,607 patients. Demographics, PHQ-9 scores, BMI, and utilization levels of protocol elements were measured for 24 months prior and 18 months post implementation of an opioid prescribing protocol within a federally qualified health center. Chisquare and t-tests were computed to estimate change in opioid prescribing, morphine equivalent dose (MED), co-medication prescribing, and number and type of protocol elements utilized. Results: The opioid protocol was associated with an increase in urine drug screens from 18.3% to 26.8% from pre- to post-implementation (p<.0001). There was no significant increase in opioid treatment agreements. Tramadol (21.4% to 16.8%, p=.0006) and antidepressant (56.0% to 51.6%, p=.012) prescribing significantly decreased. Total opioid prescriptions and maximum MED were similar from pre- to post-implementation. Protocol elements were more often used when patients had a higher opioid dose and were receiving benzodiazepines. Conclusions: Implementing a multi-faceted opioid prescribing protocol was not associated with change in number or dose of opioid prescriptions but was associated with greater use of urine drug screens, and risk reduction tools were used more often in high risk patients. Implementation research is needed to identify barriers to maximizing adherence to opioid protocols.

SPECIAL COMMUNICATION

Creating a Clinic Culture to Address the Twin Goals of Safe Opioid Prescribing for Pain Management and Treating Opioid Use Disorder Through Change Management: A Case Study

Matthew A. Breeden; Christine K. Jacobs; Matthew Witthaus; Joanne Salas; Kelly Everard; Eric Penton; Jeffrey F. Scherrer

Corresponding Author: Allen F. Shaughnessy, PharmD, MMedEd; Tufts University. Email: Allen.Shaughnessy@Tufts.edu

Publication: January February 2020 (Full article available online for free on January 3, 2020)

DOI: 10.3122/jabfm.2020.01.190223

Background: Given that prescribing practices have contributed to the current opioid epidemic and that primary care clinicians are the largest prescribers of opioids, family physicians must consider the twin goals of safely prescribing opioids for patients with chronic pain while effectively identifying and treating those who have developed opioid use disorder (OUD). However, family physicians may feel constrained by a culture and systems in their offices that do not support achieving these twin goals. Methods: In a family medicine clinic within a larger academic institution that cares for an underserved, multicultural patient population in the greater Boston area, we provide a case study that illustrates the twin goals of safe opioid prescribing and treating OUD. We used two models of change management—Lewin’s Three-Step Change Theory and the McKinsey 7S Model of Change—as a framework to describe our five-year process of employing cultural and structural elements to support these efforts. Results: Deliberate use of change management theory to support both safe opioid prescribing and treating patients with OUD over the past five years resulted in changes to the practices, people, skills, and infrastructure within our clinic. These changes have demonstrated a sense of stability and sustainability and hence now represent our clinic’s current culture. Conclusion: The Lewin and 7S models of change can be helpful guides to creating and maintaining a foundation of office-wide culture and structural support to meet the twin goals of safe opioid prescribing and treating patients with OUD.

ORIGINAL RESEARCH

Characterizing the Office-Based Buprenorphine Prescriber Population by Specialty: A 2013-2016 Medicare Claims Analysis

Rohit Abraham; Elizabeth Wilkinson; Yalda Jabbarpour; Stephen Petterson; Andrew Bazemore

Corresponding Author: Rohit Abraham;  Boston University. Email: rohit.abraham@bmc.org

Publication: January February 2020 (Full article available online for free on January 3, 2020)

DOI: 10.3122/jabfm.2020.01.190233

Introduction: Opioid use disorder (OUD) is a major and growing public health concern, and Medicare patients have nearly double the proportion of OUD prevalence as compared to those with commercial insurance. This study examines provider-level characteristics to delineate the wide variation behind buprenorphine provision, which is the mainstay of medication-assisted treatment for OUD. Methods: Using Medicare Part D Public Use Files claims data from 2013 to 2016 in all states, we assessed prescribing patterns of buprenorphine formulations for the specialties of family medicine, internal medicine, psychiatry, and general practice. We incorporated data from 2013- 2016 American Medical Association Physician Masterfile to model various provider- and arealevel characteristics as predictors of buprenorphine prescriber status. Results: Family medicine and internal medicine comprise nearly two-thirds of the outpatient buprenorphine prescriber population for Medicare beneficiaries. Yet, both specialties also have the lowest proportion of active buprenorphine prescribers, as compared to psychiatrists and general practitioners. Additional characteristics associated with buprenorphine provision include male gender, osteopathic training, Northeast region, US undergraduate medical education, more years in practice, and a higher proportion of dual-eligible patients. Conclusions: Primary care specialties such as family medicine and internal medicine currently comprise a significant majority of the US buprenorphine prescriber population for Medicare beneficiaries. Future policies should target specific demographics to enable greater patient access from physicians who are characteristically less likely to prescribe buprenorphine in order to increase overall capacity.

