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.

MARCH/APRIL 2020 ISSUE (Publication Date: March 9, 2020)

MANUSCRIPTS ACCEPTED FOR PUBLICATION (Publication Date: TBD)

COMMENTARY

Do Patients Want Help Addressing Social Risks?

Emilia H De Marchis, MD, MAS; Hugh Alderwick, BA; Laura M. Gottlieb, MD, MPH

Corresponding Author:  Emilia H De Marchis, MD, MAS; University of California, San Francisco. Email: emilia.demarchis@ucsf.edu      

Publication: March 9, 2020

Evaluations of health care-based screening programs for social risks often report that a relatively small proportion of patients screening positive for social risk factors are interested in receiving assistance from their health care teams to address them. The relatively low number of patients who desire assistance is relevant to the growing number of initiatives in U.S. health care settings designed to collect data on and address patients’ social risks. We highlight multiple studies that have found differences between positive risks screens and desire for assistance. We explore possible explanations for those differences—focusing on the fallibility of screening tools as well as patient preferences, priorities, and lived experiences—and the potential implications for health equity.

POLICY BRIEF

Despite Adequate Training, Only Half of Family Physicians Provide Women’s Health Care Services

Megan Coffman, MS; Elizabeth Wilkinson; Yalda Jabbarpour, MD

Corresponding Author:  Megan Coffman, MS; AAFP/Robert Graham Center. Email: mcoffman@aafp.org

Publication: March 9, 2020

Access to services related to reproductive and sexual health is critical to the health of women but has been threatened in recent years. Family physicians are trained to provide range of women’s healthcare services and are an essential part of the healthcare workforce in rural and underserved areas, where access to these services may be limited.

ORIGINAL RESEARCH

Improved Prenatal Counseling per Pregnancy Weight Gain Guideline Lowered Gestational Diabetes

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

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

Publication: March 9, 2020

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

ORIGINAL RESEARCH

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

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

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

Publication: March 9, 2020

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

ORIGINAL RESEARCH

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

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

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

Publication: March 9, 2020

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

ORIGINAL RESEARCH

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

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

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

Publication: March 9, 2020

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

ORIGINAL RESEARCH

Practice Facilitation Infrastructure Needed to Support Large-Scale Interventions

Shannon M. Sweeney; Jennifer R. Hemler; Andrea N. Baron; Tanisha T. Woodson; Sarah S. Ono; Leah Gordon; Benjamin F. Crabtree; Deborah J. Cohen

Corresponding Author:  Shannon M. Sweeney; Oregon Health & Science University. Email: sweenesh@ohsu.edu      

Publication: March 9, 2020

Background: Facilitation is an effective approach for helping practices implement sustainable evidence-based practice improvements. Few studies examine the facilitation infrastructure and support needed for large-scale dissemination and implementation initiatives. Methods: The Agency for Healthcare Research and Quality funded seven Cooperatives, each of which worked with over 200 primary care practices to rapidly disseminate and implement improvements in cardiovascular preventive care. The intervention target was to improve primary care practice capacity for QI and the ABCS of cardiovascular disease prevention: aspirin in highrisk individuals, blood pressure control, cholesterol management, and smoking cessation. We identified the organizational elements and infrastructures Cooperatives used to support facilitators by reviewing facilitator logs, online diary data, semi-structured interviews with facilitators, and fieldnotes from facilitator observations. We analyzed these data using a coding and sorting process. Results: Each Cooperative partnered with 2-16 organizations, piecing together 16-35 facilitators, often from other quality improvement projects. Quality assurance strategies included establishing initial and ongoing training, processes to support facilitators, and monitoring to assure consistency and quality. Cooperatives developed facilitator toolkits, implemented initiativespecific training, and developed processes for peer-to-peer learning and support. Conclusions: Supporting a large-scale facilitation workforce requires creating an infrastructure, including initial training, and ongoing support and monitoring, often borrowing from other Abstract ongoing initiatives. Facilitation that recognizes the need to support the vital integrating functions of primary care might be more efficient and effective than this fragmented approach to quality improvement.

