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.

| NOVEMBER/DECEMBER 2020 |       | VETERANS' HEALTH 2021 |       | OTHER ACCEPTED ABSTRACTS | 

NOVEMBER / DECEMBER 2020. VOLUME 33 / ISSUE 6. (Publication Date: November 13, 2020)

• PROPORTION OF FAMILY PHYSICIANS CARING FOR CHILDREN IS DECLINING
• BRCA-RELATED CANCER GENETIC COUNSELING IS INDICATED IN MORE THAN 20% OF WOMEN SEEKING PRIMARY CARE
• THE EFFECT OF DEPRESSION AND RURALITY ON GLYCEMIC CONTROL IN ADULTS WITH DIABETES
• CARDIOVASCULAR SCREENING AND LIPID MANAGEMENT IN BREAST CANCER SURVIVORS: A RETROSPECTIVE CASE-CONTROL STUDY
• ASSESSING HEART DISEASE IN LARGE POPULATION OF ADULTS WITH DOWN SYNDROME BETWEEN 1996-2016
• GLUCOSAMINE CHONDROITIN AND OVERALL MORTALITY IN A US NHANES COHORT
• PREDICTORS OF PATIENT RETENTION IN MEDICATION-ASSISTED TREATMENT IN A FAMILY MEDICINE RESIDENCY CLINIC
• LIKE A DOUBLE-EDGED SWORD: PHYSICIAN PERSPECTIVES ON MAMMOGRAPHY SCREENING FOR AVERAGE-RISK WOMEN
• PATIENT CHARACTERISTICS ASSOCIATED WITH EXPECTATIONS OF OPIOID PRESCRIPTIONS FOR ACUTE PAIN CONTROL IN THE OUTPATIENT SETTING
• HAVING A USUAL SOURCE OF CARE IS ASSOCIATED WITH LONGER TELOMERE LENGTH IN A NATIONAL SAMPLE OF OLDER ADULTS
• IDENTIFYING BARRIERS TO PATIENT PORTALS ACCESS AND USE: EVIDENCE FROM THE HEALTH INFORMATION NATIONAL TRENDS SURVEY, 2017-2018
• IMPROVING COPD SYMPTOMS USING A TEAM-BASED APPROACH IN AN APPALACHIAN POPULATION
• THE PREVALENCE OF BEHAVIORAL HEALTH PROBLEMS AMONG ADULTS WITH AND WITHOUT COMMUNICATION DISABILITIES
• RELIABILITY OF PEER REVIEW OF ABSTRACTS SUBMITTED TO ACADEMIC FAMILY MEDICINE MEETINGS
• MEDICARE ACCESS AND CHIP REAUTHORIZATION ACT: A QUALITATIVE STUDY IN SIXTEEN SMALL TO MEDIUM-SIZED PRIMARY CARE PRACTICES
• EDUCATING PATIENTS ON UNNECESSARY ANTIBIOTICS: PERSONALIZING POTENTIAL HARM AIDS PATIENT UNDERSTANDING
• ASSOCIATION OF PREDIABETES STATUS AWARENESS WITH HEALTH BEHAVIORS AND PERCEPTION OF HEALTH
• ELECTRONIC HEALTH RECORD REMINDER EFFECT ON HEPATITIS C ANTIBODY SCREENING
• EXAMINING DIABETICS' KNOWLEDGE AND UNDERSTANDING OF THE BI-DIRECTIONAL RELATIONSHIP BETWEEN DIABETES AND PERIODONTAL DISEASE
• THE GOLDEN LETTER: INNOVATION COLLABORATION TO REDUCE AVOIDABLE HOSPITAL ADMISSIONS
• AN EVIDENCE-BASED, SYSTEMATIC APPROACH TO OPIOID PRESCRIBING
• OPIOID USE DISORDER EDUCATION AND WAIVER PROVISION DURING RESIDENCY: IMPACT ON FUTURE PRESCRIBING PATTERNS
• A PROPOSED OPIOID TAPERING TOOL
• DERMOSCOPY IN THE PRIMARY CARE SETTING: PERSPECTIVES, ATTITUDES, AND PERCEPTIONS
• CURRENT INDICATIONS FOR TONSILLECTOMY AND ADENOIDECTOMY

VETERANS' HEALTH SPECIAL ISSUE 2021 (Publication Date: TBD)

• SEXUAL DYSFUNCTION AND PREFERENCES FOR DISCUSSING SEXUAL HEALTH CONCERNS AMONG VETERAN PRIMARY CARE PATIENTS
• GETTING ROUTINE INTIMATE PARTNER VIOLENCE SCREENING RIGHT: IMPLEMENTATION STRATEGIES USED IN VHA PRIMARY CARE
• VETERANS WITH NON-VA ENCOUNTERS ENROLLED IN A TRIAL OF STANDARDS-BASED, INTEROPERABLE EVENT NOTIFICATION, AND CARE COORDINATION​
• VETERANS ARE AGREEABLE TO DISCUSSIONS ABOUT FIREARMS SAFETY IN PRIMARY CARE

OTHER ABSTRACTS ACCEPTED FOR PUBLICATION (Publication Date: TBD)