ORIGINAL RESEARCH

Developing a New Approach to Improve Opioid Prescribing Practices in Primary Care: Evolution of a Quality Improvement Toolkit

Constance van Eeghen, DrPH, MHSA, MBA; Amanda G. Kennedy, PharmD, BCPS; Mark Pasanen, MD; Charles D. MacLean, MD

Corresponding Author: Constance van Eeghen, DrPH, MHSA, MBA; University of Vermont. Email: cvaneegh@med.uvm.edu 

Publication: January February 2020 (Full article available online for free on January 3, 2020)

DOI: 10.3122/jabfm.2020.01.190238

Introduction: The role of opioids in managing chronic pain has evolved in light of the opioid misuse epidemic and new evidence regarding risks and benefits of long-term opioid therapy. With mounting national guidelines and local regulations, providers need interventions to standardize and improve safe, responsible prescribing. This paper summarizes the evolution of an opioid management toolkit using a quality improvement (QI) approach to improve prescribing. Methods: The authors developed a list of opioid-prescribing best-practices and offered in-office, team-based QI projects to ambulatory clinics, updated and tested over three trials in the form of a toolkit. Outcome measures included pre- and post-project surveys on provider and staff satisfaction, toolkit completion, and process measures. The toolkit supports workflow planning, redesign, and implementation. Results: Ten clinics participated in Trial 1, completing the QI project on average in three months, with a mean of 9.1 hours of team time. Provider satisfaction with prescribing increased from 42% to 96% and staff satisfaction from 54% to 81%. The most common strategies in Trials 1 and 2 focused on regulatory compliance (35-36%), while in Trial 3 there was a strong move towards peer support (81%).  Discussion: Clinics responded to implementation of opioid-related best practices using QI with improved provider and staff satisfaction. Once the goals of regulatory compliance and workflow improvements were met, clinics focused on strategies supporting providers in the lead role of managing chronic pain, building on strategies that provide peer support.  Using QI methods, primary care clinics can improve opioid-prescribing best practices for patients.

BRIEF REPORT

Practice Predictors of Buprenorphine Prescribing by Family Physicians

Lars E. Peterson, MD, PhD; Zachary J. Morgan, MS; Tyrone F. Borders, PhD

Corresponding Author: Lars E. Peterson, MD, PhD; American Board of Family Medicine. Email:  lpeterson@theabfm.org

Publication: January February 2020 (Full article available online for free on January 3, 2020)

DOI: 10.3122/jabfm.2020.01.190235

Introduction: Both opioid use disorder (OUD) and mortality for opiate overdoses are increasing.  Family physicians (FPs) can treat OUD if they are waivered to prescribe buprenorphine. Our objective was to determine personal, practice, and community characteristics associated with FPs prescribing buprenorphine. Methods: We used data from the 2017 and 2018 American Board of Family Medicine examination registration questionnaire.  The survey asked about current prescribing of buprenorphine, as well as about practice size, organization, and location. Logistic regression was used to determine associations between buprenorphine treatment and individual, practice, and county characteristics. Results:  The questionnaire had a 100% response rate. After excluding FPs in non-continuity practices and those who could not be linked to a US county, our final sample was 2,726.  Only 161 (5.9%) prescribed buprenorphine.  Practice in a Federal Qualified Health Center (aOR=1.98 (1.08, 3.63)), in solo practice (aOR=2.60 (1.38, 4.92)), or with a mental health professional (aOR=2.70 (1.73, 4.22)) were positively associated with prescribing buprenorphine.  Practice in a rural county or in a whole county mental health professional shortage area were not associated with buprenorphine prescribing. Discussion: Few FPs prescribed buprenorphine, but those in practice settings and with supporting mental health services were more likely to prescribe. With their training in the biopsychosocial model and a more even distribution across the rural continuum, FPs are perfectly situated to meet the increasing need for MAT.  However, ensuring they have supporting mental health services will be central to having more FPs provide MAT. 

ORIGINAL RESEARCH

How Patient Education Level is Related to Decision-Making for Antidepressants: Results from a National Survey

Suzanne Brodney, PhD, RD; Floyd J Fowler Jr, PhD; KD Valentine, PhD; Michael J Barry, MD

Corresponding Author: Suzanne Brodney, PhD, RD; Massachusetts General Hospital. Email: sbrodney@mgh.harvard.edu

Publication: TBD

Background:  Despite recommendations to screen adults for depression in primary care, little is known about how people across education levels decide to treat their depression and factors that influence their decision. Methods:  Secondary analysis of a national, probability-based web survey in English-speaking adults aged 40 or older living in the US who reported they discussed starting or continuing an antidepressant with their clinician in the past two years. Respondents answered questions about knowledge, decision making process and demographics. Education level was analyzed using five ordered categories. The Shared Decision Making (SDM) Process score was used to assess patient involvement. Descriptive statistics, chi-square tests, analysis of variance and regression models were used to describe the data and test associations. Results:  Of the 5682 people invited, 3396 answered questions about health decisions (59.8% response rate) and 385 reported discussing antidepressants. The mean percent of knowledge questions answered correctly increased as education level increased (p=0.008). The mean SDM Process score also increased with education  (p=0.001). There was an association between education and who made the treatment decision suggesting that for respondents with less education, the clinician was more likely to decide (p=0.001). Respondents with less education were less likely to report they would definitely make the same decision again (p=0.000). Conclusions:  Those with less education were even less informed, had lower SDM Process scores and were less likely to think they made the right decision about antidepressants. There is a need to ensure patients are better informed about and involved in treatment for depression.

