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. In addition, ahead-of-print COVID-19 full articles are now available for download at: COVID-19 Subject Collection.

| JANUARY/FEBRUARY 2021 |       | MARCH/APRIL 2021: VETERANS' HEALTH |       | OTHER ACCEPTED ABSTRACTS | 

JANUARY/FEBRUARY 2021. VOLUME 34 / ISSUE 1. (Publication Date: January 14, 2021)

MARCH/APRIL 2021. VOLUME 34 / ISSUE 2. VETERANS' HEALTH SPECIAL ISSUE (Publication Date: March 11, 2021)

OTHER ABSTRACTS ACCEPTED FOR PUBLICATION (Publication Date: TBD)

POLICY BRIEF

The Essential Role of Family Physicians in Providing Cesarean Sections in Rural Communities

Sebastian T. Tong, MD, MPH; Aimee R. Eden, PhD, MPH; Zachary J. Morgan, MS; Andrew W. Bazemore, MD, MPH; Lars E. Peterson, MD, PHD

Corresponding Author: Sebastian T Tong, MD, MPH; Agency for Healthcare Research and Quality. Email: sebastian.tc.tong@gmail.com

Publication: 1/14/2021

Of family physicians who perform cesarean sections, more than half do so in rural communities and 38.6% provide cesarean sections in counties without any obstetrician/gynecologists. As policymakers in the United States struggle with a widening landscape of ‘obstetrical deserts,’ efforts to adequately train a family physician workforce prepared to provide cesarean sections could help maintain access to local obstetric services in rural communities and reduce perinatal morbidity and mortality.

ORIGINAL RESEARCH

Opportunities to Improve the Reporting of Primary Care Research: An International Survey of Researchers

William R. Phillips, MD, MPH; Elizabeth Sturgiss, BMed, FRACGP, MPH, PhD; Liesbeth Hunik, MD; Paul Glasziou, MBBS, FRACGP, PhD; Tim olde Hartman, MD, PhD, FP/GP; Aaron Orkin, MD, MSc, MPH, CCFP(EM), FRCPC; Joanne Reeve, BClinSci, MBChB, MPH, PhD, FRCGP; Grant M. Russell, MBBS, MFM, FRACGP, PhD; Chris van Weel, MD, PhD, FRCGP (Hon), FRACGP (Hon)

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

Publication: 1/14/2021

Purpose: To assess opportunities to improve reporting of primary care (PC) research to better meet the needs of its varied users. Methods: International, inter-professional online survey of PC researchers and users, 2018- 2019. Respondents used Likert scales to rate frequency of difficulties in interpreting, synthesizing and applying PC research reports. Free-text short answers were categorized by template analysis to record experiences, concerns and suggestions. Areas of need were checked across existing reporting guidelines. Results: Survey yielded 255 respondents across 24 nations, including: women 54.1% (138), physicians 60% (169), scientists 11% (32), educators 7% (20) and public health professionals 6% (18). Overall, 37.4% indicated difficulties using PC research reports “50% or more of the time.” The most common problems were synthesizing findings (58%) and assessing generalizability (42%). Difficulty was reported by 49% for qualitative, 46% for mixed methods and 38% for observational research. Most users wanted richer reporting of theoretical foundation (53.7%); teams, roles and organization of care (53.4%); and patient involvement in the research process (52.7%). Few reported difficulties with ethics or disclosure of funding or conflicts. Free-text answers described special challenges in reporting PC research: context of clinical care and setting; practical details of interventions; patient-clinician and team relationships; and generalizability, applicability and impact in the great variety of PC settings. Cross-check showed that few current reporting guidelines focus on these needs. Conclusions: Opportunities exist to improve the reporting of PC research to make it more useful for its many users, suggesting a role for a PC research reporting guideline.

ORIGINAL RESEARCH

Advancing the Patient EXperience (APEX) in COPD Registry: Study Design and
Strengths

Barbara P. Yawn, MD, MSc, MSPH, FAAFP; Alan Kaplan MD, CCFP(EM), FCFP; Wilson D. Pace, MD; Janwillem W.H. Kocks, MD, PhD; Lakmini Bulathsinhala, MPH; Victoria A. Carter, BSc; Ku-Lang Chang, MD, FAAFP, MRO; Chelsea L. Edwards, PhD; Chester Fox, MD, FAAFP; Gabriela Gaona, MPH; Gokul Gopalan, MD, MPH; MeiLan K. Han, MD, Msc; Maja Kruszyk BEng; Chantal E. Le Lievre, BPH; Cathy D. Mahle, PhD, MBA; Barry Make, MD; Zoe K. Philip, MPH; Chris Price, LLB; Amanda R. Ratigan, PhD, MPH; Asif Shaikh, MD, MPH; Neil Skolnik, MD; Brooklyn Stanley, MSc; David B. Price, FRCGP

Corresponding Author:  David B. Price, FRCGP; University of Aberdeen. Email: dprice@opri.sg

Publication: 1/14/2021

The APEX (Advancing the Patient Experience) in chronic obstructive pulmonary disease (COPD) registry (https://www.apexcopd.org/) is the first primary care health system-based COPD registry in the U.S. While its ultimate goal is to improve the care of patients diagnosed with COPD, the registry is also designed to describe real-life experiences of people with COPD, track key outcomes longitudinally, and assess the effectiveness of interventions. It will retrospectively and prospectively collect information from 3000 patients enrolled in 4-5 health care organizations. Information will be obtained from electronic health records, and from extended annual and brief questionnaires completed by patients prior to clinic visits. Core variables to be collected into the APEX COPD registry were agreed upon by Delphi consensus and fall into 3 domains: demographics, COPD monitoring, and treatment. Main strengths of the registry include: (i) its size and scope (in terms of patient numbers, geographic spread and use of multiple information sources including patient-reported information); (ii) collection of variables which are clinically-relevant and practical to collect within primary care; (iii) use of electronic data capture systems to ensure high-quality data and minimization of data-entry requirements; (iv) inclusion of clinical, database development, management and communication experts; (v) regular sharing of key findings, both at international/national congresses and in peer-reviewed publications; and (vi) a robust organizational structure to ensure continuance of the registry, and that research outputs are ethical, relevant and continue to bring value to both patients and physicians.

ORIGINAL RESEARCH

External Support for Practice Transformation: A Practical Taxonomy

Leif I. Solberg, MD; Anton Kuzel, MD, MHPE; Michael L. Parchman, MD, MPH; Donna R. Shelley, MD, MPH; W. Perry Dickinson, MD; Theresa L. Walunas, PhD; Ann M. Nguyen, PhD, MPH; Lyle J. Fagnan, MD; Samuel Cykert, MD; Deborah J. Cohen, PhD; Bijal A. Balasubramanaian, MBBS, PhD; Douglas Fernald, MA; Leah Gordon, MPH; Abel Kho, MD; Alex Krist, MD; William Miller, MD; Carolyn Berry, PhD; Daniel Duffy, MD; Zsolt Nagykaldi, MD

Corresponding Author: Leif I. Solberg, MD; HealthPartners Institute; Email: leif.i.solberg@healthpartners.com

Publication: 1/14/2021

Background: There is no commonly accepted comprehensive framework for describing the practical specifics of external support for practice change. Our goal was to develop such a taxonomy that could be used by both external groups or researchers and healthcare leaders. Methods: The leaders of eight grants from AHRQ for the EvidenceNOW study of improving cardiovascular preventive services in over 1500 primary care practices nationwide worked collaboratively over eighteen months to develop descriptions of key domains that might comprehensively characterize any external support intervention. Combining literature reviews with our practical experiences in this initiative and past work, we aimed to define these domains and recommend measures for them. Results: The taxonomy includes one domain to specify the conceptual model(s) on which an intervention is built and another to specify the types of support strategies used. Another five domains provide specifics about the dose/mode of that support, the types of change process and care process changes that are encouraged, and the degree to which the strategies are prescriptive and standardized. A model was created to illustrate how the domains fit together and how they would respond to practice needs and reactions. Conclusions: This taxonomy and its use in more consistently documenting and characterizing external support interventions should facilitate communication and synergies between three areas (quality improvement, practice change research, and implementation science) that have historically tended to work independently. The taxonomy was designed to be as useful for practices or health systems managing change as it is for research.

ORIGINAL RESEARCH

Engagement of Small to Medium-Sized Primary Care Practices in Quality Improvement Efforts: A Cross-Sectional Study

Tulay G. Soylu, PhD, MHA, MBA; Alison E. Cuellar, PhD, MBA; Debora Goldberg, PhD, MHA, MBA; Anton J. Kuzel, MD, MHPE

Corresponding Author: Tulay G. Soylu, PhD, MHA, MBA; Temple University. Email: tulay.soylu@temple.edu

Publication: 1/14/2021

Background: Engaging primary care practices in quality improvement (QI) efforts has been challenging. Literature provides little guidance on the engagement of small to medium-sized practices in QI. This study examined the association between practice readiness and practice characteristics and engagement during a targeted quality improvement effort. Methods: The study analyzed cross-sectional data collected by the Heart of Virginia Healthcare, a cardiovascular disease QI intervention study with 195 practices. Data sources include: (1) coach-assessed practice engagement in seven domains (outcome), (2) surveys of readiness completed by 2,529 clinicians and staff, a response rate of 86 %, and (3) surveys of practice characteristics completed by a physician leader or practice manager. We used descriptive statistics and ordered logit regression for the analysis. Results: Associations between readiness and engagement were statistically significant for clinician engagement (OR=5,74; 95% CI, 1.79-18.42, P=0.003) and leadership engagement (OR=3.19; 95% CI, 1.10-9.24, P=0.032). Adjusting for covariates, being a hospital-owned practice was associated with a lower level of clinician engagement (OR=0.35; 95% CI, 0.16- 0.76, P=0.009) relative to independent practices. Discussion: Our study highlights the importance of clinician and leadership engagement as drivers of practice readiness to change in a QI effort. Lack of clinician engagement in hospitalowned practices could be driven by other factors like burnout that need to be explored in future studies. Conclusions: Clinicians and leadership involvement in QI efforts is critical. The findings suggest that QI plans should involve clinicians and leaders early in the process to foster commitment, establish practice readiness, and sustain improvement efforts.

ORIGINAL RESEARCH

Electronic Health Record Algorithm Development for Participant Recruitment Using Colonoscopy Appointment Scheduling

Jeanette M. Daly, RN, PhD; Kim Parang, MA; Barcey T. Levy, PhD, MD

Corresponding Author: Jeanette M. Daly, RN, PhD; University of Iowa. Email: jeanette-daly@uiowa.edu

Publication: 1/14/2021

Introduction: Electronic health records (EHRs) are often leveraged in medical research to recruit study participants efficiently. The purpose of this study was to validate and refine the logic of an EHR algorithm for identifying potentially eligible participants for a comparative effectiveness study of fecal immunochemical tests (FIT), using colonoscopy as the gold standard. Methods: An Epic report was built to identify patients who met the eligibility criteria to recruit patients having a screening or surveillance colonoscopy. With the goal of maximizing the number of potentially eligible patients that could be recruited, researchers, with the assistance of information technology and scheduling staff, developed the algorithm for identifying potential subjects in the EHR. Two validation methods, descriptive statistics and manual verification, were used. Results: The algorithm was refined over three iterations leading to the following criteria being used for generating the report: Age, Appointment Made On/Cancel Date, Appointment Procedure, Contact Type, Date Range, Encounter Departments, ICD-10 codes, and Patient Type. Appointment Serial Number/Contact Serial Number were output fields that allowed the tracking of cancellations and reschedules. Conclusion: Development of an EHR algorithm saved time in that most individuals ineligible for the study were excluded prior to patient medical record review. Running daily reports that included cancellations and rescheduled appointments allowed for maximum recruitment in a timeframe appropriate for the use of the FITs. This algorithm demonstrates that refining the algorithm iteratively and adding cancellations and reschedules of colonoscopies increased the accuracy of reaching all potential patients for recruitment.

ORIGINAL RESEARCH

Barriers to Colonoscopic Follow Up After Positive FIT or Multitarget Stool DNA Testing

Gregory S. Cooper, MD; Ashley Grimes, MS; James Werner, PhD; Shufen Cao, PhD; Pingfu Fu, PhD; Kurt C. Stange, MD, PhD

Corresponding Author: Gregory S. Cooper, MD; University Hospitals Cleveland Medical Center. Email:  gregory.cooper@UHhospitals.org

Publication: 1/14/2021

Background: Fecal immunochemical testing (FIT) and multi-target stool DNA testing (mt-sDNA) are recommended colorectal cancer screening options but require follow up with colonoscopy to determine the source of a positive result. We performed a retrospective analysis in an academic health system to determine adherence to colonoscopy in these patients. Methods: We identified all patients aged 40 and older with at least one primary care visit who had a positive FIT or mt-sDNA between January 2016 and June 2018. We identified receipt of colonoscopy within 6 months of the positive test and reviewed medical records to determine reasons for lack of colonoscopy. Results: We identified 308 eligible patients with positive FIT and 323 with positive mtsDNA. 46.7% of patients with positive FIT and 71.5% of patients with positive mt-sDNA underwent colonoscopy within 6 months, and time to colonoscopy was also shorter with mt-sDNA (hazard ratio 1.83, 95% CI 1.48-2.25). These differences remained in a multivariable model adjusting for patient characteristics. Among patients without colonoscopy after positive FIT, one or more system, provider and patient related barriers were identified in 32.1%, 57.6% and 36.3%, respectively. Among patients without colonoscopy after positive mt-sDNA, corresponding frequencies were 30.4%, 43.5% and 57.6%, respectively. Conclusions: Follow up colonoscopy was higher for mt-sDNA than FIT, which could be due in part to preselection by clinicians and/or patients. Among patients who did not follow up, provider and system factors were as frequently encountered as patient factors. These findings reinforce the need for multi-level interventions to improve follow up.