• THE ESSENTIAL ROLE OF FAMILY PHYSICIANS IN PROVIDING CESAREAN SECTIONS IN RURAL COMMUNITIES
• PROVISION OF EARLY PREGNANCY LOSS CARE IN NEW YORK FEDERALLY QUALIFIED HEALTH CENTERS
• PATIENT-PROVIDER TEACH-BACK COMMUNICATION WITH DIABETIC COMPLICATIONS, HOSPITALIZATION, AND HEALTH EXPENDITURES
• EXTERNAL SUPPORT FOR PRACTICE TRANSFORMATION: A PRACTICAL TAXONOMY 
• PERCEPTIONS OF PATIENTS WITH PRIMARY NONADHERENCE TO STATIN MEDICATIONS
• OPPORTUNITIES TO IMPROVE THE REPORTING OF PRIMARY CARE RESEARCH: AN INTERNATIONAL SURVEY OF RESEARCHERS
• FACTORS INFLUENCING INCREASING TIME SPENT PRACTICING SPORTS MEDICINE BY FAMILY PHYSICIANS SPECIALIZING IN SPORTS MEDICINE
• LOW-DOSE ASPIRIN USE AMONG AFRICAN AMERICAN OLDER ADULTS
• ONE-VIEW CHEST RADIOGRAPH IS SUFFICIENT FOR INITIAL MANAGEMENT OF MOST AMBULATORY PATIENTS WITH RIB PAIN
• SUDDEN SENSORINEURAL HEARING LOSS A DIAGNOSTIC AND THERAPEUTIC EMERGENCY
• CHANGING REASONS FOR VISIT TO PRIMARY CARE OVER A 35-YEAR PERIOD
• INTERDISCIPLINARY PRIMARY CARE TEAM EXPERTISE AND DIABETES CARE MANAGEMENT IN COMMUNITY HEALTH CENTERS
• BARRIERS TO COLONOSCOPIC FOLLOW UP AFTER POSITIVE FIT OR MULTITARGET STOOL DNA TESTING
• PHARMACEUTICAL INDUSTRY INTERACTION IN UNITED STATES FAMILY MEDICINE RESIDENCIES CONTINUES TO DECREASE: A CERA STUDY
• ENGAGEMENT OF SMALL TO MEDIUM-SIZED PRIMARY CARE PRACTICES IN QUALITY IMPROVEMENT EFFORTS: A CROSS-SECTIONAL STUDY
• UPTAKE OF STATIN GUIDELINES TO PREVENT AND TREAT CARDIOVASCULAR DISEASE: A CALL TO GUIDELINE DEVELOPERS
• FEASIBILITY OF DISEASE-FOCUSED GROUP VISITS FOR ADVANCE CARE PLANNING AMONG PATIENTS WITH HEART FAILURE AND THEIR CAREGIVERS
• DO MEDICAL SCRIBES HELP PRIMARY CARE PROVIDERS MORE QUICKLY RESPOND TO OUT-OF-VISIT TASKS?
• DOCUMENTING NEW WAYS OF DELIVERING CARE UNDER OREGON'S ALTERNATIVE PAYMENT AND ADVANCED CARE MODEL
• ELECTRONIC HEALTH RECORD ALGORITHM DEVELOPMENT FOR PARTICIPANT RECRUITMENT USING COLONOSCOPY APPOINTMENT SCHEDULING
• U.S. PRIMARY CARE PHYSICIANS' VIEWPOINTS ON HPV VACCINATION FOR ADULTS 27-45 YEARS
• PARENTS' PERSPECTIVES ON THEIR CHILDREN'S HEALTH INSURANCE: PRE/POST AFFORDABLE CARE ACT
• SCREENING FOR DIABETIC RETINOPATHY WITH A NONMYDRIATIC ULTRA-WIDE-FIELD RETINA CAMERA BY FAMILY MEDICINE PHYSICIANS
• FOLLOW-UP MANAGEMENT OF PATIENTS WITH VENOUS THROMBOEMBOLISM
• MANAGEMENT OF ACUTE PULMONARY EMBOLISM: WHAT CAN PERT DO FOR YOU?
• MANAGEMENT OF EYE TRAUMA FOR NON-OPHTHALMOLOGY PROVIDERS
• ENSURING INFORMED DECISION MAKING FOR CANCER SCREENING
• HOW COMPREHENSIVE MEDICATION MANAGEMENT CONTRIBUTES TO FOUNDATIONAL ELEMENTS OF PRIMARY CARE
• METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS COLONIZATION IN THE COMMUNITY AND MORTALITY RISK AMONG ADULTS AGED 40-85
• CHALLENGES AND APPROACHES TO POPULATION MANAGEMENT OF LONG-TERM OPIOID THERAPY PATIENTS IN PRIMARY CARE
• ADVANCING THE PATIENT EXPERIENCE (APEX) IN COPD REGISTRY: STUDY DESIGN AND STRENGTHS
• HIGH-RISK, HIGHER-REWARD: SOCIAL INEQUALITIES FACING PRENATAL CARE PATIENTS IN FAMILY MEDICINE & OBSTETRICS AND GYNECOLOGY
• WHICH FAMILY PHYSICIANS SEE CHILDREN? A CROSS-SECTIONAL STUDY OF FACTORS ASSOCIATED WITH PEDIATRIC SCOPE OF CARE
• AWARENESS AND PREFERENCES FOR HEALTH CARE CHAPLAINCY SERVICES AMONG US ADULTS
• MARGARITA BURN: RECOGNITION AND TREATMENT OF PHYTOPHOTODERMATITIS
• INTEGRATING PHYSICAL THERAPISTS INTO PRIMARY CARE​
• IMPLEMENTING PRIMARY CARE MEDIATED POPULATION GENETIC SCREENING WITHIN AN INTEGRATED HEALTH SYSTEM
• HEEDING THE CALL FOR URGENT PRIMARY CARE PAYMENT REFORM: WHAT DO WE KNOW ABOUT HOW TO GET STARTED? 

POLICY BRIEF

Proportion of Family Physicians Caring for Children is Declining

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

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

Publication: November 13, 2020

Using data from 2014 to 2018, we found that the proportion of family physicians caring for children under age 5 and ages 5 to 18 has significantly declined. This has implications for the pediatric primary care workforce and may exacerbate inequities in access to care for pediatric patients in all geographies, particularly those in areas with a shortage of pediatricians. 

ORIGINAL RESEARCH

BRCA-Related Cancer Genetic Counseling is Indicated in More than 20% of Women Seeking Primary Care

Daniel J. Parente, MD, PhD

Corresponding Author: Daniel J. Parente, MD, PhD; University of Kansas Medical Center. Email: dparente@kumc.edu

Publication: November 13, 2020

Background: Guidelines updated by the United States Preventive Services Task Force (USPSTF) in 2019 recommend referral to genetic counseling for asymptomatic women that have a family history of cancers potentially associated with variants in the breast cancer type 1 and 2 susceptibility genes (BRCA1 and BRCA2). Methods: I performed a needs assessment for BRCA-related cancer genetic counseling among undifferentiated women seeking primary care at an urban, academic medical center with an underserved population. Adult, English-speaking women with outpatient primary care appointments were surveyed. Questions included personal and family history of potentially BRCA-related malignancies, history of genetic counseling and/or testing, and a version of the USPSTF-recommended Seven-Question Family History Screening (FHS-7) tool, modified to promote accessibility among women with low health literacy. Results: Out of 397 women, 97 women (24.4% ± 4.2%, 95% confidence interval) met criteria for referral to genetic counseling. Among women with referral indications, 80 women (82.4% ± 7.6%) had no prior contact with genetic counseling and/or testing services (comprising 20.1% ± 3.9% of all women surveyed). The most common indication for BRCA-related genetic counseling referral was family history of female breast cancer before age 50. Conclusions: The rate that undifferentiated women seeking primary care met 2019 USPSTF criteria for BRCA-related cancer genetic counseling referral (24.4% ± 4.2%) exceeds earlier estimates (4-5%) but agrees with later, population-level estimates (24.1%).  Health systems will need to appropriately allocate capacity to genetic counseling services and/or re-consider the appropriateness of FHS-7 as a primary care risk-stratification tool.

