Abstracts In Press

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

WELL-BEING OF THE HEALTH CARE TEAM - SPECIAL ISSUE (Publication Date: May 8, 2020)

PRACTICE-BASED RESEARCH 2020 - SPECIAL ISSUE (Publication Date: TBD)

OTHER MANUSCRIPTS ACCEPTED FOR PUBLICATION (Publication Date: TBD)

POLICY BRIEF

Burnout Among Family Physicians by Gender and Age

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

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

Publication: May 8, 2020

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

ORIGINAL RESEARCH

Joy in Work For Clinicians and Staff: Identifying Remedial Predictors of Burnout from the Mini-Z Survey

Niharika Khanna, MD, MBBS, DGO; Russ Montgomery, PhD; Elena Klyushnenkova, PhD

Corresponding Author: Niharika Khanna, MD, MBBS, DGO; University of Maryland School of Medicine. Email:  nkhanna@som.umaryland.edu

Publication: May 8, 2020

Purpose: The CMS Transforming Clinical Practice Initiative (TCPI) provided practice transformation supports to practices including coaching and learning sessions. Maryland ambulatory practices participated in the Garden Practice Transformation Network (GPTN) project as a part of the TCPI, and assessment of practices included a measure of burnout and joy in work. The goal of this study was to identify remediable predictors of burnout among GPTN-Maryland practices. Methods: Prevalence of burnout and potential burnout drivers were surveyed in the clinicians and staff using a modified Mini Z tool. Burnout drivers significantly associated with burnout symptoms were used to create a continuous 100-point score. Association between presence of burnout and burnout drivers was assessed using a Generalized Estimating Equation regression model for ordinal outcome to account for the correlation of the responses within the same practice. Results: Data from 166 responses were analyzed. Prevalence of burnout symptoms was 22%, with 35% enjoying their work. Time Constraints/Teamwork (T/T) score was constructed using factors significantly associated with burnout symptoms. T/T score increase by 1 unit was associated with 10% increase in the odds of moving from the group experiencing burnout or stress to the group who found ‘Joy in work’ (OR =1.1, 95% CI 1.07, 1.13, p<0.0001). Conclusions: The Mini Z-derived T/T score could be useful for quick assessment of the degree of burnout and identifying burnout drivers related to effective organizational structure and supportive teamwork in practice personnel. The data could be used as a starting point for change to reduce burnout in practices.

ORIGINAL RESEARCH

Team Configurations, Teamwork Efficiency and Family Physician Burnout    

Mingliang Dai, PhD; Rachel Willard-Grace, MPH; Margae Knox, MPH; Samantha A. Larson, MPH; Michael K. Magill, MD; Kevin Grumbach, MD; Lars E. Peterson, MD, PhD

Corresponding Author: Mingliang Dai, PhD; American Board of Family Medicine. Email: mdai@theabfm.org

Publication: May 8, 2020

Introduction: The delivery of team-based care relies on team structure and teamwork. Little is known about the landscape of team configurations in family medicine practices in the U.S. Teamwork between diverse team members likely impacts both performance and physician well-being. We examined team configuration and teamwork and whether they are associated with family physician well-being. Methods: We used data from practice demographic questionnaires completed by FPs who registered for the American Board of Family Medicine Family Medicine Certification Examination in 2017 and 2018. We grouped 14 types of health care professionals into MA/nurse, NP/PA, and specialist, and characterized 3 common team configurations. We used FPs’ subjective ratings to measure perceived teamwork efficiency and a validated single-item measure to identify FPs who were burned out. Results: Among 2,575 FPs in our sample, 22% worked collaboratively with MA/nurse only, 40% with MA/nurse, NP/PA or specialist, 38% with MA/nurse, NP/PA and specialist. The distribution of perceived teamwork efficiency was not statistically different across team configurations. In teams with greater perceived teamwork efficiency, FPs were less likely to be burned out. For FPs working with expansive teams, optimal perceived teamwork efficiency was associated with significantly reduced odds of burnout after controlling for practice and physician characteristics. Conclusion: Most FPs practice in multidisciplinary teams. Regardless of the team structure, FPs who perceived their teams as having greater efficiency were less likely to be burned out. We found that optimal perceived teamwork efficiency was associated with significantly reduced odds of burnout for FPs in all types of team configurations. Improving teamwork efficiency may be an effective strategy for practice organizations to support not only team functioning, but also physician well-being. 

ORIGINAL RESEARCH

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

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

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

Publication: May 8, 2020

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

ORIGINAL RESEARCH

Characterization of Burnout Among Spanish Family Physicians Treating Fibromyalgia Patients: The EPIFFAC Study

Xavier Torres, PhD; Begoña Ojeda, PhD; Antonio Collado, MD, PhD; Jesús Vergara, MD; Emili Gómez, MD; Xavier Castells, MD, PhD; Anna Arias, BSc

Corresponding Author:  Begoña Ojeda, PhD;  Hospital Clínic de Barcelona. Email: begona.ojedaballesteros@gmail.com      

Publication: May 8, 2020

Objective: Burnout among physicians has increased, affecting not only doctors but also the quality of patient care. Treating challenging disorders, such as fibromyalgia, may increase the risk of feeling burned out. Healthcare of fibromyalgia patients is increasingly being assigned to Family Physicians. Therefore, we described the demographic characteristics, work contexts, component burnout scores (exhaustion, depersonalization, personal accomplishment), and perceptions of fibromyalgia care between Spanish Family Medicine physicians with high and low levels of burnout. We then evaluated which of these variables were associated with having high or low levels of burnout. Method: This cross-sectional study assessed 506 Family Physicians recruited from the Spanish Society of Family Physicians, and randomly selected from Primary Health Care Centers. The subgrouping of Family Physicians based on their burnout scores was assessed by cluster analysis. Variables showing statistically significant differences between clusters, and significance below 0.25 in univariate logistic regressions were assessed by multivariate logistic regression analysis. Results: Family Physicians reporting higher burnout scores (25%) felt that fibromyalgia patients on sick leave increased their workload, reported no support from nurses in the treatment of fibromyalgia patients, and had a more negative impression of fibromyalgia patients. Conclusions: A quarter of Family Physicians reported feeling exhausted, detached from fibromyalgia patients, or less professionally accomplished. Several personal characteristics and contextual variables increased burnout. Several interventions to modify these variables and thus protect Family Physicians treating fibromyalgia from burnout are suggested.