ORIGINAL RESEARCH

Do Medical Scribes Help Primary Care Providers More Quickly Respond To Out-of-Visit Tasks?

Leah Zallman, MD, MPH; Wayne Altman, MD, FAAFP; Lendy Chu, MPH; Sharon Touw, MPH; Karissa Rajagopal, BA; Steven Dolat, MBA; Assaad Sayah, MD

Corresponding Author: Leah Zallman, MD, MPH; Institute for Community Health. Email: lzallman@challiance.org

Publication: 1/14/2021

Purpose: Medical scribes are charged with decreasing documentation burden associated with patient visits. Reducing time spent on documentation may afford providers the opportunity to respond to outof-visit inbox tasks faster. Methods: We compare changes in the time taken to address patient portal messages, prescription requests, and test results from before to after scribe implementation among scribed primary care providers (PCPs), compared to non-scribed PCPs during the same time period. We used generalized estimating equations with robust standard errors to account for repeated measures and the hierarchical nature of the data, and adjusted for provider and patient characteristics. Results: We examined 472,411 tasks, including 27,645 tasks for 5 scribed PCPs and 444,766 tasks of 74 non-scribed PCPs. In unadjusted analyses, we found no change in time-to-completion for prescription refill requests, results and patient portal messages; the change in time-to-completion from pre to post intervention among scribed PCPs was 1.02 times that of non-scribed providers (p=0.585) for prescription refill requests, 1.06 times that of non-scribed providers (p=0.516) for patient portal messages, and 1.02 times that of non-scribed providers (p=0.787) for results. Adjustment for provider and patient characteristics did not change these findings. Conclusions: Our study suggests that scribes are not associated with improved time-to-completion of inbox messages for PCPs. While scribes appear to have many benefits, our study suggests they may not improve time-to-completion of out-of-visit tasks. Reducing the time-to-completion for these tasks likely requires other interventions targeted to achieve those outcomes. 

ORIGINAL RESEARCH

Documenting New Ways of Delivering Care Under Oregon’s Alternative Payment and Advanced Care Model 

Erika K. Cottrell, PhD; Katie Dambrun, MPH; Jean O’Malley, MPH; R. Lorie Jacob, ScM; Ned Mossman, MPH; Charles Ashou; John Heintzman, MD

Corresponding Author: Erika K. Cottrell, PhD; Oregon Health & Science University. Email: cottrele@ohsu.edu

Publication: 1/14/2021

Background: The fee-for-service (FFS) reimbursement system that dominates health care throughout the U.S. links payment to a billable office visit with a physician or advanced practice provider. Under Oregon’s Alternative Payment and Advanced Care Model (APCM), initiated in 2013, participating community health centers (CHCs) receive per-member-per-month (PMPM) payments for empaneled Medicaid patients in lieu of standard fee-for-service Medicaid payments. With Medicaid revenue under APCM no longer tied solely to billable patient visits, the Oregon Health Authority needed a way to document the full range of care and services that CHCs provide to their patients, including non-traditional patient encounters taking place outside of face-to-face visits with a billable provider. Towards this end, program leadership defined 18 visit and non-visit-based care activities - “Care Services That Engage Patients” (Care STEPs) – that APCM CHCs were asked to document in the electronic health record (EHR) to demonstrate continued empanelment. Objective: To describe trends in rates of traditional face-to-face office visits and Care STEPs documentation among CHCs involved in the first three phases of APCM implementation. Research Design: The study population included the nine CHCs involved in the first three phases of APCM implementation. Using data from the EHR, quarterly summary rates for office visits and Care STEPs were calculated for the first 18 quarters of implementation (3/1/2013 to 6/30/2017). Results: Among participating CHCs, the mean rate of face to face visits with medical providers declined from 635±128 to 461±109 visits/1000 patients/quarter (mean difference -174, 95% -255, -94). Care STEPs documentation increased from 831±174 to 1017±369 Care Steps/1000 patients/quarter, but the difference was not statistically significant. Care STEPs within the category of New Visit Types were documented most frequently. There were significant increases in documentation of Coordination and Integration and a small, albeit significant, increase in Reducing Barriers to Health. There was a significant decline in the documentation of Care STEPs by physicians and an increase in documentation by ancillary staff. Conclusions: These findings suggest that APCM is increasing CHCs’ capacity to experiment with new ways of providing care beyond the traditional face-to-face office visit with a physician or advanced practice provider. However, CHCs may choose different ways to change the delivery of care and some CHCs have implemented these changes more quickly than others. Future mixed-methods research is needed to understand barriers and facilitators to changing the delivery of care after APCM implementation.

ORIGINAL RESEARCH

Challenges and Approaches to Population Management of Long-Term Opioid Therapy
Patients in Primary Care

Kari A. Stephens, PhD; Brooke Ike, MPH; Laura-Mae Baldwin, MD, MPH; Christine Packer; Michael Parchman, MD, MPH

Corresponding Author:  Kari A. Stephens, PhD; University of Washington. Email: kstephen@uw.edu

Publication: 1/14/2021

Purpose: Primary care is challenged with safely prescribing opioids for patients with chronic non-cancer pain (CNCP), specifically to address risks for overdose, Opioid Use Disorder, and death. We identify sociotechnical challenges, approaches, and recommendations in primary care to effectively track and monitor patients on long-term opioid therapy, a key component for supporting adoption of opioid prescribing guidelines. Methods: We examined qualitative data (field notes and post-intervention interview and focus group transcripts) from six rural and rural-serving primary care organizations with 20 clinic locations enrolled in a study evaluating a practice redesign program to improve opioid medication management for CNCP patients. Two independent researchers used content analysis to categorize data into key themes to develop an understanding of sociotechnical factors critical to creating and implementing an approach to tracking and monitoring of patients on long-term opioid therapy in primary care practices. Results: Four factors were critical to developing a tracking and monitoring system. For each we describe common challenges and approaches used by the clinics to overcome then. The first factor, buy-in and participation, was essential for accomplishing the other three. The other factors occurred sequentially: 1) cohort identification – finding the right patients, 2) data collection and extraction – tracking the right data, and 3) data use – monitoring patients and adjusting care processes. Conclusions: We identified common challenges and approaches to tracking and monitoring patients using long-term opioid therapy for CNCP in primary care. Based on these findings we provide recommendations to build capacity for tracking and monitoring for organizations that are engaged in improving safe opioid prescribing practices for CNCP in primary care.

ORIGINAL RESEARCH

A Two-Year View of Mental Health and Benzodiazepines Among Patients on Chronic Opioid Therapy

Abigail Y. Smith, MD; Julienne K. Kirk, PharmD; Paul F. Smith, BS; Brian J. Wells, MD, PhD

Corresponding Author: Julienne K. Kirk, PharmD, CDE, BCPS; Wake Forest School of Medicine. Email: jkirk@wakehealth.edu

Publication: 1/14/2021

Introduction: Higher daily doses of opioids as well as co-prescription of benzodiazepines have been associated with risk of overdose. The current study characterizes prescribing patterns in a family medicine practice with regard to patient mental health diagnoses, benzodiazepine prescriptions, morphine milligram equivalent (MME) opioid dose, and patient demographics. Methods: Patients on chronic opioid therapy were studied in 2018 and 2019. Mental health diagnosis, opioid dose, benzodiazepine prescriptions and demographic characteristics were extracted from the electronic medical record. Data were compared between years and logistic regression was used to determine which patient characteristics were associated with likelihood of decreased opioid dose. Results: A total of 387 patients were prescribed chronic opioid therapy in 2018, and 231 in 2019. In 2018, 49.9% of patients prescribed chronic opioids had mental health diagnoses. In 2019, this proportion rose to 92.2%. In 2019, 205 of the original 387 patients were still with the practice but were not prescribed chronic opioids. Among the factors studied, psychiatric diagnosis and higher opioid dose were associated with a significantly lower likelihood of tapering doses. Discussion: As practices taper or deprescribe opioids, or implement harm reduction methods such as deprescribing benzodiazepines, it is important to understand patient characteristics and their relationship to success with tapering. This study adds to the evidence that odds of successfully tapering opioids may be significantly impacted by patients’ mental health diagnosis and opioid dose.

ORIGINAL RESEARCH

Pharmaceutical Industry Interaction in United States Family Medicine Residencies Continues To Decrease: A CERA Study

Steven R. Brown, MD, FAAFP; Adriane Fugh-Berman, MD

Corresponding Author: Steven R. Brown, MD, FAAFP; University of Arizona College of Medicine. Email:  steven.brown@bannerhealth.com

Publication: 1/14/2021

Background: Pharmaceutical interaction in US residencies is common. This study explores the extent and type of learner interactions in U.S. family medicine residencies with the pharmaceutical industry and compares interactions from 2008, 2013, and 2019. Methods: We surveyed program directors of 628 family medicine residencies with eight questions utilizing the 2019 Council of Academic Family Medicine Educational Research Alliance (CERA) Survey and compared the responses to 2008 and 2013 results. Results: The survey response rate was 39%. 81% of responding residencies did not allow food or gifts, 86% did not allow drug samples, 84% did not allow industry to interact with medical students or residents, and 81% did not allow industry-sponsored residency activities. These numbers were statistically significantly higher than both 2008 and 2013. In 2019, 151 responding programs (64%) were pharma-free, that is, they answered “no” to all four questions about interactions. Pharma-free residencies were increased in 2019 compared to 26% in 2008 and 49% in 2013. University-based family medicine programs were more likely to be pharma-free. Only 21% of responding programs had a formal curriculum that explores the interaction between physicians and the pharmaceutical industry. Factors cited for decreasing interaction included: institutional policy, ethical concerns, faculty input, and local response to national legislation. Conclusions: Interaction between trainees in US family medicine residencies and the pharmaceutical industry continued to decrease. A changing national legislative landscape combined with institutional policies and concerns about industry influence on prescribing habits may be important factors driving the limiting of interactions.

ORIGINAL RESEARCH

Uptake of Statin Guidelines to Prevent and Treat Cardiovascular Disease: A Call to Guideline Developers

Sebastian T. Tong, MD, MPH; Roy T. Sabo, PhD; Camille J. Hochheimer, PhD; E Marshall Brooks, PhD; Vivian Jiang, MD; Alison Huffstetler, MD; Paulette Lail Kashiri, MPH; Alex H. Krist, MD, MPH

Corresponding Author: Sebastian T. Tong, MD, MPH; Agency for Healthcare Research and Quality. Email: sebastian.tc.tong@gmail.com 

Publication: 1/14/2021

Introduction: In December 2013, cholesterol treatment guidelines changed the approach to statin therapy by recommending fixed doses of low, medium, or high intensity statins based on cardiovascular risk. We sought to evaluate the guideline’s adoption in a diverse group of practices. Methods: Using a mixed methods approach, we analyzed electronic health record data the year prior to and 2 years following guideline publication in 45 practices across eight states. We examined associations based on patient, clinician and practice characteristics and interviewed 24 clinicians and practice leaders to inform findings. Results: The proportion of patients adherent with all recommendations two years after the guideline only increased from 18.5% to 20.3% (p<0.01). There were clinically insignificant increases in statin use across risk strata (1.7% to 3.5%) and small increases in high intensity statin use (2.6% to 4.6%). Only half of patients with cardiovascular disease (52.9%) were on any statin, not much different than patients at moderate (49.6% to 50.9%) or low (41.6% to 48.7%) risk. Multiple patient (risk, use of healthcare), clinician (age), and practice (type, rurality) factors were associated with statin use. Clinicians reported patient resistance to statins but liked having a risk calculator to guide discussions. Conclusion: Despite general agreement with statin benefit, the guideline was poorly implemented. Marginal differences in statin use between the highest and lower risk strata of patients is concerning. Rather than intensifying statin potency and recommending more patients take statins, guidelines may want to focus on ensuring that those who will benefit most get treatment.

ORIGINAL RESEARCH

Perceptions of Patients with Primary Nonadherence to Statin Medications

Derjung M. Tarn, MD, PhD; Maureen Barrientos, BA; Mark J. Pletcher, MD, MPH; Keith Cox, MA; Jon Turner, PhD; Alicia Fernandez, MD; Janice B. Schwartz, MD

Corresponding Author: Derjung Mimi Tarn, MD, PhD; David Geffen School of Medicine at UCLA; Email: dtarn@mednet.ucla.edu

Publication: 1/14/2021

Background: Despite emphasis on efforts to prevent cardiovascular disease (CVD), 13-34% of people never fill a prescribed statin (primary nonadherence). This study determined perceptions of adults with primary nonadherence to statins. Methods: Ten focus groups were conducted with 61 adults reporting primary nonadherence to statins (93% without known CVD). Participants were recruited from an academic medical center and nationwide Internet advertisements. Results: Major themes related to primary nonadherence were: 1) desire to pursue alternatives before starting a statin (e.g., diet and/or exercise, dietary supplements); 2) worry about risks and adverse effects of statins; 3) perceptions of good personal health (suggesting that a statin was not needed); and 4) doubt about the benefits of statins in the absence of disease. Additional themes included mistrust of the pharmaceutical industry, mistrust of prescribing providers, inadequate provider communication about statins, and negative prior experiences with medication. Though rare, a few patients said that high cholesterol does not require treatment if it is genetic. One-third noted during focus group discussions that they did not communicate their decision not to take a statin to providers. Conclusions: Adults with primary nonadherence to statins describe seeking alternatives, avoiding perceived risks of statins, poor acceptance/understanding of CVD risk estimates, and doubts about the benefits of statins. Many do not disclose their decisions to providers, thus highlighting the need for provider awareness of the potential for primary nonadherence at the point of prescribing, and the need for future work to develop strategies to identify patients with potential primary nonadherence. 