ORIGINAL RESEARCH

The Effect of Depression and Rurality on Glycemic Control in Adults with Diabetes

Helen Fu, PhD, RN; Victoria G. Skolnick, BA; Caroline Carlin, PhD; Leif Solberg, MD; Abagail M. Raiter, BA; Kevin A Peterson MD, MPH

Corresponding Author: Helen Fu, PhD, RN; University of Minnesota Medical School. Email: helen007@umn.edu

Publication: November 13, 2020

Background: Having depression and living in a rural environment have separately been associated with poor diabetes outcomes, but there little is known about the interaction between the two risk factors. This study investigates the association of depression and rurality with glycemic control in adults, as well as their interaction. Methods: This is a repeated cross-sectional study with data collected 2010-2017 (N=1,697,173 patient-year observations), comprising a near-complete census of patients with diabetes in Minnesota.  The outcome of interest was glycemic control defined as hemoglobin A1c under 8%. We used a logit model with clinic-level random effects to predict glycemic control as a function of depression, patient rurality, and their interaction, adjusted for differences in observed characteristics of the patient, clinic and patient’s neighborhood. Results: Having depression was associated with lower probability of achieving glycemic control (P<.001). Although rurality alone had no association with glycemic control, significant interactions existed between depression and rurality. Living in a small rural town mitigated the negative association between depression and glycemic control (P<.001). Conclusion: Although patients with depression had poorer glycemic control, living in a small rural town reduced the negative association between depression and glycemic control.

ORIGINAL RESEARCH

Cardiovascular Screening and Lipid Management in Breast Cancer Survivors: A Retrospective Case-Control Study

S Tucker Price, MD, PhD; Lisa D Mims, MD; Marty S Player, MD, MSCR; Carole Berini, MS; Suzanne Perkins, MPH; Chanita Hughes Halbert, PhD; Vanessa A Diaz, MD, MSCR

Corresponding Author: S Tucker Price, MD; Medical University of South Carolina. Email: marrison@musc.edu

Publication: November 13, 2020

Background: Cardiovascular disease (CVD) is the leading cause of death among breast cancer (BC) survivors. BC survivors are at increased risk of CVD due to a higher prevalence of risk factors. Current data is limited on the cardiovascular screening practices and lipid management in this population in primary care settings. Methods: A retrospective case control study was performed with 105 BC survivors and 210 matched controls (based on age and medical comorbidities of diabetes, hypertension, and hyperlipidemia). BC survivors were established with primary care practices within a large academic institution and had completed primary cancer treatment. Data on screening for CVD and lipid management were collected via a retrospective chart review. Results: The average BC survivor was 63 years old, with 9 years since diagnosis. Compared with matched controls, BC survivors had more cholesterol screening (88% vs. 70%, p<0.001) and active statin prescriptions (63% vs. 40%, p<0.05) if indicated by the Atherosclerotic Cardiovascular Disease Calculator. There were no differences in CVD screening in White and African American BC survivors. However, African American BC survivors were more likely to have hypertension (p<0.01) and have a body mass index in the overweight and obese category (p<0.001) than White BC survivors. Older breast cancer survivors were more likely to receive cholesterol screening. Discussion: This study demonstrates that BC survivors who have an established primary care provider have improved cholesterol screening and statin therapy based on their risk of developing chronic diseases.

ORIGINAL RESEARCH

Assessing Heart Disease in Large Population of Adults with Down Syndrome Between 1996–2016

V Fitzpatrick; A Rivelli; K Bria; B Chicoine

Corresponding Author: Veronica Fitzpatrick, DrPH, MPH; Advocate Lutheran General Hospital. Email: Veronica.fitzpatrick@advocatehealth.com

Publication: November 13, 2020

Purpose: To describe demographic factors and calculate prevalence of heart disease-related conditions among the adult Down syndrome (DS) sample population and 2) compare demographic and heart disease-related conditions between the DS sample population (N = 2342) and the general population. Methods: Utilizing a retrospective, descriptive cohort study design, analyses were based on 20 years of data collected on the Adult Down Syndrome Center patient population. Prevalence of heart disease, stroke and associated risk conditions are reported as counts (%) with corresponding odds ratio (OR) indicating odds of diagnosis among the DS sample compared to the general population. Corresponding Pearson Chisquare p-values were calculated to represent statistically significant differences between prevalence of diagnoses in the DS sample compared to the general population. In cases where prevalence was low, Fisher’s Exact Test p-value were calculated. Results: Adults with DS showed had lower odds of diagnosis of heart disease and most associated risk conditions, specifically coronary heart disease (OR=0.0537, p<0.0001), heart failure (OR=0.6353, p=0.0091), hypertension (OR=0.0325, p<0.0001), diabetes (OR=0.4840, p<0.0001), and high total cholesterol (OR=0.2086, p<0.0001), while experiencing higher odds of overweight status (OR=1.2185, p=0.0002) and obese status (OR=1.3238, p<0.0001). Conclusion: Adults with DS generally experience less heart disease and associated risk conditions commonly seen in the general population. Prevention and treatment guidelines for heart disease for the DS population should be adjusted after more research is conducted.