BRIEF REPORT

Improving Resilience and Combating Burnout in US Army Health Care Teams

Alyssa M. Coleman, MPH, CPH; Meredith M. Hartzell, PhD; Robert C. Oh, MD, MPH; Tamara S. Funari, RN, MSN, MMAS, ACNS-BC; L. Omar Rivera, PhD; Jill A. Brown, PhD 

Corresponding Author:  Jill A. Brown, PhD;  Army Public Health Center. Email: jill.a.brown26.civ@mail.mil 

Publication: May 8, 2020

Introduction: In 2015, the Army Office of the Surgeon General (OTSG) adapted a Veterans Health Administration course for healthcare teams to implement holistic health practices to improve resiliency of healthcare teams and patient care.  The Army course, Move to Health (M2H), was piloted in healthcare teams at 8 military clinics.  During the 20-hour course, healthcare teams learned techniques to improve their resiliency and created action plans to incorporate holistic health into the workplace, a known factor in decreasing burnout. Methods: A process and outcome evaluation of this course was conducted using a within-group design.  Surveys were administered to healthcare teams at pre-course  and two-month follow-up, 186 participants completed both surveys. Results: Burnout among team members did not significantly change from pre-course (52%, n = 96) to follow-up (48%, n = 90).  At follow-up, team members described using resiliency building strategies for self-care, significantly improved their self-efficacy to treat patients holistically in the patient centered care home (PCMH) model, and reported increased satisfaction with PCMH (all ps < 0.01).  However, 70% (n = 131) of team members reported that they had not completed action plan implementation and did not report improved job satisfaction. Discussion: Informed by the literature, M2H combines an individual resiliency intervention with organizational change-facilitating action plans to mitigate burnout. This manuscript explores potential reasons for why burnout did not significantly change within the two-month period following the intervention.  Reducing burnout among healthcare teams is vital to ensuring optimal healthcare is provided to the military and its beneficiaries.

BRIEF REPORT

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

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

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

Publication: May 8, 2020

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

RESEARCH LETTER

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

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

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

Publication: May 8, 2020

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

ORIGINAL RESEARCH

Automated Identification of Unhealthy Drinking: a Machine Learning Approach

Levi N. Bonnell, MPH; Benjamin Littenberg, MD; Safwan R. Wshah, PhD; Gail L. Rose, PhD

Corresponding Author: Levi N. Bonnell, MPH; University of Vermont College of Medicine. Email: levi.bonnell@med.uvm.edu

Publication: May 8, 2020

Introduction: Unhealthy drinking is prevalent in the United States, yet it is under-identified and under-treated. Identifying unhealthy drinkers can be time-consuming and uncomfortable for primary care providers. An automated rule for identification would focus attention on patients most likely to need care and therefore increase efficiency and effectiveness. The objective of this study was to build a clinical prediction tool for unhealthy drinking based on routinely available demographic and laboratory data. Methods: We obtained 38 demographic and laboratory variables from the National Health and Nutrition Examination Survey (NHANES) (1999-2016) on 43,545 nationally representative adults who had information on alcohol use available as a reference standard. Logistic regression, support vector machines, k-nearest neighbor, neural networks, decision trees, and random forests were used to build clinical prediction models. The model with the largest area under the receiver operator curve (AUC) was selected to build the prediction tool. Results: A Random Forest model with 15 variables produced the largest AUC (0.78) in the test set. The most influential predictors were age, current smoker, hemoglobin, gender, and high-density lipoprotein. The optimum operating point had sensitivity 0.50, specificity 0.86, Positive Predictive Value 0.55, and Negative Predictive Value 0.83. Application of the tool resulted in a much smaller target sample (75% reduced). Conclusion: Using commonly available data, a decision tool can identify a subset of patients who appear to warrant clinical attention for unhealthy drinking, potentially increasing the efficiency and reach of screening.

ORIGINAL RESEARCH

Building Novel Models to Identify Census Tracts for Hepatitis C Virus Screening Interventions    

Thomas Ludden, PhD; Lindsay Shade, PA-C; Jeremy Thomas, MSW; Brisa Urquieta de Hernandez, BUS; Sveta Mohanan, MD; Mark W Russo, MD; Michael Leonard, MD; Philippe J. Zamor, MD; Charity G. Patterson, PhD; Hazel Tapp, PhD

Corresponding Author: Thomas Ludden, PhD; Atrium Health. Email: Tom.ludden@atriumhealth.org

Publication: May 8, 2020

Background: Increased screening efforts and the development of effective antiviral treatments have led to marked improvement in Hepatitis C (HCV) patient outcomes. However, many people in the US are still believed to have undiagnosed HCV. Geospatial modelling using variables representing at-risk populations in need of screening for HCV and social determinants of health (SDOH) provide opportunities to identify populations at-risk of HCV. Methods: A literature review was conducted to identify variables associated with patients at-risk for HCV infection. Two sets of variables were collected: HCV Transmission Risk and SDOH Level of Need. The variables were combined into indices for each group and then mapped at the census tract level (N=233). Multiple linear regression analysis and Pearson correlation coefficient were used to validate the models. Results: 4 HCV Transmission Risk variables and 12 SDOH Level of Need variables were identified. Between the two indexes, 21 high-risk census tracts were identified that scored at least 2 standard deviations above the mean. The regression analysis showed a significant relationship with HCV infection rate and prevalence of drug use (B=0.78, p<0.001). A significant relationship also existed with the HCV infection rate for households with no/limited English use (B=-0.24, p=0.001), no car use (B=0.036, p<0.001), living below the poverty line (B=0.014, p=0.009), and median household income (B=-0.00, p=0.009). Conclusions: Geospatial models identified high priority census tracts that can be used to map high-risk HCV populations that may otherwise be unrecognized. This will allow future targeted screening and linkage-to-care interventions for patients at high-risk of HCV.