ORIGINAL RESEARCH

Low-Dose Aspirin Use Among African-American Older Adults

Mohsen Bazargan, PhD; Cheryl Wisseh, PharmD, TTS, MPH; Adinkrah Edward, MD; Shanika Boyce, MD, FAAP, MPH; Ebony O. King MD; Shervin Assari, MD, MPH

Corresponding Author: Mohsen Bazargan, PhD; Charles R. Drew University of Medicine and Science; Email: mohsenbazargan@cdrewu.edu

Publication: 1/14/2021

Objectives: Existing epidemiological information shows disparities in low-dose aspirin use by race. This study investigates the frequency, pattern, and correlates of both self and clinician-prescribed low-dose aspirin use among underserved African Americans aged 55 years and older. Methods: This cross-sectional study conducted a comprehensive evaluation of all over-the-counter (OTC) and prescribed (Rx) medications used among 683 African American older adults in South Central Los Angeles. Correlation between use of low-dose aspirin and sociodemographic variables, healthcare continuity, health behaviors, and several major chronic medical conditions were examined. In addition, the use of low-dose aspirin as self-prescribed vs. clinician prescribed was examined. Multivariate logistic regression was performed to examine correlates of low-dose aspirin use. Results: Overall, 37% of participants were taking low-dose aspirin. Sixty percent of low-dose aspirin users were taking low-dose aspirin as self-prescribed and 40% were taking it as prescribed by a clinician. Major aspirin-drug interactions were detected in 75% of participants who used low-dose aspirin, but no significant differences in aspirin-drug interactions were found between those who used aspirin as selfprescribed and those who used it as clinician-prescribed. No negative association between being diagnosed with gastrointestinal conditions and aspirin used was detected. Being diagnosed with diabetes mellitus or a heart condition was associated with higher use of aspirin. However, only 50% with high risk of CVD took prescribed (38%) or self-prescribed (62%) low-dose aspirin. One-third of participants aged 70 years and older with low risk of CVD were using aspirin. Conclusions: Among underserved African-American middle-aged and older adults, many who could potentially benefit from aspirin are not taking it; and many taking aspirin have no indication to do so and risk unnecessary side effects. Compared to non-Hispanic Whites, African Americans are more likely to be diagnosed with diabetes, hypertension, and heart conditions at earlier stages of life; as a result, the role of preventive intervention, including safe and appropriate use of low-dose aspirin among this segment of our population, is more salient. Interventional studies are needed to promote safe and effective use of lowdose aspirin among underserved African American adults.

ORIGINAL RESEARCH

One-View Chest Radiograph is Sufficient for Initial Management of Most Ambulatory Patients with Rib Pain

Emily Nishimura, BS; Alyssa Finger, BS; Mark Harris, BS; Hyo-Chun Yoon, MD, PhD

Corresponding Author: Alyssa Finger, BS; Creighton University School of Medicine; Email: AlyssaFinger@creighton.edu

Publication: 1/14/2021

Introduction: Rib series are frequently ordered for ambulatory patients who complain of rib pain or have suffered chest trauma. However, the utility of rib series in such patients has been questioned in previous studies. The objective of this study was to compare the efficacy of rib series to a single view posteroanterior chest radiograph in the clinical management of most ambulatory patients with rib pain. Methods: We reviewed all rib series for rib pain performed between 1/1/2016 and 12/31/2016 excluding patients with suspected bony metastasis, chest or rib deformities, and follow-up studies for prior rib series. We recorded any follow-up imaging and/or surgical intervention within 30±7 days, fracture diagnosis, and any complications relating to rib fractures. Results: 1791 rib series were performed during the study period. Of these, 1168 (65.2%) rib series were performed because of trauma as reported in the clinical indication (trauma cohort). 623 (34.8%) of the rib series were performed for clinical indications which did not specify acute trauma (non-trauma cohort). There were 323 (17.9%) rib series that resulted in a fracture diagnosis and 95 (5.3%) that resulted in a possible fracture diagnosis. There were 50 (2.8%) effusions, 7 (0.4%), pneumothoraces, and 1 (0.1%) hemothorax detected. Only 2 patients, one each from the trauma and non-trauma cohorts underwent subsequent intervention during the follow-up period. In both cases, the findings which led to the subsequent intervention could be seen on the initial posteroanterior chest radiograph. Conclusion: Single view chest radiograph provides sufficient information for the clinical management of ambulatory patients with rib pain. 

ORIGINAL RESEARCH

Interdisciplinary Primary Care Team Expertise and Diabetes Care Management in Community Health Centers

Chris Miller-Rosales, MSPH; Hector P. Rodriguez, PhD, MPH

Corresponding Author: Chris Miller-Rosales, MSPH; University of California, Berkeley. Email: cmiller@berkeley.edu

Publication: 1/14/2021

Background: Interdisciplinary primary care team expertise can aid patient self-management of type II diabetes, but small community health centers (CHCs) may not have the volume to consistently provide interprofessional care. We examine whether care team role expertise is associated with patients’ experiences of chronic care and if the relationship is stronger for small CHC sites. Methods: Surveys of 1,277 adults with diabetes (2012, Response Rate=47%) that assessed non-physician team roles involved in managing their chronic care, including community health workers, diabetes educators, nutritionists, pharmacists, mental health providers, and other general staff, were integrated with clinical and administrative data from 14 CHCs. Random effects regression models estimated the association of team expertise, CHC size, and 1) patients’ experiences of chronic care and 2) hemoglobin A1c control, controlling for patient comorbidities, sex, race/ethnicity/primary language, age, and insurance coverage. Results: Care teams with community health workers, diabetes educators, nutritionists, and other general staff were associated with better patients’ experiences of chronic care, but not hemoglobin A1c control. Patients of small CHC sites reported better experiences of care with each additional team role reported, but the relationship was not significant for large CHCs.Conclusions: Patients with access to care team expertise in self-management support, including diabetes educators, nutritionists, community health workers, and other general staff report better experiences of chronic care. These team roles may reduce barriers to patient self-management and improve patients’ overall experiences of chronic care, particularly in small CHC sites.

ORIGINAL RESEARCH

U.S. Primary Care Physicians’ Viewpoints on HPV Vaccination for Adults 27-45 Years

Laura P. Hurley, MD, MPH; Sean T. O’Leary, MD, MPH; Lauri E. Markowitz, MD; Lori A. Crane, PhD, MPH; Jessica R. Cataldi, MD, MSCS; Michaela Brtnikova, PhD, MPH; Brenda L. Beaty, MSPH; Carol Gorman, BA; Elissa Meites, MD, MPH; Megan C. Lindley, MPH; Allison Kempe, MD, MPH

Corresponding Author: Laura P. Hurley, MD, MPH; University of Colorado. Email: Laura.Hurley@dhha.org

Publication: 1/14/2021

Introduction: In June 2019, the Advisory Committee on Immunization Practices (ACIP) recommended shared clinical decision-making (SCDM) regarding human papillomavirus (HPV) vaccination for adults 27-45 years. Our objectives were to assess among primary care physicians: 1) recent practice regarding HPV vaccination for adults 27-45 years, 2) knowledge of HPV and the new SCDM recommendation, and 3) attitudes toward and anticipated effect of the new SCDM recommendation. Methods: In October to December 2019, we administered an Internet and mail survey to national networks of 494 general internist (GIM) and 474 family physician (FP) members of the American College of Physicians and American Academy of Family Physicians, respectively. Results: Response rate was 64% (617/968, GIM 57%, FP 71%). 58% were aware of the new ACIP recommendation; 42% had recommended HPV vaccination to adults 27-45 years, but most had administered HPV vaccine to very few of these patients (73% to 0 and 22% to 1-3). 55% and 63% were unaware that HPV vaccination does not prevent progression of existing HPVrelated cancers or infections, respectively. 57% were not sure what to emphasize when having a SCDM conversation about HPV vaccination. A majority reported they will be more likely recommend HPV vaccination to adults in the 27-45 years age range as a result of the new recommendation. Conclusions: Physicians are interested in recommending HPV vaccination for adults age 27-45 years despite ACIP not routinely recommending it in this age range. The majority need more education about the optimal use of HPV vaccine in this age group.

ORIGINAL RESEARCH

Feasibility of Disease-Focused Group Visits for Advance Care Planning Among Patients With Heart Failure and Their Caregivers

Julia I. Bandini, PhD; Alexis Coulourides Kogan, PhD; Bonnie Olsen, PhD; Jessica Phillips, MS; Rebecca L. Sudore, MD; David B. Bekelman, MD, MPH; Sangeeta C. Ahluwalia, PhD

Corresponding Author: Sangeeta C. Ahluwalia, PhD; RAND Corporation. Email: sahluwal@rand.org 

Publication: 1/14/2021

Background: Group visits have the potential to help patients identify their healthcare values and engage in the emotionally and cognitively challenging task of advance care planning (ACP) in a resource-efficient manner by providing a forum for social learning and social support. Objective: To evaluate the feasibility and acceptability of disease-specific group visits for patients with heart failure and their caregivers. Design: Feasibility trial of a 90-minute group visit held for 10 separate groups and led by a trained facilitator using the video-based PREPARE for your Care ACP tool. Setting/Subjects: Older adults with recent hospitalization for heart failure (N=36; median age=74) and their caregivers (N=21). Measurements: Pre- and post-visit surveys and a post-visit telephone interview assessing perceived value and acceptability; structured non-participant observations to assess process and feasibility. Results: Mean scores from the post-group visit evaluation showed that participants reported that they felt comfortable discussing ACP in a group (4.59), understood the information covered (4.70), and were able to identify and clarify their healthcare values (4.43). Interview and observation data demonstrated that participants were able to identify and clarify their preferences by listening and learning from a diverse range of perspectives in the group and that the disease-focused nature of the group visit created a supportive space for participants to share their experiences. Conclusions: Disease-focused ACP group visits were feasible to conduct and acceptable to participants, underscoring their value as an efficient intervention to engage patients and caregivers in the otherwise time and resource-intensive task of ACP.

ORIGINAL RESEARCH

High-Risk, Higher-Reward: Social Inequalities Facing Prenatal Care Patients in Family Medicine and Obstetrics and Gynecology

Michael Partin, MD; Ana Sanchez, MD; Jessica Poulson, BS; Arthur Berg, PhD; Jessica Parascando, MPH; Sarah Ines Ramirez, MD

Corresponding Author:  Sarah Ines Ramirez, MD; Penn State Health Hershey Medical Center. Email: sramirez2@pennstatehealth.psu.edu

Publication: 1/14/2021

Introduction: Family Medicine (FM) physicians play a vital role in caring for vulnerable populations across diverse practice settings. The significant decline in FM physicians performing deliveries compounds the estimated shortage of 9,000 prenatal care providers expected by 2030. This study investigated the social risk profile, as characterized by social determinants of health, of patients receiving prenatal care from FM versus Obstetrics and Gynecology (OB/Gyn) providers. Methods: Retrospective chart review of patients receiving prenatal care between 2015-2018 at Penn State Health Hershey Medical Center comparing social determinants of health between FM and OB/Gyn. Results: A total of 487 patient charts were reviewed with final analysis completed on 215 charts from each cohort. When compared with OB/Gyn, prenatal patients cared for by FM were more likely to be younger (27 vs 29 years old, P <0.0001), African American (28% vs 8%, P <0.0001), single (52% vs 37%, P <0.01), have high school or less education (67% vs 49%, P <0.01), utilize Medicaid (46% vs 23%, P <0.0001), and use tobacco during pregnancy (17% vs 8%, P <0.01). Additionally, FM patients had a lower rate of total Cesarean-sections (C-section), including primary and repeat, when compared to OB/Gyn (23% vs. 32%, P = 0.04). Conclusions: Our work demonstrates that when compared to OB/Gyn at our institution, FM physicians provide care to a cohort of patients with an increased burden of social risk without compromise to care as evidenced by a lower C-seciton rate and similar gestational age at delivery.

ORIGINAL RESEARCH

Factors Influencing Increasing Time Spent Practicing Sports Medicine by Family Physicians Specializing in Sports Medicine

Srikanth Nithyanandam, MBBS; Lars E. Peterson, MD, PhD; James C. Puffer, MD

Corresponding Author: Srikanth Nithyanandam, MBBS, MS; University of Kentucky; Email: sri.nisi89@uky.edu

Publication: 1/14/2021

Purpose: To determine those factors associated with family physicians certified in sports medicine (SM-FPs) devoting 75% or more of their professional time to the exclusive practice of sports medicine. Methods: Data from the American Board of Family Medicine (ABFM) sports medicine examination registration questionnaires from 2003 to 2017 were analyzed. The characteristics of SM-FPs devoting 75% or more of their time to sports medicine were compared to those SM-FPs spending less than 75% time. Multiple regression analysis was used to determine characteristics that independently predicted devoting 75% or more of their professional time to the practice of sports medicine. Results: 1112 SM-FPs recertifying in sports medicine between 2003 to 2017 were studied. They were predominately male (85.2%), allopathic (91.7%) physicians with a mean age of 47.3 years (IQR, 42.1-54.2) and devoted a median 50% of their professional time (IQR, 25-80) to sports medicine. Age less than 47.3 (OR 1.53; 1.12, 2.08), service as a collegiate team physician (OR 1.66; 1.10, 2.50), recertification in sports medicine in 2011 to 2017 compared to earlier years (OR 2.47; 1.62, 3.78), and practicing in a sports medicine clinic (OR 6.43; 4.15, 9.95) predicted greater odds of spending 75% or more of their time devoted to sports medicine. Conclusions: Those factors found to be associated with spending 75% or more of their time practicing sports medicine by SM-FPs appear to be consistent with recent trends in the recruitment and employment of these physicians and their ability to provide added value to the health care system by virtue of their additional training and expertise.