ORIGINAL RESEARCH

Glucosamine Chondroitin and Overall Mortality in a US NHANES Cohort

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

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

Publication: November 13, 2020

Purpose: To describe demographic factors and calculate prevalence of heart disease-related conditions among the adult Down syndrome (DS) sample population and 2) compare demographic and heart disease-related conditions between the DS sample population (N = 2342) and the general population. Methods: Utilizing a retrospective, descriptive cohort study design, analyses were based on 20 years of data collected on the Adult Down Syndrome Center patient population. Prevalence of heart disease, stroke and associated risk conditions are reported as counts (%) with corresponding odds ratio (OR) indicating odds of diagnosis among the DS sample compared to the general population. Corresponding Pearson Chisquare p-values were calculated to represent statistically significant differences between prevalence of diagnoses in the DS sample compared to the general population. In cases where prevalence was low, Fisher’s Exact Test p-value were calculated. Results: Adults with DS showed had lower odds of diagnosis of heart disease and most associated risk conditions, specifically coronary heart disease (OR=0.0537, p<0.0001), heart failure (OR=0.6353, p=0.0091), hypertension (OR=0.0325, p<0.0001), diabetes (OR=0.4840, p<0.0001), and high total cholesterol (OR=0.2086, p<0.0001), while experiencing higher odds of overweight status (OR=1.2185, p=0.0002) and obese status (OR=1.3238, p<0.0001). Conclusion: Adults with DS generally experience less heart disease and associated risk conditions commonly seen in the general population. Prevention and treatment guidelines for heart disease for the DS population should be adjusted after more research is conducted.

ORIGINAL RESEARCH

Predictors of Patient Retention in Medication-Assisted Treatment in a Family Medicine Residency Clinic

Kathryn Justesen, MD; Stephanie Hooker, PhD, MPH; Michelle D. Sherman, PhD, ABPP; Mary Lonergan-Cullum, PhD; Tanner Nissly, DO; Robert Levy, MD

Corresponding Author: Kathryn Justesen, MD; University of Minnesota Medical School. Email: gate0051@umn.edu

Publication: November 13, 2020

Purpose: Opioid use disorder is a prevalent and chronic condition that can lead to adverse outcomes if untreated. Medication-assisted treatment (MAT) with buprenorphine in a primary care setting has the potential to increase availability of treatment and reduce harm; however, retention in MAT is key for patient success. This study’s purpose was to examine predictors of retention in a MAT program for opioid use disorder (OUD) in a family medicine residency clinic. Methods: A retrospective chart review was conducted for 238 patients diagnosed with OUD and receiving MAT at a family medicine residency clinic between 2015-2017, with visit and prescription data collected through December 2018. Cox-proportional hazards models were used to examine the length of time in treatment. Results: Over three-fourths of our patients were retained for at least 3 months, 69% for at least 6 months, and 48% retained for at least one year. Physician continuity of care and having insurance coverage significantly predicted retention and longer duration of treatment. Conclusions: Continuity of care and having health insurance were key predictors of patient retention in MAT care. Our findings emphasize the clinical significance of maintaining physician continuity of care to improve retention of patients with OUD in MAT programs. Future research could explore what aspects of continuity of care lead to retention in OUD treatment.

ORIGINAL RESEARCH

Like a Double-Edged Sword: Physician Perspectives on Mammography Screening for Average-Risk Women

Sophia Siedlikowski; Roland Grad; Gillian Bartlett-Esquilant; Carolyn Ells

Corresponding Author: Sophia Siedlikowski; McGill University; Email: sophia.siedlikowski@mail.mcgill.ca  

Publication: November 13, 2020

Background: On balance, the benefits and harms of mammography screening put systematic screening for average-risk women into question. Since screening decisions frequently occur in primary care, it is important to understand what family physicians think of the evidence on mammography screening, and how they intend to use this information in practice. Methods: Using a cross sectional design, we obtained data from a group of physician participants who rated the daily POEM. POEMs (‘Patient Oriented Evidence that Matters’) are short research-based synopses. Physicians responded to closed and open-ended questions, based on the validated Information Assessment Method. Quantitative data were assessed with descriptive statistics. The qualitative data were subjected to inductive and deductive iterative thematic analysis. These data were organized into sub-themes, and then grouped into major themes. Results: Four relevant POEMs were identified. Each of these POEMs was rated by 1243 to 1351 physicians, and these ratings provided 310 comments. Three major themes emerged across all four POEMs: 1) Perspectives on information presented in POEMs, 2) Applying this information in practice, and 3) Confronting clinical and cultural realities. Our findings highlight important differences in the ways physicians value research-based information on mammography screening and use this information in their practice. Conclusions: Although POEMs about mammography screening raise awareness of harms and benefits, deeply rooted ideas illustrate how any change process is complex. In sum, rethinking breast cancer screening for average-risk women is challenging. 

ORIGINAL RESEARCH

Patient Characteristics Associated with Expectations of Opioid Prescriptions for Acute Pain Control in the Outpatient Setting

Eriko Onishi, MD; Jennifer Lucas, PhD; Tetsuro Maeno, MD, PhD; Steffani R. Bailey, PhD

Corresponding Author: Eriko Onishi, MD;  Oregon Health & Science University; Email: onishi@ohsu.edu  

Publication: November 13, 2020

Background: The prescription of opioids for acute pain may be a driving factor in chronic opioid abuse. We examined patients’ characteristics associated with the expectation of the receipt of opioid prescriptions for acute pain control. Methods: A one-time survey was administered to adult patients at Family Medicine clinics in the Pacific Northwest between November 2018-January 2019. Logistic regression modeled adjusted odds of expecting an opioid prescription in ≥3 of the 4 dispositional acute pain scenarios by patient demographics, opioid use, past-week pain intensity and duration, pastweek anxiety, and pain catastrophizing. Results: The survey was completed by 108 patients (62% female, 48% between 30-49 years of age, 75% non-Hispanic Whites). Most patients (71%) expected an opioid prescription in ≥1 of the four scenarios; 26% expected a prescription in ≥3 scenarios. Patients with higher levels of pain catastrophizing had more than three times greater odds of expecting opioids than those with lower pain catastrophizing (OR=3.73, p=0.032, 95%CI: 1.12-12.46); no other characteristics were statistically significant. Conclusion: Higher pain catastrophizing was associated with increased odds of expecting opioids in dispositional acute pain scenarios in outpatient settings. Future studies can determine if addressing pain catastrophizing reduces expectations of opioid prescribing for acute pain control. The finding that most patients expected opioid prescriptions in acute pain scenarios needs further exploration into other potential factors associated with these expectations. Evidence-based guidelines for condition-specific acute pain management are warranted for appropriate opioid prescribing and to guide treatment expectations. 