ORIGINAL RESEARCH

Marketing Messages in Continuing Medical Education Modules on Binge Eating Disorder 

Jin Jung, BS; Adriane Fugh-Berman, MD

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

Publication: March 9, 2020

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

ORIGINAL RESEARCH

Modifying Provider Vitamin D Screening Ordering Behavior in Primary Care: An Interrupted Time Series Analysis

Nigel L. Rozario, PhD, MS; Alica Sparling, PhD; Ryan Burns, MS; Andrew McWilliams, MD, MPH; Jennifer H. Brady, MD; Marc Kowalkowski, PhD; Jason Roberge, PhD, MPH

Corresponding Author:  Nigel Rozario, PhD, MS; Atrium Health. Email: Nigel.Rozario@AtriumHealth.org

Publication: March 9, 2020

Purpose: Clinical evidence shows minimal benefit to Vitamin D screening and subsequent treatment in the general population. This study aims to assess the effectiveness of two light touch interventions on reducing Vitamin D test orders. Methods: The outcomes were weekly average Vitamin D rates, computed from adult primary care encounters (preventive or non-preventive) with a Family Medicine (FM) or Internal Medicine (IM) provider from 6/14/2018 through 12/12/2018. We conducted an interrupted time series analysis and estimated the cost impact of the interventions. The interventions consisted of an educational memo (8/9/18) distributed to providers and removal of the Vitamin D test (FM-8/15/18; IM-10/17/18) from the providers’ quick order screen in the electronic health record (EHR). Change in order rates were analyzed among physicians(MD and DO), physician assistants(PA) and nurse practitioners(NP). Results: There were 587,506 primary care encounters (FM=367,947; IM=219,559). Vitamin D order rates decreased from 6.9% (FM=5.1%; IM=9.9%) to 5.2% (FM=4%(p<0.01), IM=7.9%(p<0.01)). For FM, the Vitamin D test order rate continued to fall at a 0.08% per week rate after the interventions (End of Study: 2.73%). The education intervention showed a relative decrease in each provider type (FM-physician=16%(p<0.01), FM-PA=47%(p<0.01), FM-NP=20%(p=0.01), IM-physician=14%(p=0.02), IM-PA=52%(p<0.01), IM-NP=34%(p=0.04)). Annualized savings was approximately one million dollars. Conclusions: Emailed evidence-based provider education may be an effective tool for modifying providers’ Vitamin D test ordering behavior. The lack of the effectiveness of the Vitamin D test removal from the quick order screen found for IM highlights the challenges facing simple EHR interventions when multiple alternate ordering pathways exist.

BRIEF REPORT

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

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

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

Publication: March 9, 2020

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

BRIEF REPORT

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

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

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

Publication: March 9, 2020

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

BRIEF REPORT

Direct-to-Consumer Prescription Drug Advertising and Patient-Provider Interactions    

Helen W. Sullivan, PhD, MPH; Kathryn J. Aikin, PhD; Jennifer Berktold, PhD; Karen L. Stein, PhD; Victoria J. Hoverman, PhD

Corresponding Author:  Helen W. Sullivan, PhD, MPH; US Food and Drug Administration. Email: Helen.sullivan@fda.hhs.gov