ORIGINAL RESEARCH

Which Family Physicians See Children? A Cross-Sectional Study of Factors Associated with Pediatric Scope of Care

Anuradha Jetty, MPH; Max J. Romano, MD, MPH; Yalda Jabbarpour, MD; Stephen Petterson, PhD; Andrew Bazemore, MD, MPH

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

Publication: 1/14/2021

Purpose: The objective of this study was to identify demographic and practice characteristics associated with family physicians’ provision of care to children including a subgroup analysis of those who see pediatric patients younger or older than 5 years of age. Methods: This cross-sectional study used data from US family physicians taking the American Board of Family Medicine (ABFM) continuous certification examination registration questionnaire in 2017 and 2018. The outcome of interest was self-reported care of pediatric patients in practice. We performed bivariate and multivariate logistic regression examining the association between various demographic and practice characteristics with the outcome of interest. We performed subgroup analyses for physicians seeing patients under 5-years-old and from 5-18-years-old. Results: Among the 11,674 family physicians included in the final analysis, 9,744 (83.8%) saw pediatric patients. Physician- and practice-level factors associated with seeing pediatric patients included rural practice, younger age, non-Hispanic White race/ethnicity, independent practice ownership, non-solo practice, lower pediatrician density, and higher income geographic area. More family physicians saw 5- to 18-year-olds than <5-year-olds (83.6% vs. 68.2%, p-value <0.001), and the factors associated with pediatric care were similar among these age subgroups. Conclusions: A majority of continuous certification US family physicians see pediatric patients in practice; however, rates of pediatric care vary widely based on various demographic and practice characteristics. Efforts to maintain a broad scope of practice for US family physicians will require exploration of the underlying mechanisms driving these practice patterns.

ORIGINAL RESEARCH

Parents’ Perspectives on Their Children’s Health Insurance: Pre/Post Affordable Care Act

John M Pascoe, MD, MPH; Adrienne Stolfi, MSPH; Gregory Eberhart, MD; Harry Khamis, PhD

Corresponding Author: John M Pascoe, MD, MPH; Wright State University. Email: susan.howard@wright.edu

Publication: 1/14/2021

Objective: To determine the prevalence and correlates of children’s underinsurance pre and post implementation of the Affordable Care Act (ACA). Study Design: A cross-sectional survey of a convenience sample of 5043 parents of children greater than six months old who had health insurance in the previous 12 months. Respondents completed the Medical Expenses for Children Survey. Pre ACA data were collected in summer/fall of 2009 - 2011 (N=3966); post ACA data were collected in summer/fall 2016 (N=1077). All data were collected within the Southwestern Ohio Ambulatory Research Network (SOAR-Net). Results: 16.3% of all study parents were unable to follow at least one recommendation of their child’s pediatrician due to their inability to pay for it. 17.3% reported it had become more difficult to obtain “needed healthcare” in the past 3 years. Factors associated with underinsurance after adjusting for demographic factors did NOT include pre/post ACA, but did include annual household income <$50,000 (AOR=2.71 {95% CI 2.15-3.40}). Poor child health was also a significant risk factor for underinsurance AOR=3.71 (95%CI 2.61-5.29). Conclusions: About one in six study children were underinsured. The ACA did not affect the underinsurance rate. Parents continued to report that it had become more difficult to obtain needed healthcare over the past three years post ACA. About one third of study parents consistently reported that the health of their underinsured child had suffered because they could not afford to pay for their child’s healthcare.

CLINICAL REVIEW

Sudden Sensorineural Hearing Loss a Diagnostic and Therapeutic Emergency: Case Report and Review of Consensus Guidelines

Andrew D.P. Prince, BA; Emily Z. Stucken, MD

Corresponding Author: Andrew D.P. Prince, BA; University of Michigan Medical School; Email: adprince@umich.edu

Publication: 1/14/2021

The family physician’s role in recognizing and managing sudden sensorineural hearing loss (SSNHL) is crucial. A recently updated Otolaryngologic clinical practice guideline (CPG) has been released for this emergency syndrome but dissemination is limited to a specialty journal. As a result, the guidelines may not be widely available in the primary care setting where patients often present. We provide this focused review to clarify and disseminate SSNHL guidelines for the frontline family physician.

BRIEF REPORT

Association of Prediabetes Status Awareness with Health Behaviors and Perception of Health

Erica Li, MD; Alexis Silverio, MPH, CSCS, CHES, NASM-FNS; Amy Cunningham, PhD, MPH; Mariana LaNoue, PhD, MS; Geoffrey Mills, MD, PhD

Corresponding Author: Erica Li, MD; Thomas Jefferson University; Email: erica.li@jefferson.edu

Publication: 1/14/2021

Introduction: Lifestyle modification can significantly reduce the risk of developing diabetes. However, the effect of prediabetes status awareness on perceptions of health and health behaviors are mixed. We used the 2015-2016 National Health and Nutrition Examination Survey (NHANES) data to evaluate the association of prediabetes status awareness with self-reported perception of health and health behaviors. Methods: A secondary analysis was performed on the 2015-2016 NHANES, which is a biannual, cross-sectional survey designed to be representative of the civilian, noninstitutionalized United States population. Survey participants were interviewed at home and invited to a mobile examination center to undergo examinations and laboratory measurements. Inclusion and exclusion criteria were applied to create prediabetesaware and prediabetes-unaware groups. The groups were propensity-score matched based on BMI, A1c, race, and education. Measures of health perception and health behaviors were analyzed, including feeling at risk for developing diabetes, general health status, perception of weight, desire to lose weight, dietary behaviors, and physical activity behaviors. Results: Participants who were prediabetes-aware were more likely to report a perceived risk of diabetes and to consider themselves overweight. Prediabetes awareness was not associated with any difference in dietary or physical activity behaviors. Conclusions: Although participants who were aware of their prediabetes status were more likely to report a perceived threat of developing diabetes, they did not report increased engagement in health behaviors. Future research can better understand how these aspects of a health belief model affect engagement in health behaviors for people with prediabetes.

BRIEF REPORT

Screening for Diabetic Retinopathy with a Nonmydriatic Ultra-Wide-Field Retina Camera By Family Medicine Physicians

Bryan A. Farford, DO; Abhimanyu S. Ahuja, BS; Michael W. Stewart, MD; James M. Naessens, ScD; Joshua J. Keith, DO

Corresponding Author: Bryan A. Farford, DO; Mayo Clinic Florida. Email: farford.bryan@gmail.com

Publication: 1/14/2021

Purpose: Diabetic retinopathy (DR) is the leading cause of blindness among working-aged adults aged 20–74 years. Despite professional association guidelines that recommend yearly screening for DR, only about 60% of Americans with diabetes mellitus (DM) receive annual examinations. The purpose of this two-phase study was to determine the ability of family medicine (FM) physicians to accurately interpret retinal images of patients with DM. Methods: Five FM physicians received a one-hour lecture on DR by a retinal specialist after which the physicians were shown 30 ultra-wide-field retina images and asked to determine whether or not the images contained signs of DR (phase 1). Patients with DM who had not received an eye exam within the past year underwent non-mydriatic retinal photography in a FM clinic (phase 2). The five FM physicians were asked to evaluate the images for signs of DR and the images were simultaneously sent to a retinal specialist for independent interpretation. The diagnoses of the FM physicians and retina specialist were compared. Patients were informed of their results and were asked to complete a brief telephone survey regarding their experience with the screening process. Results: Thirty retina images, five with DR and 25 without DR, were included in the post-lecture assessment. Each of the 30 images was reviewed by all five FM physicians. Of the five images with DR, three were correctly diagnosed by all five FM physicians, one was correctly diagnosed by four, and one was accurately diagnosed by three. Overall accuracy for the five FM physicians was 100%, 100%, 100%, 97%, and 87%. Among the 34 patients included in phase 2, three (8%) were diagnosed with DR by the retinal specialist but eight (24%) were diagnosed with DR by the FM physicians. Of the three patients with DR confirmed by the retinal specialist, only one was detected by the FM physicians (sensitivity, 33%; 95% CI, 1 – 91%). Of the 31 patients without DR as determined by the retinal specialist, 24 were accurately diagnosed by the FM physicians (specificity, 77%; 95% CI, 59 – 90%). The screening procedure was considered easy/efficient by 28 of 31 (90%) respondents. Conclusion: To improve early detection of DR new screening methods should be considered. FM physicians were able to accurately identify DR on post-lecture images but were not as accurate when evaluating images taken from patients in the FM clinic. Patients found the screening process to be easy and efficient. This study was limited by the small sample size, particularly the limited number of DR cases. Future studies that include cases with a wide variation of DR severity are needed to determine the accuracy of FM physicians at detecting DR in a clinical setting.

BRIEF REPORT

Provision of Early Pregnancy Loss Care in New York Federally Qualified Health Centers

Amanda Nagle, BS; Silpa Srinivasulu, MPH; Lisa Maldonado, MA, MPH; Gabrielle deFiebre, MPH

Corresponding Author: Silpa Srinivasulu, MPH;  Reproductive Health Access Project; Email: silpa@reproductiveaccess.org

Publication: 1/14/2021

Background: Office-based early pregnancy loss (EPL) care is safe and suitable to Federally Qualified Health Centers (FQHC); prevalence of provision in FQHCs is unknown. Methods: We conducted a mailed site-level survey of FQHCs in New York State (N=405). Sites that offered prenatal care were eligible for analysis. Questions included provision of and barriers to providing EPL care options. Content analysis was used for write-in responses to barriers. We conducted bivariate analyses using Fisher’s Exact tests and risk ratios to investigate associations between EPL care provision and the independent variables site urbanicity, prenatal clinician type, and ultrasound access. Results: Of 181 mailings returned, 63 sites were eligible (response rate 44.7%). 88.9% provided expectant management, 53.9% medication management, and 23.8% uterine aspiration. Common barriers included lack of clinical infrastructure, poor ultrasound access, and insufficient training. Some held perceived barriers regarding uterine aspiration. Sites with regular ultrasound access were 1.85 times as likely to provide two or more EPL management options as sites without regular ultrasound access (95% CI: 1.16, 2.95). Conclusions: Few New York FQHCs provided comprehensive EPL care. Supporting FQHCs to overcome barriers may expand access to EPL treatment in primary care and increase continuity and patient-centeredness.

ORIGINAL RESEARCH

Prevalence and Correlates of Sexual Dysfunction and Preferences for Discussing Sexual Health Concerns among Veteran Primary Care Patients    

Robyn L. Shepardson, PhD; Luke D. Mitzel, PhD; Nicole Trabold, PhD; Cory A. Crane, PhD; Dev Crasta, PhD; Jennifer S. Funderburk, PhD

Corresponding Author: Robyn L. Shepardson, PhD; Center for Integrated Healthcare. Email: Robyn.Shepardson@va.gov

Publication: 3/11/2021

Background: Sexual health is an important, yet often overlooked, aspect of overall health. The limited research on Veterans suggests they may be particularly at risk for sexual dysfunction. The objectives of this study were to assess the prevalence and correlates of sexual dysfunction and examine preferences for discussing sexual problems among Veteran primary care patients. Methods: In this cross-sectional study, we mailed 1500 surveys to a random sample of primary care patients from 3 VA medical centers across Central and Western New York, of which 313 were returned (21% response rate) and 248 had complete data for this analysis. Veterans (M age = 49.4 years) were mostly White (86.7%), women (60.9%), and married (79.0%). The Arizona Sexual Experiences Scale was used to screen for sexual dysfunction. Results: Half of Veterans, 62.3% of women and 32.0% of men, screened positive for sexual dysfunction. The odds of screening positive for sexual dysfunction increased with age. Over 60% of Veterans agreed that the primary care team should provide information, proactively ask patients, and inquire on medical history forms about sexual problems. Participants preferred to discuss sexual problems with primary care providers, but 59.3% were open to meeting with behavioral health providers. Conclusions: Findings suggest that primary care providers should ask all Veterans about sexual health, as sexual dysfunction was prevalent, especially among women and among men over age 65. Most Veterans were receptive to being asked about sexual problems in primary care and preferred to be asked rather than bring it up themselves. 

ORIGINAL RESEARCH

Getting Routine Intimate Partner Violence Screening Right: Implementation Strategies Used in VHA Primary Care

Omonyêlé L. Adjognon, ScM; Julianne E. Brady, MA; Megan R. Gerber, MD, MPH; Melissa E. Dichter, PhD, MSW; Alessandra R. Grillo, BS; Alison B. Hamilton, PhD, MPH; Shannon Wiltsey Stirman, PhD; Katherine M. Iverson, PhD

Corresponding Author: Omonyêlé Adjognon, ScM; VA Boston Healthcare System. Email: omonyele.adjognon@va.gov

Publication: 3/11/2021

Background: Evidence supports the clinical effectiveness of intimate partner violence (IPV) screening programs, but less is known about how to fully implement and sustain them. This qualitative study identified implementation strategies used to integrate IPV screening programs within Veterans Health Administration (VHA) women’s health primary care. Methods: Thirty-two administrators and clinician key informants from 11 VHA facilities participated in semi-structured interviews. Implementation strategies were identified using established definitions from the implementation science literature (i.e., Expert Recommendations for Implementing Change project), through a multi-step content analysis, involving site comparisons by implementation status (early vs. late adoption). Results: We identified 8 strategies used, 3 of which were present across all sites: 1) conduct ongoing IPV trainings, 2) conduct educational meetings and outreach visits, and 3) develop and distribute IPV educational materials. Five strategies were unique to early-adopting sites: 4) identify and prepare champions, 5) change record systems to remind clinicians, 6) create a learning collaborative through advisory boards or workgroups, 7) audit and feedback with relay of clinical data to providers, and 8) access new funding. Discussion: Strategies align with and extend literature identifying barriers to IPV screening implementation. Evidence that sites used multiple strategies to support implementation, with early-adopting sites using more strategies than late-adopting sites, reinforces the notion that effective IPV screening implementation in primary care requires a bundle of well-defined, carefully selected implementation strategies. Conclusions: Implementation strategies used collectively can enable integration of IPV screening programs in primary care, thereby actualizing the benefits of these practices on women’s health.