ORIGINAL RESEARCH

When Physicians Say No: Predictors of Request Denial and Subsequent Patient Satisfaction

Elizabeth M. Magnan, MD, PhD; Peter Franks, MD; Anthony Jerant, MD; Richard L. Kravitz, MD, MSPH; Joshua J. Fenton, MD, MPH

Corresponding Author: Elizabeth Magnan, MD, PhD; University of California, Davis Health System. Email: emagnan@ucdavis.edu

Publication: TBD

Background: Physician denial of patient requests is associated with lower patient satisfaction. Our objective was to explore factors that influence physician request denial and patient satisfaction after request denial. Methods: Cross-sectional observational study of 1,141 adult patients seen during 1,319 outpatient visits with 56 primary care physicians. We measured patients’ post-visit self-report of requests and request fulfillment; visit satisfaction; sociodemographics; health status; symptom burden; life satisfaction; medical skepticism; and whether patients saw their usual physician and a faculty or resident physician. We used mixed-effects regression analyses to identify predictors of request denial and visit satisfaction among patients who had a request denied. Results: Patients made at least one request at 867 visits (65.7%) with at least one denied request reported at 182 visits (21.0%). Patients who saw their usual physician were less likely to report a request denial [adjusted Odds Ratio (aOR) 0.61, 95% CI: 0.42-0.88], and patients with the highest symptom burden (aOR 2.21, 95% CI 1.38-3.55) or greater medical skepticism (aOR 1.35, 95% CI 1.03-1.78) were more likely to report request denials. After request denials, patients seeing their usual physicians reported significantly greater visit satisfaction compared to not seeing their usual physician (adjusted percentile rank in visit satisfaction: 12.4%, 95% CI: 3.5%- 21.2%). Conclusions: Approximately one-fifth of visits in primary care have a denied request. Having an office visit with one’s usual physician is associated with reduced likelihood of request denial and may mitigate the adverse impacts of request denial on patient visit satisfaction.

ORIGINAL RESEARCH

Ethical Questions Raised by Shared Electronic Health Records: An Interview Study of Primary Care Physicians

Tania Moerenhout, MD, MPhil; Gary S. Fischer, MD; Marlies Saelaert, MPhil; An De Sutter, MD, PhD; Veerle Provoost, PhD; Ignaas Devisch, PhD

Corresponding Author: Tania Moerenhout MD; Ghent University. Email: Tania.Moerenhout@ugent.be

Publication: TBD

Objective: The aim of this study is to explore whether specific ethical questions arise with the use of a shared EHR system, based on the daily experience of primary care physicians (PCPs). Methods: In this qualitative research project, we conducted 14 in-depth semi-structured interviews with PCPs in a tertiary hospital setting. Results: We identified four themes: (1) PCPs describe the EHR as a medicine with side effects, for which they provide suggestions for improvements; (2) A shared record raises ethical questions related to autonomy and trust; (3) Although use of the EHR often disturbs rapport with the patient, it can also support the patient-doctor interaction when it becomes an active part of the conversation; (4) A shared EHR may cause healthcare providers (and their relatives) to avoid seeking help for sensitive issues. Discussion: PCPs fear access to results could cause confusion and anxiety in patients, resulting in tensions between autonomy and beneficence. Improved efficiency and quality of care with a shared EHR relies on doctors trusting each other’s input to avoid duplicate tests. However, this might compromise a fundamental skeptical attitude in practicing medicine, and we should be aware of a risk of increased confirmation and anchoring bias. Conclusion: The EHR is considered to be a work-in-progress – EHR design could be improved by examining physicians’ coping strategies and implementing their suggestions for improvement. Ethical questions related to autonomy, trust and the status of records that belong to doctor-patients need to be considered in future research and EHR development.

ORIGINAL RESEARCH

Sickle Cell Disease Co-Management, Health Care Utilization and Hydroxyurea Use in North Carolina

Nancy Crego, PhD; Christian Douglas, DrPh; Emily Bonnabeau, BA; Marian Earls, MD; Kern Eason, MBA; Elizabeth Merwin, PhD; Gary Rains, BA; Paula Tanabe, PhD, MSN, MPH; Nirmish Shah, MD

Corresponding Author: Nancy Crego, PhD; Duke University. Email: nancy.crego@duke.edu

Publication: TBD

Background: Sickle cell disease (SCD) causes significant morbidity, pre-mature mortality and high disease burden, resulting in frequent healthcare use. Co-management may improve utilization and patient adherence with treatments such as Hydroxyurea. The purpose of this study was to describe acute care utilization in Medicaid enrolled patients with SCD, patient factors associated with co-management and adherence to Hydroxyurea. Methods: Data from 2,790 patients diagnosed with SCD, age 1 to 65+, enrolled at least 1 month in North Carolina Medicaid between March 2016 and February 2017 were analyzed. Outpatient visits were categorized as: primary care, hematologist and non-hematologist specialist. Nurse practitioners or physician assistants with unidentified specialty type or family practice were categorized separately. Co-management was defined as a minimum of one primary care and one hematologist visit/patient during the study period. Results: There were notable age related differences in utilization of health care services. Only 34.82% of the sample was co-managed. Co-management was higher in the 1-9 (44.88%) and 10-17 year-old groups (39.22%) versus the 31-45 (30.26%) and 65+ (18.75%) age groups. Age had the greatest influence (AUC=0.599) on whether or not a patient was comanaged. Only a third of the sample (32.24%) had at least one Hydroxyurea prescription. Age was the most predictive factor of good Hydroxyurea adherence (AUC 0.6503). Prediction by co-management was minimal with an AUC=0.5615. Conclusion: Co-management was a factor in predicting Hydroxyurea adherence, but further studies are needed to identify the frequency and components of co-management needed to increase adherence and reduce acute care utilization.