Publication: March 9, 2020

Background: Direct-to-consumer prescription drug advertising is prevalent and affects patient care. Previous research that examined its effect on the patient-provider relationship predates many changes in the advertising and medical landscape that have occurred in the last decade, such as the rise in online promotion and the push for value-based medicine. Methods: We conducted a nationally representative mail-push-to-web survey of 1,744 US adults in 2017 to explore how patients view the effects of direct-to-consumer prescription drug advertising on patient-provider interactions. Results: Most respondents (76%) said they were likely to ask a healthcare provider about advertised drugs; 26% said they had already done so. Among the 26% of respondents who talked to a healthcare provider about a specific prescription drug they saw advertised, 16% said they received a prescription for the advertised drug. Few respondents (5%) reported that advertising had caused conflict with a healthcare provider, 16% said it had caused them to question their provider’s advice, and 23% said they were likely to look for a different provider if their provider refused to prescribe a requested brand name drug. Discussion: These results suggest that direct-to-consumer advertising is driving some patients to discuss specific products with their healthcare providers, but that most patients do not believe advertising has a negative influence on the patient-provider interaction itself.

BRIEF REPORT

Thyroid Hormone Use in the United States, 1997-2016     

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

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

Publication: March 9, 2020

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

CLINICAL REVIEW

Inhaled Corticosteroid Treatment in Chronic Obstructive Pulmonary Disease—Boon or Bane? Who Are the Right Patients for this Treatment?

Alan G. Kaplan, MD

Corresponding Author:  Alan G. Kaplan, MD; Family Physician Airways Group of Canada. Email: for4kids@gmail.com

Publication: March 9, 2020

Inhaled corticosteroid (ICS)-based therapy is often used for patients with chronic obstructive pulmonary disease (COPD). However, this approach is under scrutiny because of ICS overuse in patients for whom it is not recommended and because of concerns about adverse events, particularly pneumonia, with long-term ICS use. Evidence suggests ICS may be beneficial in specific patients, namely, those with high blood eosinophil counts (e.g., ≥ 300 cells/µL) or who are at a high risk of exacerbations. According to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2019 ABCD assessment tool, these patients belong in group D. For these patients, recommended initial treatment includes ICS in combination with long-acting β2-agonists (LABAs) when blood eosinophil counts are ≥ 300 cells/µL or LABA + long-acting muscarinic antagonist (LAMA) when patients are highly symptomatic, i.e., with greater dyspnea and/or exercise limitation. Follow-up treatments for patients with persistent dyspnea and/or exacerbations may include LABA + ICS, LABA + LAMA, or LABA + LAMA + ICS, with use of ICS being guided by blood eosinophil counts. In this review, differences in the inflammatory mechanism underlying COPD and asthma and the role of ICS treatment in COPD are summarized. Furthermore, findings from recent clinical trials where use of ICS-based dual or triple therapy in COPD was compared with LABA + LAMA therapy and trials in which ICS withdrawal was evaluated in patients with COPD are reviewed. Finally, a step-by-step guide for ICS withdrawal in patients who are unlikely to benefit from this treatment is proposed. A video of the author discussing the overall takeaway of the review article could be downloaded from the link provided.

CLINICAL REVIEW

Cervical Spondylotic Myelopathy: A Guide to Diagnosis and Management   

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

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

Publication: March 9, 2020

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

CLINICAL REVIEW

Addressing Needs of Transgender Patients: The Role of Family Physicians

Asa E Radix, MD, MPH

Corresponding Author:  Asa E Radix, MD, MPH; Callen-Lorde Community Health Center. Email: aradix@callen-lorde.org

Publication: March 9, 2020

There are approximately 1 million transgender and gender diverse adults in the United States. Despite increased awareness and acceptance, they frequently encounter medical settings that are not welcoming and/or healthcare providers who are not knowledgeable about their health needs. Use of correct terminology, following best practices for name and pronoun use, and knowledge of gender affirming interventions can create office environments that are welcoming to transgender and gender non-binary clients. Health disparities faced by transgender patients that impact access to care include higher rates of mental health issues, substance use disorders, violence and poverty. Transgender women are at greater risk for HIV acquisition and are less likely to achieve viral suppression compared with cisgender (non-transgender) individuals. Medical providers can facilitate HIV prevention efforts by offering pre- and post- exposure prophylaxis (PrEP and PEP) to transgender patients at risk for HIV infection. Improving health outcomes requires attention to cultural competency and an understanding of lived experiences and priorities of transgender people.