ORIGINAL RESEARCH

Characteristics of Veterans With Non-VA Encounters Enrolled in a Trial of Standards-Based, Interoperable Event Notification, and Care Coordination 

Rebecca Kartje, MD, MS; Brian E. Dixon, MPA, PhD; Ashley L. Schwartzkopf, MSW, LSW; Vivian Guerrero, MA; Kimberly M. Judon, MPH; Joanne C. Yi, RHIA; Kenneth Boockvar, MD, MS

Corresponding Author: Rebecca Kartje, MD, MS;  U.S. Department of Veterans Affairs. Email: rebecca.kartje@va.gov

Publication: 3/11/2021

Introduction: Understanding how Veterans dually utilize VA for primary care and non-VA acute care can help policy makers predict future use of VA and non-VA healthcare resources. We aimed to describe characteristics of Veterans enrolled in a multisite clinical trial of non-VA acute event notifications and care coordination and to identify patient factors associated with non-VA acute care encounters. Methods: Characteristics of 565 Veterans enrolled in a prospective cluster randomized trial at the Bronx or Indianapolis VA Medical Centers between February 1, 2016 and February 1, 2019 were obtained by interview and chart review. Alerts of non-VA ED or inpatient admissions were based on standardized electronic messages exchanged between VA and non-VA facilities. Results: Veterans’ mean age was 75.8 years old, 98.3% were male, and 39.2% self-identified as a minority race; 81.2% reported receiving the majority of their care at the VA. There were 197 (34.9%) Veterans for whom a non-VA acute care alert was received during the study period. Patient characteristics significantly associated with a greater odds of a non-VA alert included: older age (OR = 1.05; 95% CI,1.04-1.05); endorsing that majority of care received is non-VA (OR = 1.83; 95% CI, 1.06-3.15); private insurance (OR = 1.39; 95% CI, 1.19-1.62); and higher income (OR = 4.01; 95% CI, 2.68-5.98). Conclusions: We identified several patient-level factors associated with non-VA acute care utilization which can inform the design of VA services and policies related to Veterans who experience non-VA acute care encounters and their reintegration back into the VA system.

ORIGINAL RESEARCH

Veterans Are Agreeable to Discussions About Firearms Safety in Primary Care

Summer Newell; Emily Kenyon; Khaya D. Clark; Victoria Elliott; Annabelle Rynerson; Martha S. Gerrity; Elizabeth Karras; Joseph A. Simonetti; Steven K. Dobscha

Corresponding Author: Summer Newell; VA Portland Health Care System. Email: summer.newell@va.gov 

Publication: 3/11/2021

Background: Discussing safe storage of firearms, including access, during times of crisis with Veterans in primary care settings may enhance suicide prevention efforts. However, Veteran attitudes toward discussing firearms storage safety with primary care team members are not well understood. The goal of this study is to understand the perspectives of Veterans who have positive mental health screens on discussing firearms storage safety with primary care staff during primary care visits. Methods: Individual semi-structured interviews with Veterans were conducted between April and August 2019 by telephone, qualitatively coded, and analyzed for themes. The sample was comprised of Veterans (N = 27) who had positive depression or posttraumatic stress disorder screens, and who received care from Veterans Health Administration primary care team members who had been trained to discuss firearms storage safety with patients. Results: Citing the urgent need to prevent Veteran suicide, most Veterans felt discussing firearms safety was acceptable and needed, even if discussions felt uncomfortable or they had concerns. Sources of discomfort or concerns included feeling that questioning was too personal or that providers’ motives for asking about firearms might not be clear. Veterans identified the need for providers to be transparent in their purposes for asking about firearms, and to respect Veterans’ unique relationships with firearms. Discussion: Conducting firearms safety discussions in a primary care setting with Veterans who are at elevated risk for suicide is acceptable to Veterans when a respectful, Veteran-centered, and transparent approach is used.

ORIGINAL RESEARCH

Clinical Pharmacist Integration Into Primary Care Interprofessional Teams: Team Member Perspectives

Anna Zogas, PhD; Chris Gillespie, PhD; Felicia Kleinberg, MSW; Joel I. Reisman, AB; Ndindam Nidwane, MPH; Michael Tran, PharmD, BCPS; Heather Ourth, PharmD, BCPS, BCGP; Anthony Morreale, MBA, BCPS, FASHP; Donald R. Miller, ScD; Megan B. McCullough, PhD

Corresponding Author: Anna Zogas, PhD; VA Boston Healthcare System. Email: anna.zogas@gmail.com

Publication: 3/11/2021

Background: With the restructuring of primary care into patient-centered medical homes (PCMH), researchers have described role transformations that accompany the formation of core primary care teamlets (e.g., primary care provider, registered nurse care manager, licensed practical nurse, medical support assistant). However, few studies offer insight into how primary care teamlets, once established, integrate additional extended team members, and the factors that influence the quality of their integration. Methods: We examine the process of integrating Clinical Pharmacy Specialists (CPS) into primary care teams in the Veterans Health Administration (VHA). We conducted semistructured interviews with CPS (n=6) and clinical team members (n=16) and performed a thematic analysis of interview transcripts. Results: We characterize two ways CPS are integrated into primary care teamlets: in consultative roles and collaborative roles. CPS may be limited to consultative roles by team members’ misconceptions about their competencies (i.e., if CPS are perceived to handle only medication-related issues like refills) and by primary care providers’ opinions about distributing responsibilities for patient care. Over time, teams may correct misconceptions and integrate the CPS in a more collaborative role (i.e., CPS helps manage disease states with comprehensive medication management). Conclusions: CPS integrated in collaborative roles may have more opportunities to optimize their contributions to primary care, underscoring the importance of clarifying roles as part of adequately integrating advanced practitioners in interprofessional teams.

ORIGINAL RESEARCH

Understanding the Needs and Barriers to Services Among Homeless-Experienced Veteran Families: A Sector Wheel Approach

Roya Ijadi-Maghsoodi, MD, MSHPM; Sophie Feller, MD; Gery W. Ryan PhD; Lisa Altman MD; Donna L. Washington MD, MPH; Sheryl Kataoka MD, MSHS; Lillian Gelberg MD, MSPH

Corresponding Author: Roya Ijadi-Maghsoodi, MD, MSHPM; VA Greater Los Angeles Healthcare System. Email: Rijadimaghsoodi@mednet.ucla.edu

Publication: 3/11/2021

Background: Veteran family homelessness is a significant issue, yet little is known about the needs and barriers to services of veteran families experiencing homelessness. This qualitative study examined the experiences, needs, and barriers to services among homeless-experienced veteran families to inform primary care providers for this important population. Methods: 25 semi-structured interviews were conducted from February through September 2016 with 18 veteran parents with a recent history of homelessness (9 mothers, 9 fathers), and 7 homeless service providers throughout Los Angeles County. The “Sector Wheel for UnderResourced Populations” data elicitation approach was used to conduct the interviews, which allowed the participant to guide the interview by discussing different sectors of a family’s life affected by homelessness. The interviews were audio-recorded, transcribed, and themes were coded with Atlas.ti. Results: Interviews revealed parenting stress and worsening family mental health during homelessness. Participants described barriers to navigating housing, social, and health services with children, including not knowing where to seek help, difficulty connecting to health and social services in the community, and a lack of family-focused services. Parents encountered discrimination by landlords and lack of access to permanent housing in safe neighborhoods. Conclusions: Findings demonstrate a need for delivering family centered and comprehensive services to homeless-experienced veteran families that recognize the multifaceted needs of this Abstract_Revised population. Advocacy initiatives are needed to address discrimination against veterans experiencing family homelessness and increase access to affordable permanent housing in safe neighborhoods for families. 

ORIGINAL RESEARCH

Reasons Older Veterans with Declining Health Use VA and Non-VA Care in an Urban Environment

Matthew R. Augustine, MD; Tanieka Mason, MPH; Abigail Baim-Lance, PhD; Kenneth Boockvar, MD

Corresponding Author: Matthew R. Augustine, MD; James J Peters VA Medical Center. Email: matthew.augustine2@va.gov

Publication: 3/11/2021

Background: Older veterans in urban settings rely less on Department of Veterans Affairs (VA) health care, suggesting deficits of access and services for aging veterans.  We aimed to identify reasons for VA and non-VA use across health status of older, urban-dwelling veterans. Methods: We examined open-ended responses from 177 veterans who were enrolled in primary care at the Bronx VA Medical Center, used non-VA care in prior 2 years, and completed baseline interviews in a care coordination trial from March 2016 to August 2017. Using content analysis, we coded and categorized key terms and concepts into an established access framework. This framework included five categories: acceptability (relationship, second opinion), accessibility (distance, travel); affordability; availability (supply, specialty care); and accommodation (organization, wait-time). Self-reported health status was stratified by excellent/very good, good, and fair/poor. Results: We were able to categorize the responses of 166 veterans, who were of older age (≥75 years, 61%), minority race and ethnicity (77%), and low income (<$25,000/year, 51%). Veterans mentioned acceptability (42%) and accessibility (37%) the most, followed by affordability (33%), availability (25%), and accommodation (11%).  With worse self-reported health status, accessibility intensified (Excellent/very good, 24%; Fair/Poor, 46%; p=0.031) particularly among minority veterans, while acceptability remained prominent (Excellent/very good, 49%; Fair/Poor, 37%; p=0.25). Other categories were mentioned less with no significant difference across health status. Conclusions: Even in an urban environment, proximity was a leading issue with worse health. Addressing urban accessibility and coordination for older, sicker veterans may enhance care for a growing vulnerable VA population. 

ORIGINAL RESEARCH

Depression Severity and Assignment to Psychotherapy, Medication, or Combination Treatment in Primary and Specialty Settings Among Patients With Major Depression in the Veterans Health Administration

Victor Puac-Polanco, MD, DrPH; Lucinda Leung, MD, PhD; Robert Bossarte, PhD; Corey Bryant, MS; Janelle Keusch, MPH; Howard Liu, PhD; Hannah Ziobrowski, PhD, MPH; Wilfred Pigeon, PhD; David Oslin, MD; Edward Post, MD, PhD; Ronald Kessler, PhD

Corresponding Author: Ronald Kessler, PhD; Harvard Medical School. Email: kessler@hcp.med.harvard.edu

Publication: 3/11/2021

Introduction: The Veterans Health Administration (VHA) supports the nation’s largest Primary Care-Mental Health Integration collaborative care model–(PC-MHI)–to increase treatment of mild to moderate common mental disorders in primary care and refer more severe-complex cases to specialty settings. It is unclear, though, how this treatment assignment works in practice. Methods: 2,610 patients who sought incident episode VHA treatment for depression between December 2018 and June 2020 completed a baseline self-report questionnaire about depression severity-complexity. Patients with active suicidality or history of severe mental disorders were excluded. Administrative data were used to determine settings and types of treatment over the next 30 days. Results: Thirty-four percent (34.2%) of depressed patients received treatment in a primary care (PC) setting and 65.8% in a specialty setting (SMH). PC patients had less severe and fewer comorbid depressive episodes than those in SMH. Patients with the lowest severity and/or complexity were most likely to receive PC antidepressant medication treatment, whereas those with the highest severity and/or complexity were most likely to receive combined (i.e., medication and psychotherapy) treatment in SMH settings. Although this assignment of patients across settings and types of treatment was stronger than found in previous civilian studies, it was less pronounced than expected (cross-validated AUC=.50-.68). Discussion: By expanding access to evidence-based treatments, VHA’s PC-MHI increases consistency of treatment assignment with clinical characteristics of depressed patients. Increased understanding of reasons for this assignment being less pronounced than expected and implications for treatment response will require continued study.

ORIGINAL RESEARCH

The Impact of Sex Differences in Mental Health Disorders Affecting Military Service Members With Patellofemoral Pain: A Population-Level Cohort Study

Daniel I. Rhon, DSc; Tanja C. Roy, PhD; Robert C. Oh, MD, MPH, FAAFP; Jodi L. Young, DPT

Corresponding Author: Daniel I. Rhon, DSc; Brooke Army Medical Center. Email: daniel.i.rhon.ctr@mail.mil

Publication: 3/11/2021

Background: Mental health disorders are associated with persistent knee pain, but the association between these two conditions has had litt fple investigation in the Military. The purpose of this study was to identify rates of mental health disorders in patients with patellofemoral pain, determine differences by sex, and determine if mental health co-presence influences outcomes. Methods: Using the Military Health System Data Repository (MDR) eligible patients with a new patellofemoral pain diagnosis (data from January 2009-December 2013) were categorized according to sex and presence of mental health disorders. Outcomes included odds of mental health disorder before and after initial patellofemoral pain diagnosis based on sex, and knee-related healthcare utilization (costs, visits, recurrence) between patients with and without mental health disorders. Results: In 81,832 individuals with patellofemoral pain (71.1% men; mean age 33; 91.5% active-duty), co-presence of any mental health disorders was common (18% men; 28% women). Women more likely had depression and anxiety; men more likely had PTSD and substance abuse disorders. Concurrent mental health disorders after initial patellofemoral pain diagnosis resulted in higher medical costs (mean difference $200-$456) and visits (mean 1-2.2 extra visits), and greater odds of having a recurrence (OR 1.24; 95CI 1.20, 1.28; p<0.001), compared to patients without a mental health diagnosis. Conclusion: Mental health disorders are common in military service members seeking care for patellofemoral pain. Differences in prevalence vary by sex, and the presence of mental health disorders adversely affected long-term healthcare outcomes. These are key considerations for clinicians seeing patients with patellofemoral pain in this setting.

BRIEF REPORT

Psychosocial Risk Factors for Transitions Into Housing Instability Among Women Veterans

Ellen Mulcahy, Dorota Szymkowiak, Ann Elizabeth Montgomery

Corresponding Author: Ellen Mulcahy, PhD; University of Sciences. Email: emulcahy@usciences.edu

Publication: 3/11/2021

Introduction: Preventing and ending homelessness for women veterans, a priority of the Department of Veterans Affairs (VA), can be aided by identifying factors that increase their risk for housing instability. Methods: This study relied on data from the Veterans Health Administration’s (VHA) universal screen for housing instability from FY 2013–2016, and administrative data from electronic medical records. Using logistic regression, we compared two groups of women veterans: those who consistently had stable housing and those who transitioned to unstable housing after a period of housing stability. Results: We found that a history of Military Sexual Trauma, lack of access to VA benefits and other financial resources, and single or divorced marital status were significant risk factors for women veterans’ housing instability. These findings are consistent with an existing theoretical model of housing instability and homelessness among women veterans, which highlights the importance of traumatic and adverse events and isolation as risk factors. Conclusions: These risk factors and their effect on women veterans’ housing instability can be mitigated by new and increased supportive interventions, targeted to those at highest risk. 