ORIGINAL RESEARCH

Improved Prenatal Counseling per Pregnancy Weight Gain Guideline Lowered Gestational Diabetes

Evelyn M. Figueroa, MD; Kara Nitti, MPH; Stephen M. Sladek, MD

Corresponding Author:  Stephen M. Sladek, MD; Advocate Christ Family Medicine Residency. Email: stephen.sladek@advocatehealth.com

Publication: TBD

Purpose: Excess weight gain during pregnancy is at epidemic proportions, and pregnancy complications are also on the rise. We sought to determine whether better weight gain counseling of expectant mothers will improve obstetrical outcomes. Methods: Our historical-control study design included 2 years of pre-intervention data, then 6 months of physician and staff training in prenatal weight gain counseling in accordance with 2009 Institute of Medicine guidelines, and finally 2 more years of data collection for post-intervention outcomes. Seven Family Medicine Residency clinics monitored 1,571 continuity prenatal cases. Counseling recommendations were noted, and outcomes analyzed: gestational age, birth weight, route of delivery, and the incidences of hypertension and gestational diabetes. Multiple logistic regression was used to control for demographic variables and body mass index at enrollment. Results: Institute of Medicine congruent counseling increased from 10% to 63% (p<0.01). Excess weight gain decreased from 46.4% vs 41.5% (adjusted OR=0.85, 95%CI 0.63-1.16, p=0.10). Gestational diabetes decreased significantly from 11.5% to 7.3% (p=0.008). The difference remained statistically significant even after adjusting for pre-pregnancy obesity and other clinical and demographic characteristics: adjusted OR=0.54; 95% CI 0.32-0.91, p=0.02.  Differences in gestational age, birth weight, hypertension, primary cesarean, and shoulder dystocia were not statistically significant. Conclusions: Improved weight gain counseling of prenatal patients by physicians did reduce the pregnancy complication of gestational diabetes. This occurred even though the trend toward less excess weight gain was not statistically significant.

ORIGINAL RESEARCH

Successful Health Care Provider Strategies to Overcome Psychological Insulin Resistance in U.S. and Canada     

Tricia Tang; Danielle Hessler; William H. Polonsky; Lawrence Fisher; Beverly Reede; Tanya Iranif; Urvi Desaig; Magaly Perez-Nieves

Corresponding Author:  Magaly Perez-Nieves; Eli Lilly and Company. Email: Perez_magaly@lilly.com

Publication: TBD

Purpose: To identify specific actions and characteristics of healthcare providers (HCPs) in the United States (US) and Canada that influenced patients with type 2 diabetes who were initially reluctant to begin insulin. Methods: Patients from the US (N=120) and Canada (N=74) were recruited via registry, announcements, and physician referrals to complete a 30-minute online survey based on interviews with patients and providers regarding specific HCP actions that contributed to the decision to begin insulin. Results: The most helpful HCP actions were patient-centered approaches to improve patients' understanding of the injection process (i.e., "My HCP walked me through the whole process of exactly how to take insulin" [helped moderately or a lot - US: 79%; Canada: 83%]) and alleviate concerns ("My HCP encouraged me to contact his/her office immediately if I ran into any problems or had questions after starting insulin" [US: 76%; Canada: 82%]). Actions that were the least helpful included referrals to other sources (i.e., "HCP referred patient to a class to help learn more about insulin" [US: 39.6%; Canada: 58.3%]). Conclusions: The study provides valuable insight that HCPs can use to help patients overcome psychological insulin resistance, which is a critical step in the design of effective intervention protocols. 

ORIGINAL RESEARCH

How Do Physicians Respond to Patients’ Quality of Life Goals?     

Becky A. Purkaple, MD; Zsolt J. Nagykaldi, PhD; Arrash Allahyar, BS; Robert Todd, MS; James W. Mold, MD, MPH

Corresponding Author:  Becky A. Purkaple, MD; University of Oklahoma Health Science Center. Email: Becky-purkaple@ouhsc.edu

Publication: TBD

Purpose: Patients are able to participate in quality of life (QOL) discussions, but clinicians struggle to incorporate this information into encounters and shared decision-making. We designed a study to determine if a clinician-initiated prompt could make patient visits more goaldirected. Methods: Patients were given a pre-visit questionnaire that included QOL questions. Physicians in the control were given no further prompting. The intervention physicians were prompted to ask a quality of life question: what things are you unable to do because of your health problems today?” A two-pronged design was used: one pre-post group where 3 physicians participated in 5 control and 5 intervention encounters (n=30) and a randomized group in which 11 physicians and their patients were randomly assigned to control or intervention groups (n=30). Video recordings of the encounters were reviewed to determine if QOL goals were mentioned and if they were utilized in decision-making. Results: Fifty-seven (95%) of the 60 patients provided written answers to at least one of the QOL questions on the intake form. QOL goals were mentioned during intervention encounters more often than in control groups. QOL information was used in shared decision-making in only four of the 30 (13%) intervention encounters. Conclusions: Physicians were able to engage in QOL discussions with their patients, but did not translate that information to medical decision making. More research is needed to understand why clinicians opt not to use QOL information and how to make communication more goal-directed.