ORIGINAL RESEARCH

Subjective and Objective Assessment of Cognitive Functioning in Primary Care    

Courtney Hess, MS; Boaz Levy, PhD; Ardeshir Z. Hashmi, MD; Jacqueline Hogan, MS; Sarah Greenspan, MS; Allison Elber, MS; Kathryn Falcon, MS; Daniel F. Driscoll, MD

Corresponding Author: Boaz Levy, PhD; University of Massachusetts, Boston. Email: boaz.levy@umb.edu

Publication: May 8, 2020

Purpose: This study examined the clinical utility of highly efficient subjective and objective screens of cognitive impairment. Method: One hundred and twenty-one participants (age≥65, mean=73.59, SD=6.26) completed a 2-item questionnaire of subjective memory functioning, a brief computerized cognitive test, and the Montreal Cognitive Assessment (MoCA). Next, participants were assigned to one of four conditions, based on their subjective (low/high) and objective (impaired/unimpaired) level of cognitive functioning. Further analysis divided the sample into age-based groups (i.e., younger<75 and older≥75). Results: The proportion of participants in the impaired subsample (i.e., MoCA<26), who reported a high level of subjective concern about their memory, was low (i.e., 0.15). Among unimpaired participants, Yuen tests of trimmed means detected highly significant group differences (i.e., subjective memory group, p<0.0003; age-based group, p<0.005) on the most challenging of the three computerized tasks. This task assesses cognitive control (i.e., shifting attention across sets) in less than two minutes within a self-administration format. In contrast, the MoCA, which is administered by a clinician and takes between 10 and 15 minutes to complete, offered no differentiation between either of the groups. Conclusion: Screening protocols in which cognitive testing is administered subsequent to patient complaint are prone to underdiagnosis. In addition, common dementia screens are insensitive to subjective deficits, and cognitive aging more generally, that progress within the unimpaired range. Therefore, they may lead to dismissing valid concerns that deserve preventive attention. Primary care needs efficient screening tools that are sensitive to prodromal decline. 

ORIGINAL RESEARCH

The Financial Cost of Medical Assistant Turnover in an Academic Family Medicine Center 

Jessica L. Friedman, MD, MPH; Dana Neutze, MD, PhD

Corresponding Author: Jessica L. Friedman, MD, MPH; University of North Carolina at Chapel Hill. Email: jessica_friedman@med.unc.edu

Publication: May 8, 2020

Introduction: Primary care clinics increasingly hire medical assistants (MAs) to perform a variety of clinical and administrative tasks. Anecdotal reports suggest that MA turnover is high, but no studies to date have calculated the rate or cost of MA turnover. The purpose of this study was to calculate the rate of MA turnover and associated costs in a single, large academic Family Medicine clinic. Methods: Retrospective data were collected from clinic administrators regarding MA turnover, overtime worked, salaries and benefits as well as administrator salaries and benefits and the amount of administrator time spent in MA hiring, training, and termination in 2017. Results: During 2017, MA turnover rate was 59%. The total estimated cost of MA turnover was $213,000. The per-MA cost of turnover was $14,200, or approximately 40% of the average annual salary of MAs. Conclusion: Turnover rate in this practice was similar to other estimates of primary care clinic staff and allied health professionals. The estimated cost of MA turnover relative to annual salary was significantly greater than that in other fields, likely reflecting the costs of training MAs. Establishing a method for calculating the turnover rate and costs can allow other healthcare systems to better describe turnover and evaluate retention strategies. 

ORIGINAL RESEARCH

Having a Primary Care Provider is the Strongest Predictor of Successful Follow-up of Inner-City Patients Enrolled in a Randomized Cardiovascular Trial

Samuel H. Friedman, MD; Chinazo O. Cunningham, MD, MS; Juan Lin, PhD; Linda B. Haramati, MD, MS; Jeffrey M. Levsky, MD, PhD

Corresponding Author: Samuel Friedman, MD;  Albert Einstein College of Medicine. Email: samuel.friedman@med.einstein.yu.edu

Publication: May 8, 2020

Purpose: Ethnic minorities, women, and those of low socioeconomic status are widely underrepresented in clinical trials. Few studies have explored factors associated with successful followup in these historically difficult to reach patients. This study’s objective was to identify patient characteristics and methods of contact that predict successful contact for follow-up in an urban, predominantly ethnic minority, female-majority, poor population to help devise strategies to improve retention. Methods: We retrospectively reviewed records from a prospective randomized control trial of 400 hospitalized chest pain patients to determine which characteristics were associated with successful telephone follow-up at one year after enrollment. We assessed demographic variables, medical history and social factors using bivariate analyses. A multivariate analysis was performed using variables from the bivariate analysis with p≤0.2. Results: The overall successful one-year follow-up rate was 95%(381/400). Study participants who completed follow-up were significantly more likely to have a primary care physician (PCP) [88%(337/381) versus 68%(13/19)], speak English natively [52%(199/381) versus 26%(5/19)], have a higher Charlson comorbidity index score, and be female [64.0%(244/381) versus 42.1%(8/19)]. Having a PCP and native English language remained significant at multivariate analysis. Socioeconomic status score, quantity of contact information recorded at recruitment and insurance status were not significantly associated with successful follow-up. Conclusions: Patients engaged with the healthcare system by having a PCP are significantly more likely to achieve follow-up. Successful follow-up is also associated with native English speaking. The potential of improving follow-up by facilitating connections with healthcare providers requires further study.