ORIGINAL RESEARCH

Having a Usual Source of Care is Associated with Longer Telomere Length in a National Sample of Older Adults

Peter Baltrus, PhD; Chaohua Li, MPH; Anne Gaglioti, MD, MS, FAAFP

Corresponding Author: Anne Gaglioti, MD, MS, FAAFP; Morehouse School of Medicine; Email: agaglioti@msm.edu  

Publication: November 13, 2020

Objective: To provide a potential biological mechanistic link for the well-established association between primary care access and reduced mortality, this study sought to measure the impact of having a usual source of healthcare on leukocyte telomere length (LTL). Data Sources: Our study population included 3,202 participants aged 50-84 years from National Health and Nutrition Examination Survey (NHANES) 1999-2001. Study Design: Cross sectional Study. LTLs between people with and without a usual source of care were compared using unadjusted and adjusted linear regression models. Fully adjusted models accounted for demographic characteristics, health status, and health behaviors. Principal Findings: After controlling for individual factors, health conditions, and health behaviors, people who had a usual source of healthcare had significantly longer LTL ( = 89.8 base pairs, p-value = 0.005) compared to those without a usual source of care; corresponding to approximately 7 years of life. Conclusions: Having a usual source of healthcare is associated with longer LTL among older adults. This study provides a potential biologic link for the noted association between primary care access and reduced mortality that has been observed at the individual and population level. 

ORIGINAL RESEARCH

Identifying Barriers to Patient Portals Access and Use: Evidence from the Health Information National Trends Survey, 2017-2018

Sherine El-Toukhy, PhD, MA; Alejandra Méndez, MPH; Shavonne Collins, BS; Eliseo J. Pérez-Stable, MD

Corresponding Author: Sherine El-Toukhy, PhD, MA; National Institutes of Health; Email: sherine.el-toukhy@nih.gov

Publication: November 13, 2020

Background: Patient access to their medical records, through patient portals, facilitates information exchange and provision of quality healthcare. Understanding factors that characterize patients with limited access to and use of patient portals is needed. Methods: Data were from the 2017-18 Health Information National Trends Survey 5, cycles 1 and 2, a nationally representative survey of US adults ≥18 years old (N=6,789). Weighted multivariate logistic regressions modeled the associations between patient characteristics and access to, facilitators of use, and use of patient portals and their functions. Results: Individuals without (vs. with) a regular doctor (AOR 0.4, CI 0.3-0.5) or health insurance (AOR 0.4, CI 0.2-0.7), those with high school (AOR 0.4, CI 0.3-0.5) or with vocational/some college (AOR 0.5, CI 04.-0.7) education (vs. college/ postgraduate), or those with limited English proficiency (vs. those who speak English very well) (AOR 0.7, CI 0.5-0.9) were less likely to report accessing their personal medical records. Women (vs. men) were more likely to report accessing their medical records (AOR 1.5, CI 1.2-1.8). Similar patterns were found for patient portals access and facilitators of use. Less consistent associations emerged between patient characteristics and use of patient portal functionalities. Conclusions: Patient portals access and use are low. Having a primary care clinician, patient’s educational attainment, and being a woman were factors associated with patient portal access and use, but not race/ethnicity. Once access was achieved, use of patient portal functionalities was generally uniform across demographic segments. Facilitating patient portal access and use among all patient populations is warranted.

ORIGINAL RESEARCH

Improving COPD Symptoms Using a Team-Based Approach in an Appalachian Population

Shaylee Peckens, MD; Megan M. Adelman, PharmD; Amie M. Ashcraft, PhD, MPH; Jun Xiang, MS; Brittany Sheppard; Dana E. King, MD, MS

Corresponding Author: Amie M. Ashcraft, PhD, MPH; West Virginia University School of Medicine; Email: amashcraft@hsc.wvu.edu

Publication: November 13, 2020

Chronic obstructive pulmonary disease (COPD) is the third leading cause of death in the United States (US), with West Virginia bearing a disproportionate disease burden. Complex COPD cases can be difficult to manage during a standard primary care provider (PCP) visit, and pharmacological treatment regimens should be individually tailored to each patient. To address these needs, the West Virginia University Department of Family Medicine created an interdisciplinary COPD specialty clinic that uses a team-based approach to treat patients with COPD. In order to evaluate the effectiveness of the specialty clinic, we conducted a retrospective chart review to examine the impact of the clinic on patient hospitalizations, emergency department visits, and urgent care visits six months and one year before and after initiating care at the clinic. We also examined the impact of the clinic on patients’ self-reported nicotine dependency, COPD symptoms, and tobacco use behavior. Patients referred to the clinic and having at least one visit from February 2015 to February 2019 were included in this study (n=149). Patients treated at the COPD specialty clinic had significantly fewer hospital admissions and ED visits six months after and one year after initiating care at the clinic as compared to six months before and one year before, respectively. Patients at this clinic also reported smoking significantly fewer cigarettes per day with significantly fewer self-identifying as smokers, and experiencing significantly reduced COPD symptoms. An interdisciplinary, teambased approach was effective for improving the health of COPD patients in an Appalachian academic primary care practice. 

ORIGINAL RESEARCH

The Prevalence of Behavioral Health Problems Among Adults with and without Communication Disabilities

Michelle L. Stransky, PhD; Jennifer Y. Oshita, MS, CCC-SLP; Megan A. Morris, PhD, MPH, CCC-SLP

Corresponding Author: Michelle L. Stransky, PhD; Boston Medical Center; Email: michelle.stransky@bmc.org