RESEARCH LETTER

A Descriptive Assessment of Primary Care Provider Knowledge, Attitudes, and Beliefs Regarding Hair Care Maintenance as a Barrier to Increased Physical Activity in African American Women     

Sophia O. Tolliver, MD, MPH; Jennifer L Hefner, PhD, MPH; Starling D. Tolliver, MS; Leon McDougle, MD, MPH

Corresponding Author:  Sophia O. Tolliver, MD, MPH; The Ohio State University College of Medicine. Email: sophia.tolliver@osumc.edu

Publication: TBD

Introduction: African American (AA) women have reported hair maintenance as a barrier to regular exercise, however, to our knowledge, this study is the first to identify primary care provider thoughts, attitudes, beliefs, and knowledge regarding hair as a barrier to increased physical activity amongst AA females. Methods: A 13-question electronic survey was sent via email to 151 clinicians working within a Department of Family Medicine’s 8 ambulatory clinics within a large urban academic medical center. Results:  62 primary care clinicians completed the survey; a response rate of 41%. The vast majority of respondents (95%) sometimes/often engage in discussions with AA female patients regarding physical activity. However, 76% of respondents have never included a hairstyling or maintenance assessment in that discussion and only 34% noted being comfortable discussing this topic. Among a list of potential barriers to exercise, hair maintenance/scalp perspiration was rarely endorsed as important by clinicians. Discussion: This study  highlights a need for increased education among primary care providers regarding AA hair care and maintenance practices as a barrier to increased physical activity in AA women. If specific barriers to increasing healthy habits amongst AA women are to be addressed, there must be a baseline knowledge of hair care and maintenance barriers, an understanding of the strong influence of cultural norms and practices as it relates to physical activity and exercise, and an increased comfortability when engaging in difficult cross-cultural conversation to ultimately  improve health outcomes in AA females.

BRIEF REPORT

Thyroid Hormone Use in the United States, 1997-2016     

Michael E. Johansen, MD, MS; Julie P. Marcinek, DO; Jonathan Yun, MD

Corresponding Author:  Michael E Johansen, MD, MS; Grant Family Medicine, OhioHealth. Email: mikejoha3@gmail.com

Publication: TBD

Background: Thyroid disorders are among the most commonly treated conditions by the United States health care system. The number of patients reporting thyroid hormone use has increased in recent years, but it is unknown if there have differential increases in the number of treated individuals within different demographic groups. Previous research has also not evaluated how expenditures for different thyroid hormone medications have changed in recent years. Methods: Using data from the 1997 through 2016 Medical Expenditure Panel Survey, we calculated the proportion of adults reporting thyroid hormone prescriptions by three demographic variables (age, sex, and race) and determined expenditures from thyroid hormone prescriptions by medication type (overall, generic, Synthroid or Cytomel, and other brand). Results: Between 1997 and 2016, the proportion of adults who reported thyroid hormone use increased from 4.1% (95% CI 3.7-4.4) to 8.0% (95% CI 7.5-8.5). Most of the growth in thyroid hormone use occurred among adults aged > 65 and use was also more common amongst females and non-Hispanic Whites. Expenditures from thyroid hormones increased from $1.1 billion (95% CI 0.9-1.3) in 1997 to $3.2 billion dollars (95% CI 2.9 to 3.6) in 2016. Generic thyroid hormone prescriptions comprised 18.1% of all thyroid hormone prescriptions in 2004 (95% CI 15.8-20.4) and 80.8% of all thyroid hormone prescriptions (95% CI 78.4- 83.2) in 2016. Conclusions: Thyroid hormone use nearly doubled over the last twenty years, and increased use was associated with being older, female, and non-Hispanic white. During the same time period, thyroid hormone expenditures almost tripled. 

BRIEF REPORT

Factors Influencing Uptake of Changes to Clinical Preventive Guidelines: Perspectives from Clinician and Practice Leader     

Vivian Jiang, MD; E. Marshall Brooks, PhD; Sebastian T. Tong, MD, MPH; John Heintzman, MD; Alex H Krist, MD, MPH

Corresponding Author:  Vivian Jiang, MD; Virginia Commonwealth University. Email: vjiang2@gmail.com

Publication: TBD

Background: Despite widespread recognition that adherence to clinical preventive guidelines improves patient outcomes, clinicians struggle to implement guideline changes in a timely manner. Multiple factors influence guideline adoption and effective implementation. However, few studies evaluate their collective and inter-related effects. This qualitative study provides a comprehensive picture of the interplay between multiple factors on uptake of new or changed preventive guidelines. Methods: Semi-structured interviews conducted in 2018 with a diverse sample of clinicians and practice leaders sought to understand patient, clinician, practice, health system, environment, and guideline factors of influence. An immersion-crystallization approach was used to identify emergent themes. Results: Interviewees expressed motivation to adhere to guidelines but also valued sharing decisions with patients. Personal biases and fears affected both clinician and patient guideline adoption. Practices facilitated implementation through workflow optimization and encouraging a culture of evidence-based practice while a key health system function was to maintain electronic health record alerts. More traditional environmental factors, such as insurance coverage or transportation, were less of a barrier to guideline adoption and implementation than the influence of media and specialists. Various specific guideline characteristics also affected ease of adoption and implementation. Different settings expressed greater health system, practice, or clinician centric approaches to guideline implementation. Conclusions: Guideline uptake is influenced by a complex interplay of multiple levels of factors including the patient, clinician, practice, health system, environment, and guideline levels. Comprehensively understanding all levels of influence for each specific clinical setting may help to determine the optimal intervention(s) for improving uptake of evidence-based guidelines.