COMMENTARY

High Volume Portal Usage: Impact on Practice Resources    

Augustine Chavez, MD; Jesse Bracamonte, DO; Molly Kresin, DO; Michael Grover, DO; Michael Yardley, MBA

Corresponding Author: Augustine Chavez, MD; Mayo Clinic Arizona. Email: Chavez.Augustine@mayo.edu

Publication: May 8, 2020

Patient portals have both patient centered benefits and substantial impacts on practices.  Successful implementation of a patient portal can be achieved with a comprehensive team approach. Increased portal usage results in high volume patient secure messaging.  We describe the impact of high patient message volume on our fee for service academic Family Medicine practice. Practice adaptations are necessary to manage volume, length, and complexity of messages.  Dedicated staff with specialized training to handle patient messages and ample protected time for providers are important to minimize clerical burden associated with in patient portal use.

RESEARCH LETTER

Primary Care Physician Factors Associated with Inbox Message Volume 

David Margolius, MD; Jonathan Siff, MD, MBA; Kathryn Teng, MD, MBA; Douglas Einstadter, MD, MPH; Douglas Gunzler, PhD; Shari Bolen, MD, MPH

Corresponding Author: David Margolius, MD; MetroHealth System. Email: DMargolius@metrohealth.org

Publication: May 8, 2020

Introduction: The objective of this study was to better understand the relationship between panel size, full-time status, and estimated socio-economic status of a patient panel with types and amount of primary care clinician inbox messages. Methods: The study used data from the EPIC Signal database to examine inbox volume and types of messages for 86 primary care clinicians at 19 primary care sites. We measured correlations and performed multiple regression analysis to understand the relationship between inbox volume and types of messages and three factors: panel size, full-time status, and estimated socio-economic status of patient panels. Results: The study found positive correlation between the number of messages and panel size, full-time status, and estimated socio-economic status of patient panels. The number of patient portal messages generated from patient panels with higher socioeconomic status accounted for the positive correlation in total inbox messages and that factor. Discussion: These findings contribute to our understanding of primary care workload, specifically as it relates to panel size, full-time status, and patient panel socio-economic status. Increase in clinical time or panel size need to come with trained team members or additional time to address inbox messages.

SPECIAL COMMUNICATION

A Population Health Assessment Engine (PHATE): Integrating Community and Clinical Data to Assess Patient Risks and Improve Health

Pavela G. Bambekova, BS; Winston Liaw, MD, MPH; Robert L. Phillips, Jr., MD, MSPH; Andrew Bazemore, MD, MPH

Corresponding Author: Pavela G. Bambekova, BS; University of Texas Health San Antonio. Email: bambekova@livemail.uthscsa.edu

Publication: May 8, 2020

Clinicians are concerned about their patients’ social determinants of health (SDH), yet they are unsure how to effectively gather patient-level SDH data and intervene without adding to current administrative burdens. Designed properly, clinical registries offer solutions to integrate neighborhood SDH data with clinical data from electronic health records (EHRs), enabling the understanding of community factors to guide patient care. Federal and state interest in adjusting reimbursements based on SDH further underscores the need for strategies that integrate SDH and clinical data. The Population Health Assessment Engine (PHATE) exemplifies a registry-based SDH data integration solution that adjusts payments, contributes to public health surveillance, organizes care around hot spots (gaps in quality or uncontrolled disease), assesses patient risk, and connects with community organizations. PHATE also permits residency training to meet community health competency milestones by incorporating the PHATE curriculum. These functions enhance value, and their utility in education and care delivery would benefit from further investigation.

SPECIAL COMMUNICATION

Primary Care is an Essential Ingredient to a Successful Population Health Improvement Strategy

Jennifer E. DeVoe, MD, DPhil

Corresponding Author: Jennifer E. DeVoe, MD, DPhil; Oregon Health & Science University. Email: devoej@ohsu.edu

Publication: May 8, 2020

Primary care teams bridge health care to other sectors, making effective connections between health care and health. If health care systems want to improve patient and population health, the important role of primary care must be recognized, celebrated, and strengthened. This commentary explores several of the current “hot topics” in policy discussions (e.g., social determinants of health, population health) and gives examples of how these theoretical discussions are relevant to the real world of patient care. It concludes with a few key points relevant to how the system can better support the important population health improvement work done by primary care teams. For example, changes in the way primary care is delivered, reimbursed, and measured are needed to support the health promoting and healing work that happens continuously, not just during a clinic visit or inside the clinic walls. Renewed investments must be made to strengthen delivery models that enable longitudinal, trusting relationships to develop between patients and primary care teams. Payment systems must shift away from fee-for-service models to new holistic reimbursement methods that reflect the value of a comprehensive scope of primary care practice and continuity of care. And, measuring what matters in primary care will help to re-align our focus on health.

CLINICAL REVIEW

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

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

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

Publication: May 8, 2020

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

REFLECTIONS IN FAMILY MEDICINE

The Unexpected Volunteer

Henry Bair, BS

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

Publication: May 8, 2020

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

CLINICAL REVIEW

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

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

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

Publication: TBD

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

ORIGINAL RESEARCH

Practitioner Engagement in Activities of the National Dental Practice-Based Research Network: 7-Year Results    

Rahma Mungia, BDS, MSc; Ellen Funkhouser, MS, DrPH; Sonia K. Makhija, DDS, MPH; Stephanie C. Reyes, BA; Rachel Cohen, MPH; David L. Cochran, DDS, MS, PhD; Cyril Meyerowitz, DDS, MS; D. Brad Rindal, DDS; Valeria V. Gordan, DDS, MS, MSCI; Jeffrey L. Fellows, PhD; Meredith Trejo, MPH; Thomas W. Oates, DMD, PhD; Jason D. McCargar, DMD; Pamela A. McMahon, DDS; Gregg H. Gilbert, DDS, MBA; National Dental PBRN Collaborative Group.