Publication: November 13, 2020

Background: Adults with communication disabilities (CD) experience poor health and healthcare outcomes. Few studies have examined behavioral health outcomes among this population. We compare the behavioral health of adults with CDs to their peers without such disabilities. Methods: Retrospective cohort study examining the 2012 National Health Interview Survey Voice, Speech, and Language Supplement. We compared adults (>17 years old) with voice only (n=2,169), speech/language (SL) only (n=730), and speech/language and voice (SLV; n=450) disabilities to adults without CDs (n=29,873). Outcomes include behavioral health diagnoses (eg, depression), substance misuse (eg, excessive alcohol or tobacco use), experiences (eg, nonspecific psychological distress), and healthcare utilization. Unadjusted Pearson’s chi square and adjusted logistic regression analyses controlling for sociodemographic, health, and other disability measures were conducted. Results: Adults with CDs more frequently reported diagnoses (7.1-35.9% vs. 1.8-8.6%), substance misuse (SL only: 15.5% vs. 5.5% ), and non-specific psychological distress (SL only: 14.7%, SLV: 22.3% vs. 2.3%) compared to adults without CDs (all P<0.001). These findings were consistent for all outcomes and in multivariate analyses. Odds ratios ranged from 1.4 (99.7% CI: 1.1-1.7) to 5.0 (99.7% CI: 3.6-6.8). Adults with CDs more frequently endorsed visiting mental health professionals compared to adults without CDs (voice only: 11.4%, SL only: 19.1%, SLV: 23.1%; vs 6.8%, all P<0.001), but these differences became non-significant in multivariate analyses. Conclusions: Adults with CD experience poorer behavioral health and healthcare outcomes compared to persons without CDs. Barriers to identification and treatment related to CDs must be addressed for persons with CDs.

ORIGINAL RESEARCH

Reliability of Peer Review of Abstracts Submitted to Academic Family Medicine Meetings

Joshua J. Fenton, MD, MPH; Hazel Tapp, PhD; Netra M. Thakur, MD, MPH, FAAFP; Andrea L. Pfeifle, EdD, PT, FNAP

Corresponding Author: Joshua J. Fenton, MD, MPH; UC Davis Medical Center; Email: jjfenton@ucdavis.edu

Publication: November 13, 2020

Purpose: To assess the reliability of peer review of abstracts submitted to the academic family medicine meetings in North America. Methods: We analyzed reviewer ratings of abstracts submitted: 1) as oral presentations to the North American Primary Care Research Group (NAPCRG) meeting from 2016-2019, as well as 2019 poster session or workshop submissions; and 2) in 12 categories to the Society of Teachers of Family Medicine (STFM) Spring 2018 meeting. In each category and year, we used a multi-level mixed model to estimate the abstract-level intraclass correlation coefficient (ICC) and the reliability of initial review (using the abstract-level ICC and the number of reviewers per abstract). Results: We analyzed review data for 1,554 NAPCRG oral presentation abstracts, 418 NAPCRG poster or workshop abstracts, and 1,145 STFM abstracts. Across all years, abstract-level ICCs for NAPCRG oral presentations were below 0.20 (range: 0.10 in 2019 to 0.18 in 2016) and were even lower for posters and workshops (range: 0.00-0.10). After accounting for the number of reviewers per abstract, reliabilities of initial review for NAPCRG oral presentations ranged from 0.24 in 2019 to 0.30 in 2016 and 0.00 to 0.18 for posters and workshops in 2019. Across 12 STFM submission categories, the median abstract-level ICC was 0.21 (range: 0.12-0.50) and the median reliability was 0.42 (range: 0.25- 0.78). Conclusions: For abstracts submitted to North American academic family medicine meetings, inter-reviewer agreement is often low, compromising initial review reliability. For many submission categories, program committees should supplement initial review with independent post-review assessments. 

ORIGINAL RESEARCH

Medicare Access and CHIP Reauthorization Act: A Qualitative Study in Sixteen Small to Medium-Sized Primary Care Practices in Virginia

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

Corresponding Author: Tulay G. Soylu, PhD, MHA, MBA; George Mason University; Email:  tsoylu@gmu.edu

Publication: November 13, 2020

Background: Despite major efforts to transition to a new physician payment system under the Medicare Access and CHIP Reauthorization Act (MACRA), little is known about how well practices are prepared. This study aimed to understand how small and medium-sized primary care practices in the Heart of Virginia Healthcare perceive their quality incentives under MACRA. Methods: This study analyzed data from 16 focus groups (70 participants), which yielded a range of physician, advanced practice clinician, office manager, and staff perspectives. Focus groups were audio-recorded and transcribed, then imported into NVivo for coding and analysis of themes. A multidisciplinary research team reviewed the transcripts to maximize coding insights and to improve validity. Results: The main findings from the focus groups are: (1) MACRA awareness is relatively higher in independent practices; (2) steps taken toward MACRA differ by practice ownership; (3) practices have mixed perceptions about the expected impact of MACRA. Two additional themes emerged from data: (1) practices that joined accountable care organizations are taking proactive approaches to MACRA; (2) independent practices face ongoing challenges. Conclusions: This study highlights a dilemma in which independent practices are proactively attempting to prepare for MACRA’s requirements, yet they continue to have major challenges. Practices are under extreme pressure to comply with reimbursement regulations, which may force some practices joining a health system or merging with another practice or completely closing the practices. Policymakers should assess the unintended consequences of payment reform policies on independent practices and provide support in transitioning to a new payment system.

ORIGINAL RESEARCH

Educating Patients on Unnecessary Antibiotics: Personalizing Potential Harm Aids Patient Understanding

Benjamin J. Miller; Kathryn A. Carson, ScM; Sara Keller, MD, MPH, MSPH

Corresponding Author: Sara Keller, MD, MPH, MSPH; Johns Hopkins Medicine; Email: Bmille91@jhmi.edu

Publication: November 13, 2020

Introduction: Antibiotic resistance is a public health emergency fueled by inappropriate antibiotic use. Public education campaigns often focus on global antibiotic resistance or societal harm of antibiotic misuse. There has been little research into what messages have the greatest impact on patient preferences for non-indicated antibiotics in ambulatory clinics. Methods: We administered a survey at a primary care clinic in Baltimore, MD. 250 participants rated 18 statements about potential harm from antibiotics on how each statement changed their likelihood to request antibiotics for an upper respiratory tract infection (URI). Statements focused on potential harm either to the individual, to contacts of the individual, to society, and related or not to antibiotic resistance. Initial and final likelihood of requesting antibiotics was measured, and the impact of the statements in each category were compared using general linear models and Wilcoxon rank sum or Kruskal-Wallis tests. Results: All statements decreased patient likelihood to request antibiotics. Statements about harm to the individual or contacts of the individual decreased participant likelihood to request antibiotics significantly more than statements about societal harm of antibiotic misuse. Statements not discussing antibiotic resistance decreased participant likelihood of requesting antibiotics significantly more than statements discussing antibiotic resistance. Overall likelihood to request antibiotics decreased after the survey by 2.2 points on an 11-point Likert scale (p<0.001). Conclusion: When dissuading patients from requesting non-indicated antibiotics, providers and public health campaigns should focus on potential harm of non-indicated antibiotics to the individual rather than societal harm or antibiotic resistance.