BRIEF REPORT

A Multilevel Approach to Designing and Evaluating a Prediabetes Shared Decision Aid    

Beth A. Careyva, MD; Kyle Shaak, MPH; Nicole M. Burgess, BS; Melanie B. Johnson, MPA; Elaine Seaton Banerjee, MD, MPH; Yoonjie Chung, MD; Allison N. Davis; Colleen Payton, PhD, MPH

Corresponding Author:  Beth A. Careyva, MD; Lehigh Valley Health Network. Email: beth_a.careyva@lvhn.org

Publication: TBD

Background: Prediabetes is increasing in prevalence and is associated with risk of developing diabetes, heart disease, stroke, and retinopathy. Clinicians have limited tools to facilitate prediabetes discussions within primary care visits. Purpose: 1) Develop a Patient and Stakeholder Advisory Committee (PASAC) to design, evaluate, and revise a prediabetes shared decision aid and 2) evaluate the feasibility and experience of implementing the tool within primary care practice. Methods: A prediabetes decision aid (double-sided infographic with decision questions) was created by a PASAC, which included patients, primary care clinicians, diabetes educators, endocrinologists and pharmacists. Five clinicians within 3 primary care practices tested the prediabetes tool with 50 adult patients with prediabetes. Patients completed 2 surveys immediately after the office visit and 6 weeks later. Clinicians and PASAC members completed a post-intervention survey. Results: The prediabetes shared decision aid was created through a deliberative process over 3 PASAC meetings. 96% of patients felt the tool prepared them to decide on a diabetes prevention plan. 100% of clinicians would use the tool again and felt the tool did not extend visit length. Discussion: It was feasible to co-create a prediabetes shared decision aid within a PASAC and implement the tool within a primary care setting. Patients and clinicians reported a prediabetes discussion, which may mitigate rates of progression to diabetes and associated complications. Future research should evaluate which of the intervention components most effectively promotes discussion of prediabetes within a primary care setting. 

RESEARCH LETTER

Job Satisfaction and Its Associated Factors among General Practitioners in China: A Nationwide Survey    

Liqing Li, PhD; Yong Gan, PhD; Heng Jiang, PhD; Yudi Yang, MS; Xiaogang Zhou, PhD; Yanling Zheng, MS; Fang Yu, BS; Jianxin Liu, MS; Yanyan Zhong, MS; Yanli Chen, BS; Minyi Yu, MS; Ling Liu, BS; Juan Liu, PhD; Zuxun Lu, PhD

Corresponding Author:  Zuxun Lu, PhD; Huazhong University of Science and Technology. Email: zuxunlu@yahoo.com

Publication: TBD

Objectives: Investigation is scare on job satisfaction among general practitioners (GPs) in China. This study aimed to investigate job satisfaction of GPs in China and explore its determinants. Methods: A multistage stratified random sampling method was used to collect data with a structured self-administered questionnaire from 3,236 GPs (response rate, 99.8%) working in community health institutions in China between October, 2017 and February, 2018. Multiple linear stepwise regression analysis was used to analyze the associated factors with job satisfaction among GPs. Results: Among these respondents, 1,215 (37.5%), 352 (10.9%), and 1,669 (51.6%) GPs were dissatisfied, moderate and satisfied for current job, respectively. Male GPs, a higher education level, at a higher professional title, at a lower level of income; and those with heavy work stress had a lower job satisfaction. In addition, GPs who often worked overtime, who were at a higher level of emotional exhaustion (EE), at a higher level of depersonalization (DP), at a lower level of personal accomplishment (PA), and who had less occupational development opportunities reported a lower level of job satisfaction. Conclusion: The findings suggest that job satisfaction among Chinese GPs is at a moderate level. Region, sex, professional title, education level, working overtime, income level, EE, DP, PA, work stress and occupational development opportunities were significant predictors of job satisfaction.

CLINICAL REVIEW

Providing Diagnosis and Symptoms Management for Patients With Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS)   

Kenneth J. Friedman, PhD; H. Andrew Selinger, MD

Corresponding Author:  H. Andrew Selinger, MD; Quinnipiac University. Email: haselinger@qu.edu

Publication: TBD

Up to 2.5 million Americans suffer from Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) making it likely that a family physician will see one or more of these patients. ME/CFS is a chronic disease, currently more disabling than HIV/AIDS and more difficult to treat. There are no medications to address its underlying cause or primary symptom: post-exertional malaise (PEM). Currently, diagnosis is based upon the presenting symptoms in accordance with Institute of Medicine criteria. Complete recovery is unlikely, although improvements of symptoms and quality of life are possible for the majority of patients. There is no disease-confirming, clinical, laboratory test, but such tests are useful in determining the presence of comorbidities. Patient care consists of providing symptom relief, managing comorbidities (if present), and educating the patients to stay within their energy envelope, “pacing” their activities, so as not to trigger PEM and other symptoms. School-age children are treated similarly but have the additional need of physician assistance in obtaining home instruction or partial day attendance at school, and support in maintaining social contacts with peers and family. The family physician who works with ME/CFS patients will be performing critical roles of coordinating care, determining appropriateness of referral and supporting patients as they develop broader insights into their own lifestyles and behaviors which will help them achieve their best possible quality of life.