CLINICAL REVIEW

Prognostic Indices for Advance Care Planning in Primary Care: A Scoping Review

Peter Kim; Barcey T. Levy; Jeanette M. Daly; Maresi A. Berry-Stoelzle; Megan E. Schmidt; LeAnn C. Michaels; David A. Dorr

Corresponding Author:  Barcey T. Levy, MD, PhD; University of Iowa. Email: barcey-levy@uiowa.edu

Publication: March 9, 2020

Background: Patient identification is an important step for advance care planning (ACP) discussions. Objectives: We conducted a scoping review to identify prognostic indices potentially useful for initiating ACP. Eligibility criteria: We included studies that developed and/or validated a multivariable prognostic index for all-cause mortality between 6 months and 5 years in community-dwelling adults. Source of Evidence: PubMed was searched in October 2018 for articles meeting our search criteria. If a systematic review was identified from the search, we checked for additional eligible articles in its references. Data abstraction: We abstracted data on population studied, discrimination, calibration, where to find the index, and variables included. Each index was further assessed for clinical usability. Results: We identified 18 articles with a total of 17 unique prognostic indices after screening 9,154 titles. The majority of indices (88%) had c-statistics greater than or equal to 0.70. Only 1 index was externally validated. Ten indices, 8 developed in the U.S. and 2 in the U.K., were considered clinically usable. Conclusion: Of the 17 unique prognostic indices, 10 may be useful for implementation in the primary care setting to identify patients who may benefit from ACP discussions. An index classified as ‘clinically usable’ may not be easy-to-use because of a large number of variables that are not routinely collected and the need to program the index into the electronic medical record.

REFLECTIONS IN FAMILY MEDICINE

Crashing Out of a Career   

Brenda Neufeld, MD

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

Publication: March 9, 2020

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

RESEARCH LETTER

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

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

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

Publication: TBD

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

RESEARCH LETTER

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

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

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

Publication: TBD

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

CLINICAL REVIEW

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

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

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

Publication: TBD

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

POLICY BRIEF

Burnout Among Family Physicians by Gender and Age

Aimee R. Eden, PhD, MPH; Yalda Jabbarpour, MD; Zachary J. Morgan, MS; Elizabeth Wilkinson, BA; Lars E. Peterson, MD, PhD

Corresponding Author:  Aimee R. Eden, PhD, MPH; American Board of Family Medicine. Email: aeden@theabfm.org      

Publication: TBD

Using data from 2017 to 2018, we found that female family physicians, especially those younger than 40 years of age, experience burnout at higher rates than males. This has implications for the primary care workforce and suggests pathways for policy makers and health system administrators to more effectively tackle burnout in their organizations. 

ORIGINAL RESEARCH

Indicators of Workplace Burnout among Physicians, Advanced Practice Clinicians and Staff in Small to Medium-Sized Primary Care Practices

Debora Goldberg, PhD, MHA, MBA; Tulay G. Soylu, PhD, MHA, MBA; Victoria M. Grady, PhD; Panagiota Kitsantas, PhD; James D. Grady, DMD; Len M. Nichols, PhD

Corresponding Author:  Debora Goldberg, PhD, MHA, MBA; George Mason University. Email: dgoldbe4@gmu.edu      