Corresponding Author: Rahma Mungia, BDS, MSc, DDPHRCS; University of Texas Health Science Center. Email: mungia@uthscsa.edu

Publication: TBD

Purpose: To (1) quantify practitioner activities of the National Dental Practice-Based Research Network for which Continuing Education (CE) credits were received (study training, videos, webinars, meetings, and symposia); (2) quantify practitioner co-authoring Network publications and presentations; and (3) test whether practitioner characteristics were associated with participation in these activities. Methods: A retrospective analysis of 4,361 practitioners who enrolled in the Network between April 12, 2012 and October 12, 2018.  Results: Overall, 59% (n=2,586) of practitioners earned CE credit from the Network; among these, 68% (n=1,757) from a video, 62% (n=1,592) attended an annual Network meeting, 31% (n=549) due to training for a Network clinical study, 9% (n=226) attended a national symposium, and 7% (n=170) participated in a Network webinar. Members of two large group practices earned on average more CEs than practitioners from other practice settings. Four percent (n=159) of practitioners co-authored a Network presentation or publication. Practitioners who received their dental degree before 2000, were general practitioners, or were members of two large group practices, were more likely to have co-authored a publication or presentation. Conclusion: This Network used a broad range of activities to engage community practitioners. These activities were successful in sustaining a high level of practitioner engagement in clinical research and its relevance to everyday clinical practice.

ORIGINAL RESEARCH

Practice Transformation Support and Patient Engagement to Improve Cardiovascular Care: A Report from EvidenceNOW Southwest    

W. Perry Dickinson, MD; Donald E. Nease, Jr., MD; Robert L. Rhyne, MD; Kyle E. Knierim, MD; Douglas H. Fernald, MA; Dionisia R. de la Cerda, MPA; L. Miriam Dickinson, PhD

Corresponding Author: W. Perry Dickinson, MD; University of Colorado. Email: perry.dickinson@cuanschutz.edu

Publication: TBD

Purpose: To improve cardiovascular care through supporting primary care practices’ adoption of evidence-based guidelines. Study Design: A cluster randomized trial compared two approaches:  1) standard practice support (practice facilitation, practice assessment with feedback, health information technology assistance, and collaborative learning sessions), and 2) standard support plus patient engagement support. Methods: Primary outcomes were cardiovascular clinical quality measures collected at baseline, 9, and 15 months. Implementation of the first 6 “Building Blocks of High Performing Primary Care” was assessed by practice facilitators at baseline, 3, 6, and 9 months. Clinical quality measures from practices not involved in the study served as an external comparison. Results: 211 practices completed baseline surveys. There were no differences by study arm (OR (95% CI)): aspirin use (1.03 (0.99,1.06)), blood pressure (0.98 (0.95,1.01)), cholesterol (0.96 (0.92,1.00)), smoking (1.01 (0.96,1.07)); however, there were significant improvements over time in  aspirin use (OR=1.04 (1.01,1.07)), cholesterol (OR=1.05 (1.03,1.08)), and smoking (OR=1.03 (1.01,1.06)), but not blood pressure (OR=1.01(0.998,1.03)). Improvement in enrolled practices was greater than external controls across all four measures (all p<0.05). Implementation improved in both arms for Team-Based Care, Patient-Team Partnership, and Population Management, and improvement was greater in enhanced intervention practices (all p<0.05).  Leadership and Data Driven Improvement (p<0.05) improved significantly, with no difference by arm. Greater improvement in Building Block implementation was associated with greater improvement in blood pressure measures (p<0.05). Conclusions: Practice transformation support can assist practices with improving quality of care. Patient engagement in practice transformation can further enhance practices’ implementation of aspects of new models of care.

ORIGINAL RESEARCH

Self-Reported Opioid Use and Driving Outcomes Among Older Adults: Findings from the AAA LongROAD Study    

Marian E. Betz, MD, MPH; Hailey Hyde, MPH; Carolyn DiGuiseppi, MD, PhD, MPH; Timothy F. Platts-Mills, MD, MSc; Jason Hoppe, DO; David Strogatz, PhD; Howard F. Andrews, PhD; Thelma J. Mielenz, PT, PhD, MS; Linda L. Hill, MD, MPH; Vanya Jones, PhD, MPH; Lisa J. Molnar, PhD; David W. Eby, PhD; Guohua Li, DrPH, MD

Corresponding Author: Marian E. Betz, MD, MPH; University of Colorado. Email: marian.betz@ucdenver.edu

Publication: TBD

Background: Opioid medications are important therapeutic options to mitigate the harmful effects of pain but can also impair driving ability. We sought to explore opioid use, pain levels, and driving experiences among older drivers. Methods: Cognitively intact drivers age 65-79 were recruited for the multisite AAA Longitudinal Research on Aging Drivers (LongROAD) study (n = 2990). This cross-sectional analysis used data from the baseline questionnaire and “brown-bag” medication review. Results: Among LongROAD participants (47% male, 88% White, 41% aged 65-69 years), 169 (5.7%) reported currently taking an opioid, with a median daily dose of 20 morphine milligram equivalents. Participants did not differ significantly in opioid use by age, gender, race, or ethnicity (p>0.05). After adjustment for age, gender, race and ethnicity, participants who were taking opioids (versus not) were significantly more likely to report self-regulated driving reduction and reduced driving ability. However, these effects became non-significant when hospitalization, impaired physical function and other factors associated with opioid use were controlled. Conclusions: In this study from a large, geographically diverse sample of older adults, there was an association between opioid use and several self-reported measures of driving behavior and ability.  However, future work should clarify the effects on driving of opioid use from the effects of the painful medical conditions for which the opioids are being taken. Clinicians should continue to discuss the risks and benefits of opioid medications with patients, including risks related to driving safety.