RESEARCH LETTER

Anti-Hypertensive Medication Combinations in the United States   

Michael E. Johansen, MD, MS; Jonathan Yun, MD, MPH; James M. Griggs, MD; Elizabeth Anne Jackson, MD, MPH; Caroline R. Richardson, MD

Corresponding Author:  Michael E Johansen, MD, MS; OhioHealth. Email: mikejoha3@gmail.com

Publication: TBD

Background: Examining the anti-hypertensive regimens of individuals with different comorbidities may offer insights into how we can improve hypertension management. Methods: The Medical Expenditure Panel Survey (2013-2015) was used to describe the most common single-, two-, three-, and four-drug hypertension regimens among hypertensive adults in four different comorbidity groups: 1. Hypertension only; 2. Hypertension and diabetes; 3. Hypertension and cardiovascular disease (coronary heart disease or stroke history); and 4. Hypertension, diabetes, and cardiovascular disease. Results: 15,901 adults with hypertension taking anti-hypertensive medications were included in the study. 58.6% (95% CI: 57.3-59.8) took multiple anti-hypertensive medications, but the proportion of adults taking multiple anti-hypertensives varied by comorbidity group. Regimens including an ACE-inhibitor/ARB were the most prevalent regimens among individuals taking ≥2 anti-hypertensive medications. The most common two-drug regimen for both the hypertension-only and hypertension-diabetes groups was an ACE-inhibitor/ARB with thiazide. The most prevalent regimen for the two cardiovascular disease groups was an ACE-inhibitor/ARB with beta-blocker. Conclusions: Most individuals with hypertension use between 2-5 medications and the medications comprising these regimens vary by comorbidity. The ACCOMPLISH trial suggested that certain combinations may lead to superior cardiovascular outcomes. Research comparing the efficacy of different hypertension medication combinations among individuals with different comorbidities could lead to better patient hypertension-related outcomes.

ETHICS FEATURE

An Ethical Framework to Manage Patient Requests for Medical Marijuana   

Michael Redinger, MD, MA; Nicole Fledderman, BS; Parker Crutchfield, PhD

Corresponding Author: Nicole Fledderman, BS; Western Michigan University. Email: Nicole.fledderman@med.wmich.edu

Publication: TBD

An increasing number of states are legalizing marijuana use for medicinal purposes despite marijuana use remaining criminalized at the federal level and continued Schedule I status by the Federal Drug Administration (FDA). Many of those states in which medical marijuana is legal require physician involvement to facilitate patient access. Additionally, physicians may have ethical objections to medical marijuana use or may not believe there is adequate scientific evidence to support its use. The constellation of these factors creates an ethical quandary for physicians when approached by patients for assistance in accessing medical marijuana. This paper provides an ethical framework which provides guidance to physicians in managing these patient requests taking into consideration the above ethically relevant factors.

CLINICAL REVIEW

Cervical Spondylotic Myelopathy: A Guide to Diagnosis and Management   

Johnathon R. McCormick, BS; Andrew J. Sama, BA; Nicholas C. Schiller, BS; Alexander J. Butler, MD; Chester J. Donnally III, MD

Corresponding Author:  Johnathon R. McCormick, BS; University of Miami. Email: jmccormick@med.miami.edu

Publication: TBD

Cervical spondylotic myelopathy (CSM) is a neurologic condition which develops insidiously over time as degenerative changes of the spine result in compression of the cord and nearby structures. It is the most common form of spinal cord injury in adults, yet its diagnosis is often delayed. The purpose of this article is to review the pathophysiology, natural history, diagnosis and management of CSM with a focus on the recommended timeline for physicians suspecting CSM to refer patients to a spine surgeon. Various processes underlie spondylotic changes of the canal and are separated into static and dynamic factors. Not all patients with evidence of cord compression will present with symptoms, and progression of disease varies by patient. The hallmark symptoms of CSM include decreased hand dexterity and gait instability as well as sensory and motor dysfunction. MRI is the imaging modality of choice in patients with suspected CSM, but CT-myelography may be used in patients with contraindications. Patients with mild CSM may be treated surgically or non-operatively, while those with moderate-severe disease are treated operatively. Due to the long-term disability that may result from delay in diagnosis and management, prompt referral to a spine surgeon is recommended for any patient suspected of having CSM. This review provides information and guidelines for practitioners to develop an actionable awareness of CSM.

REFLECTIONS IN FAMILY MEDICINE

Crashing Out of a Career   

Brenda Neufeld, MD

Corresponding Author:  Brenda Neufeld, MD; University of Arizona. Email: brendaneufeld@hotmail.com

Publication: TBD

This article is a reflection on unexpected retirement, and includes memories and thoughts about a career with the Indian Health Service near the border with Mexico, serving the Tohono O’odham tribe. It details the circumstances of a move to Arizona, struggles with chronic illness, and an unexpected stay with the tribe for an entire career. Strategies that helped cope with sudden retirement are detailed, including connections with patients by letter and phone and cultivation of acceptance, gratitude, and satisfaction. The essay includes reflection on ways in which patient encounters and a career remain alive through memory and on what gives meaning following retirement. 