Publication: TBD

Background: The rising prevalence of burnout among physicians and other healthcare professionals has become a major concern in the United States. Identifying indicators of burnout could help reduce negative consequences such as turnover, loss of productivity, and adverse health behaviors. The goal of this study was to examine whether individual behaviors and attitudes towards major disruptive change has an effect on workplace burnout. Methods: This study analyzed survey responses from 1273 healthcare professionals from 154 small to medium-sized primary care practices participating in the EvidenceNOW initiative in Virginia. Healthcare professionals’ behaviors and attitudes, such as anxiety and withdrawal, were assessed to determine associations with workplace burnout. Results were examined by professional role. Results: Workplace burnout was reported by 31.6% of the physicians, 17.2% of advanced practice clinicians, 18.9% of clinical support staff, and 17.5% of administrative staff. Regardless of burnout status, results show all healthcare professional groups had high levels of anxiety. Providers had significantly higher scores for anxiety than all other healthcare professionals. Providers who experienced higher levels of anxiety and withdrawal were more than three times as likely to report burnout compared to those who experienced low levels in these domains. Conclusions: Understanding individual behaviors and attitudes towards disruptive change may help practice leaders and policymakers develop strategies to reduce burnout among healthcare professionals. Programs should focus on strengthening the work environment of small to medium-sized practices to improve organizational capacity for change and address high levels of anxiety experienced by physicians, advanced practice clinicians and staff.

BRIEF REPORT

Gender Differences in Personal and Organizational Mechanisms to Address Burnout Among Family Physicians

Aimee R. Eden, PhD, MPH; Yalda Jabbarpour, MD; Zachary Morgan, MS; Mingliang Dai, PhD; Megan Coffman, MS; Andrew Bazemore, MD, MPH

Corresponding Author:  Aimee R. Eden, PhD, MPH; American Board of Family Medicine. Email: aeden@theabfm.org

Publication: TBD

Background: Few studies have examined how interventions designed to address physician burnout might impact female and male physicians differently. Our aim was to test whether there are gender differences in individual approaches to address burnout and/or in organizational support aimed at physician well-being. Methods: An online survey was administered in 2019 to family physicians in California and Illinois who are either board certified by the American Board of Family Medicine, a member of their state Academy of Family Physicians, or both. Descriptive statistics and bivariate independence tests were performed for each personal step and organizational support to determine whether there was any gender difference. Results: A total of 2,176 family physicians (58% female and 42% male) responded to the survey. 55% of female and 50% of male physicians were burned out. Female physicians were more likely to reduce work hours/go part time and to employ domestic help; males were more likely to spend more time on hobbies. Only 8% reported taking no personal steps to address burnout. Male and female physicians reported similar types of organizational support aimed at physician wellness, yet 20% reported that their organization did not provide any type of well-being support. Conclusions: We identified gendered differences in physician responses to burnout. Effectively mitigating burnout may require different individual-level approaches and different organizational support mechanisms for female and male physicians.

REFLECTIONS IN FAMILY MEDICINE

The Unexpected Volunteer

Henry Bair, BS

Corresponding Author:  Henry Bair, BS; Stanford University. Email: hbair@stanford.edu

Publication: TBD

In this narrative account, the author, a medical student, describes his encounters with several inpatients at a community hospital. He becomes acquainted with a patient’s son, who, initially withdrawn, over the course of his mother’s hospitalizations transforms into a compassionate volunteer. This change is especially emphasized when the author meets another patient who recognizes the volunteer and reveals his very different past.

CLINICAL REVIEW

Breast Cancer Screening in Older Women: The Importance of Shared Decision-Making    

Sarina Schrager, MD, MS; Viktoriya Ovsepyan, BA; Elizabeth Burnside, MD, MS, MPH

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

Publication: TBD

Incidence of breast cancer increases with age up until age 80. Screening mammography has demonstrated efficacy in decreasing mortality from breast cancer among women between 50-74 years of age. However, most major organizations do not include women over 74 in their recommendations due to the lack of evidence in this age group. This paper will review current recommendations for breast cancer screening in women over the age of 74. It will also present clear guidelines for primary care clinicians to follow that incorporate shared decision-making techniques, tools for estimating the risks and benefits of screening mammography, and strategies for integrating a patient’s life expectancy and co-morbidities into the decision-making process. We also emphasize the importance of using thoughtful communication strategies in order to fully engage older women in the breast cancer screening discussion.

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