ORIGINAL RESEARCH

Association of Patient-Provider Teach-Back Communication with Diabetic Complications, Hospitalization, and Health Expenditures among Individuals with Diabetes: A Population-Based Cohort Study

Young-Rock Hong, PhD, MPH; Jinhai Huo, PhD, MD, MSPH; Ara Jo, PhD, MS; Michelle Cardel, PhD, MS, RD; Arch G. Mainous III, PhD

Corresponding Author: Young-Rock Hong, PhD, MPH; University of Florida; Email: youngrock.h@phhp.ufl.edu

Publication: November 13, 2020

Background and Objectives: The purpose of this study is to examine the patterns of patient teach-back experience (also known as “interactive communication loop”) and determine its association with risk for diabetic complications and hospitalization, and health expenditures among individuals with diabetes. Methods: A retrospective cohort study of 2,901 US adults aged 18 or older with a confirmed diagnosis of diabetes was conducted using data from the 2011-2016 Longitudinal Medical Expenditure Panel Survey. Survey-design adjusted multivariable models were used to examine whether having patient teach-back experience at the baseline year (Year 1) is associated with development of diabetic complications, hospitalization, and health expenditure at follow-up year (Year 2). Health expenditures were adjusted for inflation and expressed in 2017 US dollars. All adjusted models included patient sociodemographic and clinical characteristics. Results: Analyses found that patients with teach-back experience were less likely to develop diabetic complications (adjusted OR: 0.70, 95% CI: 0.52-0.96) and be admitted to the hospital due to diabetic complications (adjusted OR: 0.51, 95% CI: 0.29-0.88) at one-year follow-up. Patients having teach-back experience also had a significantly smaller increase in total expenditures of $1,920 compared with those not having teach-back of $3,639 (a differential change of -$1,579 [95% CI, -$1,717 to -$1,443], P<.001). Conclusions: Teach-back could be an effective communication strategy that has potential to improve health outcomes, resulting in savings in diabetes care.

BRIEF REPORT

Electronic Health Record Reminder Effect on Hepatitis C Antibody Screening

Elie Mulhem; Indigo Brown; Ke Song

Corresponding Author: Elie Mulhem; Oakland University William Beaumont School of Medicine. Email: Elie.mulhem@beaumont.edu

Publication: November 13, 2020

In the United States, national guidelines recommend screening adults born between 1945 and 1965 for hepatitis C, but screening rates in this population continue to be low. We added a hepatitis C screening reminder to the Epic Electronic Health Record and educated physicians on the use of Health Maintenance section of Epic. We assessed the effect of this intervention on the completion of screening hepatitis C antibody tests. We examined data from two years before and after the addition of the reminder. Completed hepatitis C antibody testing increased from 733 to 6502, and the rate of positive testing decreased from 5.9% to 2.0%. Implementing the electronic health record reminder and educating providers on the routine use of the Health Maintenance section increased hepatitis C screening for at risk adults. 

BRIEF REPORT

Examining Diabetics’ Knowledge and Understanding of the Bi-Directional Relationship Between Diabetes and Periodontal Disease

Oluwamurewa Oguntimein, PhD, MHS, CHES; James Butler III, DrPH, MEd; Sharon Desmond, PhD; Kerry M. Green, PhD; Xin He, PhD; Alice M. Horowitz, PhD

Corresponding Author: Oluwamurewa Oguntimein, PhD, MHS, CHES; University of Maryland; Email: murewa.oguntimein@gmail.com 

Publication: November 13, 2020

Introduction: There is a paucity of research on awareness, education, and interventions that address increased risk of developing periodontal disease, the sixth complication of diabetes. Examining diabetics’ knowledge and understanding of the bidirectional relationship between periodontal disease and diabetes could inform future diabetes self-management care. We assessed diabetics’ knowledge and understanding of the bi-directional relationship between diabetes and periodontal disease; examined gender, education and income differences in this knowledge and understanding, as well as other differences in dental hygiene practices. Methods: A web-based survey was conducted using a convenience sample of diabetics. Results: A total of 927 diabetics participated in the study. Gender and education were significantly associated with diabetics’ knowledge and understanding of the bidirectional relationship between diabetes and periodontal disease. After controlling for diabetes duration, dental insurance status, and other covariates, males had less knowledge and understanding of the bi-directional relationship between diabetes and periodontal disease compared to females (p<.0001). Those with higher education (p<.002) and those who received healthcare provider recommendations to obtain regular dental visits (p<.00001) had greater understanding of the association between diabetes and periodontal disease. Conclusions: This study highlights the need for: 1) educating male and low education diabetics in particular about their increased risk of periodontal disease and the need for regular dental visits; and, 2) healthcare providers and dental health providers to work together to address the needs of their diabetic patients.

BRIEF REPORT

The Golden Letter: Innovation Collaboration to Reduce Avoidable Hospital Admissions

Mruga Nanavati, Stephen Saenz, Kiersten Swayne, and Peter Carek

Corresponding Author: Mruga Nanavati; University of Florida; Email: mruga.13@gmail.com

Publication: November 13, 2020

Purpose: Emergency Department (ED) over-utilization and avoidable hospital admissions have been identified as areas of improvement. Studies have shown that ensuring adequate primary care follow-up after discharge from ED is an area that can be targeted to help decrease hospitalizations. Methods: Between April 2017 and December 2018, any family medicine patient presented by the ED for admission who was determined to be a candidate for rapid primary care follow-up, was offered a “Golden Letter.” This letter guaranteed that the patient would be evaluated within 48 hours of discharge at one of our clinics. We studied the impact on reducing hospital admissions, 30-day ED revisits, and 30-day hospitalizations. Our data analysis included gender, age, and insurance status. Results: A total of 191 ED encounters that may have been admitted to the hospital were instead given a golden letter after shared decision making. 104 (54.5%) completed a follow-up appointment within 48 hours. The 30-day ED revisit rate was 34% (65 encounters) with 33 (31.7%) of these patients having completed a follow-up visit and 32 (36.8%) did not follow-up. There were 35 (18.3%) hospital admissions within 30 days of the ED visit. Of the patients admitted, 12 (11.5%) completed a follow-up visit and 23 (26.4%) did not complete a follow-up visit. Conclusion: This initiative effectively reduced the number of low-acuity admissions and 30-day hospitalizations. This concept can provide a significant reduction of healthcare resource utilization and cost by ensuring safe ED discharge and rapid outpatient follow-up for low-acuity patients. 