SPECIAL COMMUNICATION

Alexa: “Can You Be My Family Medicine Doctor?” The Future of Family Medicine in the Coming Techno-World

Allen F. Shaughnessy, PharmD, MMedEd; David C. Slawson, MD; Ashley P. Duggan, PhD

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

Publication: TBD

Even before social distancing disrupted normative expectations and prompted an immediate shift to remote doctor/patient interactions, technology companies – Amazon, Apple, and Google – were preparing to disrupt medical care through the innovative use of technology. This article presents a possible scenario for how technology, in the near future, will completely up-end primary care practice. What does face-to-face interaction accomplish that cannot be done remotely? What do family physicians offer that can’t be accomplished by technology? More than just relationship, family medicine brings the therapeutic use of the self to engage with people, an ability to advocate for patients, and the ability to step back and reflect on the power of relationships. In addition, family physicians bring wisdom, making decisions in the liminal state between patient and physician, the resulting product of the human connection but also the ability to manage complexity using the best evidence. The ability to do both gives family medicine physician the skills to leverage but also control the coming big data.

CLINICAL REVIEW

Follow-up Management of Patients With Venous Thromboembolism: Critical Therapeutic and Diagnostic Decisions After the Initial Treatment Period

Timothy M. Fernandes, MD, MPH; Manreet Kanwar, MD; Richard H. White, MD

Corresponding Author: Timothy M. Fernandes, MD, MPH; University of California, San Diego. Email: tfernandes@ucsd.edu

Publication: TBD

Background: Venous thromboembolism (VTE) is a common medical problem seen in primary care settings. The most common long-term adverse sequelae are recurrent thromboembolism and incomplete resolution of the embolic material, which may result in pulmonary hypertension after pulmonary embolism and post-thrombotic changes in the leg after deep vein thrombosis. Although there are detailed guidelines for diagnosing and treating acute VTE, there are few focused articles that provide recommendations for primary care physicians (PCPs) about how to manage VTE patients after completion of the initial period of anticoagulation treatment. Observations: In this article, we highlight a number of important clinical decisions that must be addressed after the first 3 months of anticoagulation treatment is complete, with a focus on particular management issues for PCPs. Conclusions: The 2 most important decisions the PCP must make are to determine, first, if symptoms of acute VTE have indeed resolved, and second, if they have resolved, to assess the long-term risk of recurrent VTE versus the risk of potential bleeding and decide if anticoagulation should be stopped, or if indefinite anticoagulation treatment is indicated. Among higher-risk patients who may benefit from indefinite anticoagulation, the PCP should discuss both the risks and benefits of anticoagulation treatment, empowering the patient to actively participate in this important shared decision-making process.

CLINICAL REVIEW

Management of Acute Pulmonary Embolism: What Can PERT Do For You?

Jason Cuomo, MD; Vishal Arora, MD; Thaddeus Wilkins, MD

Corresponding Author: Jason Cuomo, MD;  Medical College of Georgia. Email: jcuomo@augusta.edu

Publication: TBD

Despite recent advances in the assessment, risk stratification, and treatment of acute pulmonary embolism (PE), it remains a leading cause of cardiovascular morbidity and mortality in the US each year. Patient presentation and prognosis are heterogenous, and a variety of diagnostic and therapeutic instruments have arisen to assist in providing patients with the appropriate level of care and aggressiveness of approach. Fortunately, a growing number of institutions now have pulmonary embolism response teams (PERT) that urgently assist with risk assessment and management of patients with massive and submassive PE. In service of providers at the point of contact with acute PE, this review aims to summarize the data pertinent to rapid risk assessment and the interpretation of diagnostics used to that end. The role of PERT and the indications for systemic fibrinolysis and invasive therapies are also discussed.

CLINICAL GUIDELINES AND PRIMARY CARE

Management of Eye Trauma For Non-Ophthalmology Providers

Jonathan Y. Rho, BS; Stephen C. Dryden, MD; Brian M. Jerkins, MD; Brian T. Fowler, MD

Corresponding Author:  Jonathan Rho; Hamilton Eye Institute, University of Tennessee Health Science Center. Email: rho.jonathan@gmail.com

Publication: TBD

Eye trauma is frequently seen by non-ophthalmology providers. This article elucidates a methodological approach to eye trauma. The first step is to address any life-threatening conditions. Then a focused history and exam is discussed, starting externally. Then, key history, physical, pathophysiology, and basic management of common, serious eye injuries are discussed: chemical injury, orbital fractures, open globe, traumatic hyphema, retinal detachment, traumatic optic neuropathy, and eyelid laceration. Finally, we highlight the practicality of telemedicine for areas where ophthalmology coverage is lacking.

SPECIAL COMMUNICATION

Ensuring Informed Decision Making For Cancer Screening

Stephen H. Bradley, MRCP; Matthew J. Thompson MPH, DPhil; Brian D. Nicholson, MRCGP

Corresponding Author:  Stephen H. Bradley, MRCP; University of Leeds. Email: medsbra@leeds.ac.uk

Publication: TBD

The history of cancer screening has demonstrated that the case for cancer screening is not straightforward.   In contemporary practice sharing decision making with patients has increasingly become expected of Family Physicians.   At the same time increasing emphasis has been placed on encouraging patients to participate in screening programmes as a means to improve cancer outcomes. The success of cancer screening is often judged by the numbers of those who participate. Improving cancer outcomes should be a priority for Family Medicine, but the importance of this goal should not undermine doctors’ commitment to help patients make informed decisions that are consistent with their own values and priorities. If we are serious about empowering patients, we need to be more open about the limitations of cancer screening, so as to help patients make up their own minds.

REFLECTIONS IN FAMILY MEDICINE

How Comprehensive Medication Management Contributes to Foundational Elements of Primary Care

Kylee A. Funk, PharmD; Lindsay A. Sorge, PharmD, MPH; Andrew W. Bazemore, MD, MPH; Todd D. Sorensen, PharmD; Mary T. Roth McClurg, PharmD, MHS; Jennifer K. Carroll, MD, MPH

Corresponding Author:  Kylee A. Funk, PharmD; University of Minnesota. Email: kafunk@umn.edu

Publication: TBD

Pharmacists are more often being recognized as a critical component of the primary care team. Previous literature has not clearly made the connection to how pharmacists and comprehensive medication management (CMM) contribute to recognized foundational elements of primary care. In this reflection, we examine how the delivery of CMM both supports and aligns with Starfield’s 4Cs of Primary Care. We illustrate how the delivery of CMM supports first contact through increased provider access, continuity through empanelment, comprehensiveness by addressing unmet medication needs, and coordination through collaborating with the primary care team and broader team. The provision of CMM addresses critical unmet medication-related needs in primary care and is aligned with the foundational elements of primary care. 

RESEARCH LETTER

Methicillin-Resistant Staphylococcus Aureus Colonization in the Community and Mortality Risk Among Adults Aged 40-85

Arch G Mainous, PhD; Benjamin J. Rooks, MS; Peter J. Carek, MD, MS

Corresponding Author:  Kylee A. Funk, PharmD; University of Minnesota. Email: kafunk@umn.edu

Publication: TBD

Introduction: The objective of this study was to assess the 11-year mortality risk of Methicillin resistant Staphylococcus aureus (MRSA) colonization in community dwelling adults aged 40-85. Methods: The study analyzed the National Health and Nutrition Examination Survey (NHANES) 2001-2004 linked to the National Death Index through December 31, 2015. Our cohort of community adults aged 40-85 was 6,085 participants (representing 118,718,486 adults). Mortality risk from MRSA colonization was examined with an 11 year followup. Results: The 11 year mortality rates were 35.9% (95% CI: 25.4-46.4%) for MRSA-colonized and 17.8% (95% CI: 16.4-19.2%) for non-colonized participants. After adjusting for potential confounders the hazard ratio for mortality among those colonized with MRSA was 1.75 (95% CI: 1.12, 2.73). Discussion: MRSA colonization in middle aged and older adults in the community is associated with a significantly increased mortality risk. Considering that this effect was in the community and not in hospitalized patients, this finding of an increased mortality risk is especially troubling.

ORIGINAL RESEARCH

Awareness and Preferences for Health Care Chaplaincy Services Among US Adults

Geila Rajaee, MPH, MPA, MDiv; Minal R. Patel, PhD, MPH

Corresponding Author: Minal Patel, PhD, MPH; University of Michigan School of Public Health. Email: minalrp@umich.edu

Publication: TBD

Purpose: Healthcare chaplains intervene on unmet religious/spiritual (R/S) needs in healthcare settings, which are associated with poor outcomes. Little is known about demand for their services. The purpose of this study was to describe population-level awareness and perceptions of healthcare chaplains, and preferences for their services. Methods: Data came from a cross-sectional survey in 2018 of a nationally representative sample of U.S. adults ≥ 18 years of age through the Ipsos Government & Academic Omnibus survey panel (n=1,020). Participants were asked about preferences for chaplain services in inpatient and outpatient settings, previous experience and awareness of chaplains, and their level of importance on having their R/S needs and sources of meaning addressed. Results: Mean age of the sample was 47.6. The majority were aware of chaplains (85%), but only 15% indicated that they had previous experience with one. Compared to those who were aware of chaplains, adults who were unaware were younger (38 vs. 49 years, p=<0.001), male (p=0.007), a racial/ethnic minority (p=<0.001), and had lower educational attainment (p=0.01). Seventy-percent reported an interest in having R/S, or existential needs met in the context of healthcare. The least desired services in both the inpatient and outpatient settings related to religious needs, whereas more participants indicated a desire to receive support to explore spiritual or existential needs. Conclusions: The majority of the U.S. population say they are aware of chaplains and desire their services, yet few report previous experience with them in healthcare. More behavioral interventions are needed to better connect patients to chaplains. 

BRIEF REPORT

Margarita Burn: Recognition and Treatment of Phytophotodermatitis

Ganesh Maniam, BA, MBA; Katelyn MacLeay Light, MD; Joanna Wilson, DO

Corresponding Author:  Ganesh Maniam, BA, MBA; Texas Tech University Health Sciences Center. Email: Ganesh.Maniam@ttuhsc.edu

Publication: TBD

Phytophotodermatitis is a cutaneous reaction caused by direct contact with phototoxic agents and subsequent sunlight exposure. Furocoumarins and psoralens are two such phototoxic agents that can cause this reaction, and these organic chemical compounds are found in many plant species consumed by humans Following contact exposure to such foods and ultraviolet radiation exposure via direct sunlight, phytophotodermatitis can occur. Due to the etiology of these rashes relating closely to the outdoor consumption of margaritas, the rash may be known by patients as “margarita burn”. The classically described clinical triad in these patients is a sequence of rash progression: first as erythematous macules or patches, which later become vesicles and appear similar to second degree burns, before finally becoming an asymptomatic hyperpigmentation. However, the wide variety of presentations may cause a difficult diagnosis due to confusion with other similar skin conditions. This case presents a 26-year-old female diagnosed with phytophotodermatitis following utilization of citrus fruits for margaritas while outdoors in direct sunlight. The diagnosis of phytophotodermatitis is often made clinically, but can be complicated due to its similarity in appearance to many other common cutaneous reactions. In this patient, the differential diagnosis included solar erythema, contact dermatitis (type IV hypersensitivity reaction), polymorphic light eruption, or drug-related photosensitivity. Careful history taking is essential in not only narrowing down the differential diagnosis, but also in avoiding unnecessary tests or ineffective treatments. A discussion of this case may assist physicians in the recognition and treatment of similar cases.

FAMILY MEDICINE AND THE HEALTH CARE SYSTEM

Integrating Physical Therapists Into Primary Care

Thomas Bodenheimer, MD, MPH; Joseph Kucksdorf, DPT, OCS; Alyssa Torn, DPT, OCS; James Jerzak, MD

Corresponding Author:  Thomas Bodenheimer, MD, MPH; University of California, San Francisco. Email:  tombodie3@gmail.com

Publication: TBD

Most primary care practices have insufficient capacity to meet patient demand. Physical therapists working on primary care teams can add capacity to see more patients without increasing primary care provider burnout.   Bellin Health in Wisconsin has pioneered the co-location and integration of physical therapists into primary care pods. For patients with musculoskeletal complaints, providers make warm handoffs to the physical therapist who is a few steps away.  The physical therapist performs most of the visit, providing diagnosis, treatment, and patient education. Research studies show that – compared with physician management – appropriate patients managed by physical therapists have better outcomes, lower costs, and higher patient satisfaction.  The integration program is popular among physicians, patients, and physical therapists themselves. In a fee-for-service environment, the business case for this innovation requires an increased number of follow-up referrals to the physical therapy department. In the COVID-19 era, physical therapists can provide telehealth care via video visits with equal quality compared with in-person visits.  The Bellin Health program is a blueprint for other primary care practices to integrate physical therapists into primary care teams.