ORIGINAL RESEARCH

Period Prevalence Rates and Impact of Comorbid Widespread Pain in Adults with Chronic Low Back Pain: A Pain Research Registry-Based Study

John C. Licciardone, DO, MS, MBA; Vishruti Pandya, MBBS, MHA

Corresponding Author: John C. Licciardone, DO, MS, MBA; University of North Texas Health Science Center. Email: john.licciardone@unthsc.edu

Publication: TBD

Introduction: Widespread pain (WP) is emerging as a key comorbid condition in patients with chronic low back pain (CLBP). This study measured the prevalence of comorbid WP in adults with CLBP, WP predictors, and impact on patients. Methods: Patients with CLBP were recruited from the Pain Registry for Epidemiological, Clinical, and Interventional Studies and Innovation from 2016 through 2019. They were followed over 12 months to measure annual WP period prevalence rates using an item from the minimum dataset recommended by the National Institutes of Health Task Force on Research Standards for Chronic Low Back Pain. Patients were classified as not having WP, having non-persistent WP, or having persistent WP. Pain intensity, back-related disability, and quality of life were measured using a numerical rating scale, the Roland-Morris Disability Questionnaire, and the PROMIS-29 instrument, respectively. Results: A total of 358 patients were studied, including 56 (16%) without WP, 272 (76%) with nonpersistent WP, and 30 (8%) with persistent WP. There were no significant differences among the WP groups with regard to age, sex, or CLBP duration. However, being non-White and having moderate or high levels of pain catastrophizing remained significant predictors of nonpersistent or persistent WP after adjusting for potential confounders. Patients reported greater pain intensity and back-related disability and poorer quality of life over 12 months with increasing levels of WP persistence (P<0.001 for each measure). Conclusion: Greater efforts are needed in primary care to help close these gaps in pain intensity, back-related disability, and quality-of-life outcomes associated with WP.

ORIGINAL RESEARCH

Implementing a Sustainable Model for the Delivery of Preventive Services in Rural Counties (The Healthier Together Study)

Zsolt Nagykaldi, PhD; Dewey Scheid, MD; Yan D Zhao, PhD; Bhawani Mishra, PhD; Tracy Greever-Rice, PhD

Corresponding Author: Zsolt Nagykaldi, PhD; University of Oklahoma Health Sciences Center. Email: znagykal@ouhsc.edu 

Publication: TBD

Objective: The Healthier Together study aimed to implement and evaluate a sustainable, rural community-based patient outreach model for preventive care provided through primary care practices located in three rural counties in Oklahoma. Community-based Wellness Coordinators (WCs) working with primary care practitioners (PCPs), county health departments, local hospitals, and health information exchange (HIE) networks helped residents receive high-priority evidencebased preventive services. Methods: The WCs used a wellness registry connected to electronic medical records and HIEs and called patients at the county level, based on PCP-preferred protocols. The registry flagged patientlevel preventive care gaps, tracked outreach efforts, and documented the delivery of services throughout the community. Return on investment (ROI) in participating organizations was estimated by the study team. Results: Forty four of the 59 eligible clinician practices participated in the study. Two regional HIEs supplied periodic health data updates for 71,989 patients seen in the three implementation counties. A total of 45,862 outreach calls were made by 6 WCs, 100,896 high-priority recommendations were offered to patients based on care gaps and 14,043 additional services were delivered. Of all the patients reached, only 1,917 (4.2%) were up-to-date on all prioritized services. Participating primary care practices significantly improved the delivery of preventive services (mean increase: 20.2% across 12 services; p<0.001; range: 7% to 43%) and realized a mean ROI of 68%. Health systems that employed the WCs earned a mean revenue of $175,000, realizing a 75% ROI for the outreach program. Conclusions: Although health care is under-resourced and segmented in many rural counties, when stakeholder partnerships are established, they may be able to achieve and economically sustain community-wide health improvement by creating a win-win situation for all partners.

ORIGINAL RESEARCH

The Impact of Social and Clinical Complexity on Diabetes Control Measures in Community Health Centers

Erika Cottrell, PhD, MPP; Jean P. O’Malley, MPH; Katie Dambrun, MPH; Michelle A Hendricks, PhD; Brian Park, MD; Hongzhi Xu, PhD, MPH, MS; Mary Charlson, MD; Andrew Bazemore, MD MPH; Elizabeth Ann Shenkman, PhD; Abby Sears, MHA, MBA; Jennifer E. DeVoe, MD, DPhil

Corresponding Author: Erika Cottrell, PhD, MPP; OCHIN, Inc. Email: cottrelle@ochin.org

Publication: TBD

Purpose: In an age of value-based payment, primary care providers (PCPs) are increasingly scrutinized on performance metrics that assess quality of care, including the outcomes of their patient population in key areas such as diabetes control. Although such measures often adjust for clinical complexity, most do not account for social risk factors, despite research demonstrating the strong association between social factors and health. Methods: Using patient electronic health record data from two large community health center networks serving safety net patients, we assessed the effect of both clinical and social risk factors on poor glucose control among diabetics. Logistic regression results were used to estimate the impact of adjusting for both clinical and social complexity on provider performance metrics. Clinical complexity was measured at the patient-level using the Charlson Comorbidity Index. Social complexity was measured at the neighbhorhood-level using the Social Deprivation Index. Results: Clinical complexity alone was not consistently associated with poor diabetes control (i.e., HbA1c>9) in diabetic patients with HbA1c testing during the study period. However, increasing social complexity was significantly associated with higher rates of poor diabetic control in both cohorts. After adding adjustment for social complexity down to the national median score, our models suggest that approximately 25% of providers would have 1-2% improvement in their diabetes control metric, with 45% showing a 2-5% improvement. Conclusions: Providers caring for patients with greater social risk factors may benefit from having their performance metrics adjusted for the social complexity of their patient populatiions. 