BRIEF REPORT

An Evidence-Based, Systematic Approach to Opioid Prescribing

Kelly Bossenbroek Fedoriw, MD; Amy Prentice, MSW, LCSW; Sue Slatkoff, MD; Linda Myerholtz, PhD

Corresponding Author: Kelly Bossenbroek Fedoriw, MD; University of North Carolina at Chapel Hill; Email: kelly_fedoriw@med.unc.edu

Publication: November 13, 2020

Background and Objectives: Opioid misuse has become a national crisis. In response to the need for improved standards of opioid prescribing within medical practices, a university-based academic family medicine practice developed, implemented, and evaluated a series of initiatives to ensure appropriate opioid prescribing and support clinicians in the practice in providing optimal care. Methods: In 2015-8 the University of North Carolina Family Medicine Center developed and implemented a practice-wide opioid prescribing policy, created a Controlled Medication Advisory Board (CMAB), provided regular feedback to clinicians on opioid prescribing, and trained selected providers in management of opioid use disorder. The impact of these opioid stewardship initiatives on prescribing patterns, utilization of the CMAB, and provision of medications for opioid use disorder was evaluated using electronic health record data from 2015-2018 and chart audits. Results: Between 2014 and 2018 the opioid prescribing rate per 100 patient visits decreased by 31% and the rate of concomitant use of benzodiazepines and opioids decreased by 56%. The CMAB received 117 referrals between 2015 and 2018, 60% of which resulted in recommended revision in the treatment plan. Conclusions: Safe opioid prescribing is essential to mitigate the opioid crisis. An evidence-based standardized protocol, coupled with support for providers and patients, Abstract can reduce prescribing and improve patient safety, thereby enhancing the comprehensiveness and quality of patient care.

BRIEF REPORT

Opioid Use Disorder Education and Waiver Provision During Residency: Impact on Future Prescribing Patterns

Victoria Boggiano, MD, MPH; Courtenay Gilmore Wilson, PharmD, BCACP, CPP; E. Blake Fagan, MD; Julienne Kirk, PharmD; Kelly Bossenbroek-Fedoriw, MD; Casey R Tak, PhD, MPH

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

Publication: November 13, 2020

Background: Family medicine residency programs vary in the extent of training offered on opioid use disorder (OUD) in their curricula. The purpose of this study was to determine the impact of OUD education and buprenorphine waiver provision on post-residency buprenorphine prescribing patterns. Methods: Three North Carolina family medicine residency programs differed in the extent to which they taught OUD, including buprenorphine waiver provision. Program A required OUD education and assisted residents in obtaining a waiver; Program B offered OUD education and did not assist with obtaining a waiver; and Program C did not offer OUD education. In November 2019, graduates from these three programs were surveyed regarding the extent to which they engaged in treatment of OUD. Descriptive statistics were used to characterize the survey participants and their responses. Results: Of the 62 graduates invited to participate, 49 (79.0%) responded. Across the three programs, the percentage of graduates with a waiver varied significantly (p-value < 0.0001): Program A (84.2%), Program B (33.3%), and Program C (0.0%).  Of those who were not waivered, Program B had a larger percentage that desired to prescribe buprenorphine products (70.0%) as compared to Program C (9.1%) (p-value = 0.009). Conclusions: Family medicine residency graduates from programs with more integrated OUD education were more likely to obtain and utilize a waiver to prescribe buprenorphine-containing medications post-graduation.

RESEARCH LETTER

A Proposed Opioid Tapering Tool

Benjamin Lai, MB, BCh, BAO, MSc; Daniel Witt, BS; Thomas Thacher, MD; Terrence Witt, MD

Corresponding Author: Benjamin Lai, MB, BCh, BAO, MSc; Mayo Clinic, Rochester, MN; Email: lai.benjamin@mayo.edu 

Publication: November 13, 2020

Introduction: Previous studies suggest a lack of confidence among primary care providers in managing patients on chronic opioid therapy (COT) for chronic non-cancer related pain (CNCP). The US Department of Health and Human Services (HHS) recently introduced guidelines on opioid tapering. In light of these recommendations, our group developed an opioid tapering software to assist healthcare providers in managing patients on COT. Methods: The initial iteration of our software utilizes RedCap for the application programming interface (API). This tool is designed to reduce a patient’s prescribed chronic opioids by 5-10% every month, or 5 morphine milligram equivalents per day (MMED), whichever is the greatest, in line with HHS guidelines. Users can also adjust the rate of taper. Discussion: Our group plans to use this software in an upcoming pilot study to taper patients on COT for CNCP. We are exploring the possibility of transitioning our software into other available APIs with the goal of integrating this software into major electronic health record systems. Our group envisions that our software will provide an additional tool within a patient-centered, multi-modal framework in managing patients on COT for CNCP. 

RESEARCH LETTER

Dermoscopy in the Primary Care Setting: Perspectives, Attitudes, and Perceptions

Natalie M. Williams, BS; Ashfaq A. Marghoob, MD; Elizabeth Seiverling, MD; Richard Usatine, MD; Darren Tsang, MD, MPH; Natalia Jaimes, MD

Corresponding Author: Natalia Jaimes, MD; University of Miami Miller School of Medicine; Email: njaimes@med.miami.edu

Publication: November 13, 2020

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: TBD

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

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: TBD

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

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: TBD

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

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: TBD

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

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: TBD

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: TBD

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. 

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: TBD

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.

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: 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.

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: TBD

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

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: TBD

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

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: TBD

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

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: TBD

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

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: TBD

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

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: TBD

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

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: TBD

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

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: TBD

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

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: TBD

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.

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: TBD

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.

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

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: TBD

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

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: TBD

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

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: TBD

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

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: TBD

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

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 preventative 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 preventative 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 preventative 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.

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: TBD

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: TBD

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.

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