RESEARCH LETTER

Implementing Primary Care Mediated Population Genetic Screening Within an Integrated Health System

Sean P. David, MD, SM, DPhil; Henry M Dunnenberger, PharmD; Raabiah Ali, MPH; Adam Matsil, MS; Amy A Lemke, PhD, MS; Lavisha Singh, MPH; Anjali Zimmer, PhD; Peter J Hulick, MD, MMSc

Corresponding Author:  Sean P. David, MD, SM, DPhil; University of Chicago. Email:  SDavid@northshore.org 

Publication: TBD

Introduction: Genetic screenings can have a large impact on enabling personalized preventive care. However, this can be limited by the primary use of medical history-based screenings in determining care. The purpose of this study was to understand the impact of DNA10K, a population-based genetic screening program mediated by primary care physicians within an integrated health system to emphasize its contribution to preventive healthcare. Methods: Construction of the patient experience as part of DNA10K shaped the context for PCP engagement within the program. A cross-sectional analysis of patient consents, orders, tests, and results of nearly 10,000 patients within the primary care specialties of family medicine, internal medicine or obstetrics/gynecology between April 1, 2019 and January 22, 2020 was conducted. Results: Across all specialties, a median number of 7.5 cancer and cardiovascular disease variants per PCP was found. The average age of the study population was 49.6 years. Over 8% of these patients had at least one actionable genetic risk variant and almost 2% of patients had at least one CDC Tier 1 variant. The median numbers of patients per PCP with either hereditary breast and ovarian cancer, Lynch Syndrome, or Familial Hypercholesterolemia was 1 (Interquartile Range 0-2). Discussion: The analysis of test results and the engagement of an integrated healthcare system in the implementation of a genetic screening program suggests that it can have a large impact on population health outcomes and minimal referral burden to PCPs if identified risks can lead to preventive care. 

POLICY BRIEF

Heeding The Call For Urgent Primary Care Payment Reform: What Do We Know About How To Get Started?

Stephanie B. Gold, MD; Larry A. Green, MD; John M. Westfall, MD, MPH

Corresponding Author: Stephanie B. Gold, MD; University of Colorado Anschutz Medical Campus. Email: stephanie.gold@ucdenver.edu              

Publication: TBD

The COVID-19 pandemic has added further urgency to the need for primary care payment reform. Fee-for-service payments limit the flexibility of practices to respond to crises and leave practices without sufficient revenues when visit volumes decrease. Historic fee-for-service payments have been inadequate and prior implementations of prospective payments have encountered challenges; as such, there is a need to bring forward the best available evidence on how to design prospective payments for payers and policymakers. Evidence suggests setting primary care investment at 10-12% of the total cost of care, approximately translating to an average $85 per member per month, with significant variation based on age and adjustment for medical and social measures of risk. Enhanced investment in primary care should be aligned across payers and support practice transformation to advanced models of care.

 

POLICY BRIEF

Proportion of Family Physicians in Solo and Small Practices is on the Decline

Anuradha Jetty, MPH; Stephen Petterson, PhD; Yalda Jabbarpour, MD

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

Publication: TBD

Although solo and small practices are a vital part of primary care, the proportion of family physicians reporting working in practices with five or fewer providers declined from 15% to 11% for solo and 37% to 34% for small (2-5 providers) practices from 2014 to 2018. These decreasing trends are concerning, mainly when a low proportion of FPs have solo practices in rural locations given the access to care challenges in these underserved populations.

ORIGINAL RESEARCH

Clinician Perspectives on Group Visits for Advance Care Planning among Older Adult Patients and Caregivers Affected by Heart Failure

Alexis Coulourides Kogan, PhD; Kya Kraus, MS; Bonnie Olsen, PhD; Julia I. Bandini, PhD; Sangeeta C. Ahluwalia, PhD

Corresponding Author: Alexis Coulourides Kogan, PhD; University of Southern California. Email: acoulour@usc.edu

Publication: TBD

Background: Advance care planning (ACP) is critical for older adults with heart failure, however, patient- and clinician-level barriers exist. Using a group visit (GV) approach to engage patients in ACP has proven effective among a general geriatric population, yet little is known about clinician perceptions/likelihood of referral. Methods: Qualitative study to understand clinician perspectives on GVs for ACP among older adult patients with heart failure and their caregiver. Twenty physicians and advance practice providers in family, internal, cardiology, and palliative medicine at an academic health center in Los Angeles County participated in telephone-based interviews guided by a semi-structured research protocol. Transcripts were analyzed used a grounded theory approach. Results: Results highlight variability in clinician engagement in ACP but greater agreement around the factors that prompt discussions. Qualitative themes included: 1) Inherent properties of GVs (characteristics that make a GV an ideal format for most are also what makes them less ideal for some, and risk-to-benefit ratio for GVs); 2) Purpose of GVs (general education, “priming the pump” for subsequent discussions, providing the tools for action); and 3) Format and procedures for GVs (participant inclusion/exclusion considerations, organizing groups by a unifying characteristic, and the link back to clinicians). Conclusions: This is the first study to gain clinician insights into ACP GVs specific to patients and caregivers affected by heart failure. Results shed light on an important topic and, corroborated by prior research, suggest key considerations for conducting GVs for ACP among older adult patients with heart failure and their caregivers.

BRIEF REPORT

Association of Prediabetes Status Awareness With Health Behaviors and Perception of Health

Erica Li, MD; Alexis Silverio, MPH, CSCS, CHES, NASM-FNS; Amy Cunningham, PhD, MPH; Marianna D. LaNoue, PhD, MS; Geoffrey Mills, MD, PhD

Corresponding Author: Erica Li, MD; Thomas Jefferson University. Email: erica.li@jefferson.edu

Publication: TBD

Introduction: Lifestyle modification can significantly reduce the risk of developing diabetes. However, the effect of prediabetes status awareness on perceptions of health and health behaviors are mixed. We used the 2015-2016 National Health and Nutrition Examination Survey (NHANES) data to evaluate the association of prediabetes status awareness with self-reported perception of health and health behaviors. Methods: A secondary analysis was performed on the 2015-2016 NHANES, which is a biannual, cross-sectional survey designed to be representative of the civilian, noninstitutionalized United States population. Survey participants were interviewed at home and invited to a mobile examination center to undergo examinations and laboratory measurements. Inclusion and exclusion criteria were applied to create prediabetesaware and prediabetes-unaware groups. The groups were propensity-score matched based on BMI, A1c, race, and education. Measures of health perception and health behaviors were analyzed, including feeling at risk for developing diabetes, general health status, perception of weight, desire to lose weight, dietary behaviors, and physical activity behaviors. Results: Participants who were prediabetes-aware were more likely to report a perceived risk of diabetes and to consider themselves overweight. Prediabetes awareness was not associated with any difference in dietary or physical activity behaviors. Conclusions: Although participants who were aware of their prediabetes status were more likely to report a perceived threat of developing diabetes, they did not report increased engagement in health behaviors. Future research can better understand how these aspects of a health belief model affect engagement in health behaviors for people with prediabetes.

FAMILY MEDICINE AND THE HEALTH CARE SYSTEM

Changing Reasons for Visit to Primary Care Over a 35-Year Period

Wyatt P. Bensken, BS; Weichuan Dong, MA; Heidi Gullett, MD, MPH; Rebecca S. Etz, PhD; Kurt C. Stange, MD, PhD

Corresponding Author: Wyatt P. Bensken, BS; Case Western Reserve University; Email: wpb27@case.edu

Publication: TBD

Objective: To understand changes in reasons for visit to primary care in the face of an aging population, growing evidence for proactive preventive and chronic disease services, and the rise of the chronic care model. Methods: We examined the reason for visit to all physicians and particularly to primary care physicians (family/general practice, internal medicine, pediatrics) in the nationally-representative National Ambulatory Medical Care Survey physician-report of visits from 1980-2015, after harmonizing data to account for changes in variable definitions over time. Results: Among all physicians, the percent of visits for prevention increased from 17% in 2001 to 20% in 2015. Visits for chronic illness declined slightly between 1980 and 2000, then increased from 37% of visits in 2001 to 40% by 2015. Of those visits which were for primary care, most continued to be for acute problems – with the percent of visits for acute illness declining over the past 15 years, after remaining steady for two decades. Preventive care visits increased from 19% in 2001 to 26% in 2015. The percent of primary care visits for chronic conditions declined between 1980 and 2000, and then remained fairly steady, accounting for 30% in 2001 and 31% in 2015. In more granular reason for visit data, visits for general medical exam declined slightly from 1975 – 1990, then have increased steadily, while visit rates for hypertension, diabetes, and well-baby care remained steady. Conclusions: Findings show an increasing emphasis on preventive care over the past 15 years as the US Preventive Services Task Force assumed prominence. The growing emphasis on chronic disease management in theory and guidelines is not reflected in the percent of primary care visits for chronic illness. This study highlights the potential utility of longitudinal data within a historical interpretive frame, while raising questions about the utility of using physician report of main reason for visit to classify complex primary care visits.

ORIGINAL RESEARCH

Practitioner Use of Primary Care Research Reports: An International Survey

William R. Phillips, MD, MPH; Elizabeth Sturgiss, BMed, FRACGP, MPH, PhD; Angela Yang; Paul Glasziou, MBBS, FRACGP, PhD; Tim olde Hartman, MD, PhD, FP/GP; Aaron Orkin, MD, MSc, MPH, CCFP(EM), FRCPC; Grant M. Russell, MBBS, MFM, FRACGP, PhD; Chris van Weel, MD, PhD, FRCGP (Hon), FRACGP (Hon)

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

Publication: TBD

Purpose: To assess how primary care practitioners use reports of general health care and primary care research and how well reports deliver what they need to inform clinical practice. Methods: International, inter-professional online survey, 2019, of primary care clinicians who see patients at least half time. Respondents used frequency scales to report how often they access both general health care (GHC) and primary care (PC) research and how frequently reports meet their needs. Free-text short comments recorded comments and suggestions. Results: Survey yielded 252 respondents across 29 nations, 55% (121) women, including 88% (195) physicians – of which 88% (144) were family physicians/general practitioners – nurses 5% (11) and physician assistants 3% (7). Practitioners read research reports frequently but find they usually fail to meet their needs. For PC research, 33% (77) accessed original reports in academic journals weekly or daily and 36% found reports meet their needs "frequently" or "always." They access reports of GHC research slightly more often but find them somewhat less useful. Practitioner comments called for easier access to research findings, greater focus on generalizability and implementation across PC settings, and richer description of the context of clinical care, relationships and teams. Conclusions: PC practitioners access original research in academic journals frequently but find reports meet their information needs less than half the time. PC research reflects the unique PC setting and so reporting has distinct focus, needs and challenges. Practitioners desire improved reporting of study context, interventions, relationships, generalizability and implementation.

ORIGINAL RESEARCH

Initial Medical Screening in Patients With Musculoskeletal Pain That is Likely Chronic

Lisa C. Carlesso, PT, PhD; Debbie Ehrmann Feldman, PT, PhD; Richard L. Nahin, MPH, PhD

Corresponding Author: Lisa C. Carlesso, PT, PhD; McMaster University; Email: carlesl@mcmaster.ca

Publication: TBD

Purpose: To explore medical diagnostic testing of new cases of musculoskeletal conditions associated with chronic pain. Methods: Using nationally representative data from the 2007-2015 National Ambulatory Medical Care Survey, we analyzed cross-sectional data of people having visits with a new musculoskeletal pain (MSKP) condition that is likely chronic identified using pre-determined ICD-9 codes. We documented depression screening, prescribing of diagnostic imaging and blood tests and explored associations between patient and provider factors for each. Results: Over the 9-years of the survey, there were 11,994 initial visits for chronic MSKP, resulting in an average of 36.8 million weighted visits per year or approximately 11.8% of the population. Proportions for depression screening, prescribed imaging and blood tests were: 1.79%, 36.34%, and 9.70%. People on any public health insurance had twice the increased relative odds to be screened for depression Odds ratio (OR) 2.26 95% confidence interval (CI) (1.20, 4.28). Orthopedists had three times increased relative odds to prescribe imaging compared to family physicians OR 2.77 95% CI (2.25, 3.42). Oncologists had four times increased relative odds to prescribe blood tests OR 4.00 95%CI (1.34, 11.93). Survey year was significantly associated with depression screening (Wald p-value=0.0202) and ordering any type of imaging (Wald p-value=0.0001). Conclusions: Observed rates of depression screening and non-indicated imaging for patients with chronic MSKP have fluctuated over time. The impact of these fluctuations on clinical practice is as yet unknown. The type of non-recommended actions varied by specialty of the physician. Future studies should assess the underlying reasons affecting imaging rates and their trends, to increase our understanding of prescribing related to these tests.

ORIGINAL RESEARCH

Examining Variations in Action Plan Quality Among Adults With Type 2 Diabetes in Primary Care

Pernille H. Kjaer; Lawrence Fisher; Michael Potter; Mansi Dedhia; José Parra; Niels Ejskjaer; Søren Skovlund; Danielle Hessler

Corresponding Author: Pernille H. Kjaer; Aalborg University; Email: p.horsted@rn.dk 

Publication: TBD

Introduction: Collaborative goal-setting and action-planning are key elements of selfmanagement support for people with type 2 diabetes (T2D), however little is known regarding action plan quality or correlated of quality in primary T2D care. Methods: T2D patients from 12 primary care sites participated in either: Connection to Health (CTH; 6 practices), consisting of a health survey followed by collaborative action planning, or enhanced Engagement CTH (EE-CTH; 6 practices), including additional training in relationship building promoting patient engagement. Action plan quality was rated using an adapted version of the Goal-Setting Evaluation Tool for Diabetes (GET-D) (dual coding of 20%, IRR >80%). Associations with patient characteristics were examined using generalized linear mixed models adjusting for clustering by clinic and intervention arm. Results: With a mean (SD) score of 14.62 (3.87) on a 0-20 scale (n=725), overall action plan quality was moderate-high. Higher health literacy (B=1.184, 95% CI [.326, 2.041], p=.007), and having no social risks (B=.416, 95% CI [.062, .770], p=.021) were associated with higher action plan quality, whereas gender, age, language, education level, depression, stress, and health distress were unrelated to quality (p=n.s.). Higher quality was associated with greater patient confidence in the plan (B=.050, 95% CI [.016, .084], p=.004). Conclusions: While there was considerable difference in action plan quality ratings, ratings did not systematically differ based on most patient demographic or mental health measures. Results suggest that action planning should be tailored to health literacy and social risks. Further research should examine associations between quality and longer term clinical outcomes.