ORIGINAL RESEARCH

Implementing Office-Based Opioid Treatment Models in Primary Care Settings

 E. Marshall Brooks, PhD; Sebastion Tong, MPH, MD

Corresponding Author: E. Marshall Brooks, PhD; Virginia Commonwealth University. Email: edward.brooks@vcuhealth.org

Publication: TBD

Background: Primary care practices are ideal sites to integrate medication assisted treatment (MAT) for opioid use disorder (OUD), but little is known about how practices have achieved this. Our study aimed to describe the implementation experiences and treatment models of practices implementing MAT. Methods: We conducted a qualitative analysis of MAT integration at 26 practices across Virginia after the state implemented the Addiction and Recovery Treatment Services (ARTS) benefit in 2017. Data collection activities included interviews with clinic team members, including buprenorphine waivered prescribers, behavioral health clinicians, care coordinators, and peer counselors. We used a template analysis approach to thematically analyze data. Results: Our study identified various ways in which MAT can be implemented in primary care clinics and other ambulatory settings. While state regulations and treatment guidelines suggest co-locating behavioral health counseling and medication management, providing care coordination and conducting regular urine drug screens, we found a wide spectrum of ways in which practices can adapt and innovate treatment models to fit local needs. Discussion: As the fight against the opioid epidemic continues, we need to identify feasible and effective MAT treatment models and integration approaches for primary care. 

ORIGINAL RESEARCH

Primary Care Physician Characteristics Associated with Prescribing Potentially Inappropriate Medication in Elderly Patients

 Avanthi Jayaweera; YoonKyung Chung, PhD; Yalda Jabbarpour, MD

Corresponding Author: Yalda Jabbarpour, MD; Robert Graham Center for Policy Studies. Email: yjabbarpour@aafp.org

Publication: TBD

Background: Despite the high risk of adverse drug events associated with potentially inappropriate medications (PIMs), primary care physicians (PCPs) continue to prescribe them for the elderly. The objective of this study was to explore PIM prescribing behavior in relation to characteristics among PCPs practicing in the United States. Methods: We conducted a retrospective cohort study of PCPs in the 2013-2015 Medicare Part D Public Use File. We obtained physician characteristics from the 2015 AMA Masterfile. For each PCP, we calculated the ratio of primary care-relevant PIM claims to all drug claims (PIM rate) based on Beers Criteria. We used a multivariate regression model to assess the associations between physician characteristics and PIM rate. Results: The study sample contained 111,461 PCPs who specialized in family medicine, internal medicine, general practice and geriatric medicine. Although the mean PIM rate was low at 4.9%, it varied widely across PCPs with the bottom quartile at 1.2% and the top quartile at 10.1%. PCPs in the top quartile were on average older, more likely to be male, have a D.O degree, practice in the South, and have a smaller Medicare patient panel. A multivariate analysis confirmed that even after adjusting for patient panel characteristics, physician characteristics including gender, age, professional degree, specialty, practice location, practice size, and patient panel size were associated with PIM rate. Conclusion: Identifying PCPs with higher PIM rates can guide future interventions to increase safe prescribing for elderly populations.

ORIGINAL RESEARCH

A Scoping Review on Clinical Decision Support Systems for Opioid Prescribing for Chronic Non-Cancer Pain in Primary Care Settings

Sheryl Spithoff, MD, MSc; Stephanie Mathieson, PhD; Frank Sullivan, FRSE, FRCP, FRCGP; Qi Guan, MSc; Abhimanyu Sud, MD, CCFP; Susan Hum, MSc; Mary Ann O’Brien, PhD

Corresponding Author: Sheryl Spithoff, MD, MSc; University of Toronto. Email: sheryl.spithoff@wchospital.ca

Publication: TBD

Background and Objectives: Clinical decision support systems (CDSSs) may help clinicians prescribe opioids for chronic non-cancer pain (CNCP) more appropriately. This scoping review determined the extent and range of the current evidence on CDSSs for opioid prescribing for CNCP in primary care, and whether investigators followed best evidence and current guidance in designing, implementing and evaluating these complex interventions. Methods: We searched nine electronic databases and other data sources for studies from January 1st 2008 to October 11th 2019. Two reviewers independently screened the citations. One reviewer extracted data and a second verified for accuracy. Inclusion criteria: study of a CDSS for opioid prescribing for CNCP in a primary care clinical setting. We reported quantitative results in tables and qualitative results in narrative form. Results: Our search yielded 5068 records of which 14 studies met our inclusion criteria. All studies were conducted in the United States. Six studies examined local (eg, health centre) CDSSs and eight examined prescription drug monitoring program (PDMP) CDSSs. Three CDSSs incorporated evidence-based components. Study aims were heterogeneous and study designs included both quantitative and qualitative methodologies. No studies assessed patient health outcomes. Few studies appeared to be following guidance for evaluating complex interventions. Conclusions: Few studies have rigourously assessed the use of CDSSs for opioid prescribing for CNCP in primary care settings. Going forward, investigators should include evidence-based components into the design of CDSSs and follow guidance for the development and evaluation of complex interventions.

POLICY BRIEF

The Evolving Family Medicine Team

Yalda Jabbarpour, MD; Anuradha Jetty, MPH; Mingliang Dai, PhD; Michael Magill, MD; Andrew Bazemore, MD, MPH

Corresponding Author: Yalda Jabbarpour, MD; The Robert Graham Center for Policy Studies. Email: yjabbarpour@aafp.org

Publication: TBD

A decade of practice transformation, consolidation, and payment experimentation have highlighted the need for team-based primary care, but little is known about how team composition is changing over time.   Surveys of Family Physicians (FPs) from 2014-18 reveal they continue to work alongside inter-professional team members and suggest slow but steady growth in the proportion of FPs working with nurses, behaviorists, clinical pharmacists, and social workers.