ORIGINAL RESEARCH

Eliminating Patient Identified Barriers to Care to Decrease Medicaid Inpatient Admission Rates and Improve Quality of Care: A Team-Based Approach   

Toren Davis, DO; Janalynn Beste, MD; Sonali Batish, MPH; Rebecca Watford; LPN; Shanon Farrell, BSPH

Corresponding Author:  Toren Davis, DO; New Hanover Regional Medical Center. Email: Toren.davis@NHRMC.org

Publication: TBD

Background and Objectives: The goal of this study was to decrease admission and readmission rate for the 2,296 Medicaid patients in our clinic. Our focus was to eliminate patient identified barriers to care that led to decreased quality of care. The identified barriers for our clinic included distance to care, poor same-day access, communication, and fragmented care. A team-based, collaborative approach using members from all aspects of patient care. Methods: An initial survey identified which barriers to care our patients felt obstructed their care. With this data, along with a national literature review, our team used biweekly quality team meetings with LEAN methodology and PDSA cycles to create a four-phase quality improvement project. A home visit program to decrease distance to care, walk-in clinic to improve same day access, strengthened collaboration with outside care managers and clinic staff to improve communication, and the introduction of an in-house phlebotomist to improve fractionated care were created and studied between June 2015 and December 2018. Admission rate, avoidable readmission rate as well as other quality of care measurements were assessed with EMR reports and through North Carolina Medicaid data reports. Results: Overall Medicaid admissions decreased 32.7% from starting numbers, 40.2% below expected benchmarks. Avoidable readmissions decreased 41.8%, 53.8% below the expected benchmark. Improvements in same day access numbers and lab completion rate were also seen. Discussion: The team based approach to eliminating patient identified barriers decreased both admissions and avoidable readmissions for our Medicaid patients. It also improved quality of care measures. This approach has been shown to be beneficial at our clinic and can easily be replicated in other settings. 

ORIGINAL RESEARCH

Marketing Messages in Continuing Medical Education Modules on Binge Eating Disorder 

Jin Jung, BS; Adriane Fugh-Berman, MD

Corresponding Author:  Adriane Fugh-Berman, MD; Georgetown University Medical Center. Email: ajf29@georgetown.edu

Publication: TBD

Background: In 2015, Vyvanse (lisdexamfetamine) became the first FDA-approved treatment for Binge-Eating Disorder (BED), a condition first recognized by the DSM–V in 2013. Because pharmaceutical companies use continuing medical education (CME) to help sell drugs, we explored possible bias in CME modules on BED. Methods: We utilized a qualitative thematic analysis research approach to identify and classify patterns in CME activities focusing on BED. Results: We identified 27 on-line CME activities on BED in 2015. All were funded solely by Shire, which manufactures lisdexamfetamine. Seven of 16 presenters disclosed financial ties with Shire. Twenty-nine slides recurred in at least two CME modules, and 12 slides were repeated in five or more modules. Diagnosis-related themes included: BED is a real, treatable disease; BED is highly prevalent but often missed; BED can occur in anyone; BED results in poor quality of life; many patients with BED are obese; BED makes losing weight difficult. Treatment related themes included: Lisdexamfetamine is highly effective; topiramate is limited by substantial adverse effects; and other therapeutic options for BED are inferior to lisdexamfetamine because they do not cause weight loss. Although amphetamines can cause addiction, myocardial infarction, stroke, and death, no module mentioned these serious adverse effects. Conclusions: It appears that CME is being used to promote lisdexamfetamine for weight loss (a contraindicated use) and to highlight benefits of lisdexamfetamine while underplaying the risks.

ORIGINAL RESEARCH

Turning Points as Opportunities to Partner with the Patient: A Qualitative Study of Patients Living with Type 2 Diabetes or Prediabetes 

Christy JW Ledford, PhD; Carla L. Fisher, PhD; Lauren A. Cafferty; Jeremy T. Jackson; Dean A. Seehusen, MD, MPH; Paul F. Crawford, MD

Corresponding Author:  Jeremy T. Jackson; Military Primary Care Research Network. Email: jtjackson@hjf.org      

Publication: TBD

Introduction: Understanding patients’ perspectives about their diabetes and what causes those perspectives to shift is critical to building a treatment strategy with the patient and facilitating patient self-management behavior. Key “turning points” can provide crucial opportunities to enact a change in perspective. The goal of this study is to identify “turning points” that have significance to diabetes-related health. Methods: Research coordinators interviewed 33 patients aged 25 to 65 diagnosed with type 2 diabetes mellitus (T2DM) or prediabetes (preDM) at medical centers in Augusta, Georgia, and Las Vegas, Nevada. Retrospective interview technique (RIT) and turning point analysis was employed to plot health or diabetes management changes from diagnosis up to the present day. The constant comparative method was used to conduct a thematic analysis. Axial coding identified properties characterizing each turning point. Results: Patients reported five inter-related turning points occurring at various times after diagnosis: 1) gaining knowledge, either through patients own research and/or a healthcare class; 2) making lifestyle changes, including exercising and healthier eating; 3) encountering a life-changing event/transition, including events that derailed healthy behavior, motivated health behavior, and removed barriers to enacting healthy behavior; 4) receiving social support, either through holding patients accountable or encouraging them to enact healthy behavior; and 5) interacting with clinicians, such as medication changes or behavior changes critical to disease management. Discussion: These turning points provide specific moments throughout diabetes care in which family physicians can effectively partner with patients. By prompting, facilitating, or attending to these turning points, family physicians can partner with patients throughout diabetes care.

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