ORIGINAL RESEARCH

Medication Adherence and Characteristics of Patients Who Spend Less on Basic Needs to Afford Medications

Karthik W. Rohatgi, BA; Sarah Humble, MS; Amy McQueen, PhD; Jean Hunleth, PhD; Su-Hsin Chang, PhD; Cynthia Herrick, MD, MPHS; Aimee S. James, PhD, MPH

Corresponding Author: Karthik W. Rohatgi, BA; Washington University; Email: karthik.rohatgi@wustl.edu

Publication: TBD

Introduction: Among individuals with low income, medication cost is a well-established barrier to medication adherence. Spending less on basic needs to pay for medication is a particularly concerning cost-coping strategy and may be associated with worse health outcomes. The aims of this study were (1) to describe the demographic and health status characteristics of those who report spending less on basic needs to pay for medication, and (2) to understand the associated psychosocial and financial challenges of individuals who make these choices. Methods: We administered a survey to primarily low-income adults (n=270) in St. Louis, Missouri as part of a larger study from 2016-2018. Logistic regression was used to model the odds of reporting spending less on basic needs in order to pay for medication. Results: Spending less on basic needs to pay for medication was significantly more likely in individuals with fair or poor health status (OR = 2.00; 95% CI, 1.03 to 3.93), greater number of chronic conditions (OR = 1.21 per additional 1 condition, 95% CI, 1.06 to 1.40), greater medication expenditure (OR = 1.41 per additional $100; 95% CI, 1.11 to 1.89), and difficulty paying bills (OR = 1.43; 95% CI, 1.11 to 1.85). Individuals who spent less on basic needs were less likely to be fully adherent to their medication regimen (OR = 0.38; 95% CI, 0.18 to 0.77). Conclusions: Screening for unmet basic needs and offering referrals to social safety net programs in the primary care setting may help patients achieve sustainable medication adherence.

ORIGINAL RESEARCH

How Are Family Physicians in Kansas Responding to the COVID-19 Pandemic? 

Samuel Ofei-Dodoo, PhD, MPA, MA; Colleen Loo-Gross, MD, MPH; Rick Kellerman, MD

Corresponding Author: Samuel Ofei-Dodoo, PhD, MPA, MA; University of Kansas School of Medicine-Wichita; Email: sofeidodoo@kumc.edu

Publication: TBD

Introduction: The novel coronavirus infectious disease (COVID-19) has spread rapidly with vast global implications. This study assessed how family physicians in Kansas were responding to COVID-19 and the effects of the pandemic on the physicians’ well-being. Methods: The authors conducted a cross-sectional survey of 113 family physicians in Kansas between May 22, 2020 and June 25, 2020. The study participants completed an anonymous, 18-item survey assessing family physicians’ concerns about being exposed to COVID-19, levels of personal depression, anxiety, stress, and burnout in addition to demographic information. Results: There was a 45.6% response rate, with 50.4% (n=57) of the respondents reporting manifestations of burnout. The physicians who personally treated any presumptive or confirmed COVID-19 patient, compared to those who did not, were more likely to report at least one manifestation of burnout (odds ratio[OR]=3.96; 95% confidence interval [CI], 1.38-11.36; P = .011), experience emotional exhaustion (OR=3.21; 95% CI, 1.01-10.10; P<.05), and feel a higher level of personal stress (OR=1.13; 95% CI, 1.01-1.27; P=.011). Conclusion: Our findings demonstrate that the COVID-19 pandemic may be taking an emotional toll on family physicians in Kansas. This study provides a baseline from which to continue further monitoring of outcomes such as burnout, depression, anxiety, and stress, to determine the need for interventions, and influence the implementation of programs to support physician wellness. These data can help drive wellness and mental health support initiatives at local, state, and national levels to help diminish the negative impact of the COVID-19 pandemic on physicians.

ORIGINAL RESEARCH

Variation in Primary Care Wait Times in Medicaid: Explanatory Factors From an Experimental Design

Evelyn G. Gotlieb; Karin V. Rhodes, MD, MS; Molly K. Candon, PhD

Corresponding Author: Evelyn G. Gotlieb; University of Pennsylvania; Email:  egotlieb@wharton.upenn.edu

Publication: TBD

Background: Timely access to primary care is important, particularly among patients with acute conditions and patients seeking a gateway to specialty care. Due to concerns that expanded Medicaid eligibility would compromise access to primary care among new Medicaid beneficiaries, an experimental study was conducted to test the ability to obtain timely appointments across 10 states in 2012, 2014, and 2016. While access to primary care appointments for simulated Medicaid patients significantly increased, wait times also increased. The current study explores the determinants of wait times and investigates whether they pose a greater barrier to Medicaid beneficiaries. Methods: Using data from the experimental study, we conducted linear regressions to determine the association between the number of days to scheduled appointments and the simulated patient’s clinical scenario (routine check-up vs. undiagnosed hypertension), practice-level characteristics, and county-level measures of primary care supply. We also stratified analyses based on the county-level concentration of Medicaid beneficiaries. Results: Simulated Medicaid patients faced 1.3 day longer wait times than commercially-insured ones. Participation in accountable care organizations and integrated health systems was associated with longer wait times, but did not appear to reduce wait time disparities across insurance types. Notably, the presence of federally qualified health centers in a given county was associated with lower wait times for simulated Medicaid patients. Conclusions: These findings highlight the complexity of access disparities for Medicaid patients and provide insight for future waves of health care reform.

BRIEF REPORT

Primary Care Physicians’ Perspective on Pharmacists Delivering Vaccines to Adults

Christine E. MacBrayne, PharmD, MSCS; Laura Hurley, MD, MPH; Sean O’Leary, MD, MPH; Jessica Cataldi, MD, MSCS; Lori Crane, PhD, MPH; Carol Gorman, BA; Michaela Brtnikova, PhD, MPH; Brenda Beaty, MSPH; Allison Kempe, MD, MPH

Corresponding Author: Christine MacBrayne, PharmD, MSCS, BCIDP; Children’s Hospital Colorado; Email: Christine.macbrayne@childrenscolorad.org

Publication: TBD

Introduction: Since 2009, pharmacists in all fifty states have been authorized to provide vaccinations to adults in some capacity. The objective of this study was to assess primary care physicians’ (PCPs) experiences with and attitudes about pharmacists administering vaccinations to their adult patients. Methods:  Internet and mail survey from January-February 2019 of PCPs representative of the American College of Physicians’ and American Academy of Family Physicians’ memberships. Results: Response rate was 69% (642/926). Ninety-eight percent of respondents agreed (79% ‘Strongly,’ 19% ‘Somewhat’) that it is their responsibility to assure that their adult patients receive recommended vaccinations even if they get them outside of their practice. Most respondents agreed that pharmacists either did not have access to patient medical information (33% ‘Strongly’, 45% ‘Somewhat’) or did not have adequate vaccination history (33% ‘Strongly,’ 41% ‘Somewhat’) to determine if an adult needs a vaccination.  The majority also agreed that pharmacists did not inform them when vaccinations were given (35% ‘Strongly,’ 39% ‘Somewhat’) and did not enter vaccinations administered into immunization information systems (IIS) (20% ‘Strongly,’ 37% ‘Somewhat’).  However, 83% agreed (31% ‘Strongly’, 52% ‘Somewhat’) that it is helpful to have pharmacists share the role of vaccinating adults with physicians. Conclusions: PCPs have mixed feelings about pharmacists delivering vaccines to adults. Universal use of IIS by pharmacists could partially address physicians’ concerns by providing a systematic way for pharmacists and physicians to share patient vaccination histories.

FAMILY MEDICINE AND THE HEALTH CARE SYSTEM

Slow Medicine: In Defense of Primary Care

Elena Hill, MD/MPH

Corresponding Author: Elena Hill, MD/MPH; Bronxcare Health Systems; Email: Ehill3047@gmail.com

Publication: TBD

This is an opinion piece that examines the dichotomy of “fast medicine” (which involves high medical use and spending) and what I refer to as “slow medicine”. It discusses ethical questions around which of these two frameworks really confers better “health” to patients – using examples from a real patient scenario of mine who was considering undergoing a relatively high-risk carotid endarterectomy. It then re-affirms the importance of primary care to conferring health and the ultimate value of primary care, or “slow medicine”. I believe it is a timely discussion as we continue to advocate for more primary care resources in our health care system.

CLINICAL REVIEW

Diagnosis and Management of Hypermobility Spectrum Disorders in Primary Care

Karina Atwell, MD, MPH; William Michael, MD; Jared Dubey, DO; Sarah James, DO; Andrea Martonffy, MD; Scott Anderson, MS; Nathan Rudin, MD; Sarina Schrager, MD, MS

Corresponding Author: Sarina Schrager, MD, MS; University of Wisconsin; Email: sbschrag@wisc.edu

Publication: TBD

Hypermobility spectrum disorders (HSDs) encompass an array of connective tissue disorders characterized by joint instability and chronic pain. Fatigue and other systemic symptoms that affect daily functioning may occur, as well. Accurate data on incidence and prevalence of HSDs is hampered by lack of awareness of these conditions and the wide heterogeneity of their clinical presentation. Identifying which type of HSD is present is important in guiding appropriate care. In particular, making the diagnosis of Hypermobile Ehlers-Danlos Syndrome (hEDS) is important, as individuals with hEDS may be a risk for more significant multisystem involvement. Diagnostic criteria for hEDS include measures of joint hypermobility, skin and other connective tissue findings, and lack of evidence of a different type of Ehlers-Danlos Syndrome. Beyond accurate diagnosis, HSDs pose many challenges for primary care providers, as ongoing patient education, patient empowerment, and coordination of a multi-disciplinary treatment team are integral to proper care. This paper describes the incidence and prevalence, pathophysiology, diagnosis, and management of HSDs, including clinical cases exemplifying how joint hypermobility might present within a primary care setting.

ORIGINAL RESEARCH

A Multidisciplinary Diabetes Clinic Improves Clinical and Behavioral Outcomes in a Primary Care Setting Within a Family Medicine Residency Program

Shay Phillips PharmD, BCPS, CDCES, BC-ADM; Jamayla Culpepper MD, MPH; Madelyn Welch BA; Katherine J. O’Hare BSPH; Willa Chen, BS; Yhenneko Taylor PhD; William Anderson, MS; Hazel Tapp PhD

Corresponding Author: Shay Phillips PharmD, BCPS, CDCES, BC-ADM; Atrium Health Carolinas Medical Center; Email: shay.phillips@atriumhealth.org

Publication: TBD

Background: The percentage of adults achieving hemoglobin A1c (A1c) goals less than 7% continues to suffer, highlighting a need to implement more effective healthcare strategies. Use of multidisciplinary teams is recommended. The study objective was to evaluate the effects of a multidisciplinary approach on behavioral outcomes and mean change in A1c in the immediate start (intervention) versus 6-month delay (control) groups at 6 months. Methods: This randomized controlled study assessed 111 patients recruited from a safety-net primary care clinic between February 2014 and August 2018. A pharmacist-led multidisciplinary team (physician champions; social worker; behavioral health; nurses; residents, and research assistant) enhanced coordination, integration, and intensification of diabetes care. A1c values were measured every 3 months and the self-efficacy scale to measure behaviors was evaluated at baseline and at 6 months. Depression screening and diabetes self-management education were incorporated into visits, and patients eligible for shared decision making (SDM) contributed to therapy choices. Results: The average patient age was 55 years. Sixty-six percent of the patients were female; greater than 80% were African American. After 6 months from baseline, the intervention group showed an A1c decrease of 2.4 compared to the control group’s decrease of 1.1 (p= 0.02). The mean increase in the self-efficacy score in the intervention group at baseline versus after 6 months showed a statistically significant change (p = 0.01) compared to the control group (p = 0.26). Results revealed a post-hoc association between A1c and PHQ-9 such that patients with a higher baseline PHQ-9 score (> 10) experienced a greater mean decrease in A1c. Conclusions: Use of a multidisciplinary clinic team in a safety-net primary care practice improved mean A1C control and behavioral outcomes for patients with type 2 diabetes as compared to control group.

BRIEF REPORT

Practice Patterns of Family Physicians With and Without Addiction Medicine Board Certification

Sebastian T. Tong, MD, MPH; Zachary J. Morgan, MS; Andrew W. Bazemore, MD, MPH; Aimee R. Eden, PhD, MPH; Ruchi M. Fitzgerald, MD; Lars E. Peterson, MD, PhD

Corresponding Author: Sebastian T. Tong, MD, MPH; Agency for Healthcare Research and Quality; Email: sebastian.tc.tong@gmail.com

Publication: TBD

Background: The American Board of Medical Specialties recognized addiction medicine (ADM) as a subspecialty in 2016, which was timely given the recent rise in substance use disorder (SUD). The impact of this dual board opportunity on Family Medicine has not been described. Our study enumerates and characterizes physicians dually certified in Family Medicine and ADM. Methods: We linked American Board of Medical Specialties data from March 2020 on physicians dually boarded in Family Medicine and ADM to responses on demographic and scope of practice questions in the American Board of Family Medicine (ABFM) National Graduate Survey and Family Medicine Certification Examination Registration Questionnaire. Results: Of current ABFM Diplomates, 0.53% (492/93,269) are also boarded in ADM. Based on survey responses from a subset of dually certified physicians, those who are dually certified are more likely to practice in federally qualified health centers and to hold a faculty position. Dually certified physicians are more likely to provide HIV/AIDS and hepatitis C management and are as likely as non-dually certified physicians to provide newborn care, obstetric deliveries, inpatient adult medicine care and intensive care. Discussion: While only a small proportion of family physicians carry dual ADM board certification, those that do disproportionately serve vulnerable populations, while retaining broad scope of care. Further work is needed to examine whether SUD treatment access could be addressed by implementing models that support dually certified physicians in consultative and educational efforts that would amplify their impact across the primary care workforce.

 

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