BRIEF REPORT

From the Patient Perspective: The Value of Treating Opioid Use Disorder in Family Medicine

Claire Kane, BA; Catherine Leiner, BS; Chase Harless, MSW; Kathleen A. Foley, PhD; E. Blake Fagan, MD; Courtenay Gilmore Wilson, PharmD, BCACP, CPP

Corresponding Author: Courtenay Gilmore Wilson, PharmD, BCACP, CPP; UNC Health Sciences at MAHEC. Email: Courtenay.wilson@mahec.net

Publication: TBD

Introduction: Despite evidence demonstrating that medications for opioid use disorder (OUD) reduce morbidity and mortality, the majority of patients do not receive treatment. The National Academies of Science call for more research exploring the patient’s perspective of treatment modalities in order to increase access to individualized, patient-centered care. We aim to build on existing literature by describing patient experiences treated for OUD in a rural family medicine setting. Methods: We employed a convenience sampling methodology to complete brief, structured interviews with thematic data analysis for 30 of 57 eligible patients receiving office-based opioid treatment (OBOT) in the primary care setting. Results: Participants’ experiences with OBOT were generally positive and shaped by societal structures and institutions, their life before treatment, their treatment history, and the kind of care they received in OBOT. Patients identified accessibility and privacy as advantages to receiving OBOT in primary care. Discussion: This research identifies ways providers can provide individualized and effective OUD treatment within the family medicine setting.

BRIEF REPORT

The Ability of Smaller Primary Care Practices to Report Clinical Quality Measures: More Evidence of the Size Paradox?

Michael L. Parchman, MD, MPH; Melissa L. Anderson, MS; Robert B. Penfold, PhD; Elena Kuo, PhD, MPH; David A. Dorr, MD, MS

Corresponding Author: Michael L. Parchman, MD, MPH; Kaiser Permanente of Washington. Email: parchman.m@ghc.org 

Publication: TBD

Purpose: To assess if primary care practices with and without support from a larger organization differ in their ability to produce timely reports on cardiovascular disease (CVD) quality measures. Background: Although many primary care practices are now part of larger organizations, it is not clear if such a shift will improve the ability of those who work in these primary care settings to easily access and use their own data for improvement. Methods: Smaller primary care practices were enrolled in a trial of external practice support to build quality improvement (QI) capacity. A request for clinical quality measure (eCQM) data was sent to each practice and study outcomes were defined based on the date on which practices first submitted valid data for at least one of the three measures. A practice survey completed by a clinic manager captured practice characteristics, including the presence of quality improvement support from a larger organization. Results: Of the 209 enrolled practices, 205 had complete data for analysis. Practices without central QI support had higher rates of eCQM submission at 30 days (38% v. 20%) and 60 days, (63% v. 48%) than practices with central QI support. Practices with central QI support took longer to submit data (median 57 days) compared to practices without centralized support (median 40 days) although this difference was not significant. Conclusion: The ability of smaller practices without centralized QI support to report their eCQMs more quickly may have implications for their subsequent ability to improve these measures.

ORIGINAL RESEARCH

HPV Vaccination Initiation and Completion Among Adult Males in the United States: Prevalence and Associated Factors

Yuqi Guo, PhD; Jessamyn Bowling, PhD

Corresponding Author: Yuqi Guo, PhD; University of North Carolina at Charlotte. Email: yguo16@uncc.edu 

Publication: TBD

Background: Men accounted for 43% of HPV-related cancer cases, but the HPV vaccination rate of adult males remain low. The purposes of this study were to a) estimate the initiation and completion rate of HPV vaccine and b) analyze factors associated with HPV vaccine initiation and completion among adult males. Method: This study analyzed predisposing factors, enabling factors, reinforcing factors, and situational factors associated with the initiation of HPV vaccine among 3228 male adult participants of the 2018 Behavioral Risk Factor Surveillance System. Two binary logistic regressions were estimated based on the Systems Model of Clinical Preventive Care. Results: The initiation rate and completion rate of HPV vaccine among males aged 18 to 33 years old was 14.1% (n=454) and 35.4% (n=161) respectively. Among male adults in the U.S., the likelihood of initiating HPV vaccine significantly associated with age (odds ratio [OR] = 0.87, p < 0.00), having routine check-ups (OR = 1.29, p < 0.05), and having high HPV risk behaviors (OR = 1.53, p < 0.01). However, the likelihood of completing HPV vaccines significantly associated with age (OR = 0.85, p < 0.00) and having high HPV risk behaviors (OR = 1.79, p < 0.01). Conclusions: Having primary healthcare providers and regular check-ups are important to male adults to have HPV vaccines. Promoting access to health care resources may improve current vaccination rates among males.

CLINICAL REVIEW

Diagnosis and Management of Atopic Dermatitis for Primary Care Providers

Patrick Fleming, MD, MSc, FRCPC; Yue Bo Yang, BSc; Charles Lynde, MD, FRCPC; Braden O’Neill, MD, DPhil, CCFP; Kyle O. Lee, BM, BS, CCFP

Corresponding Author: Kyle O. Lee, BM, BS, CCFP; Sumac Creek Health Centre. Email: Kyle.Lee@mail.utoronto.ca 

Publication: TBD

Objective: To provide primary care providers an up-to-date approach to the diagnosis and management of atopic dermatitis (AD). Quality of evidence: PubMed, MEDLINE, and Cochrane databases were searched for relevant meta-analyses, randomized controlled trials, systematic reviews, and observational studies about the diagnosis and management of AD. Main message: AD is a common chronic skin disease characterized by immune dysregulation and skin barrier dysfunction. It has a substantial impact on quality of life across all ages. Despite this, AD is often still undertreated due to inaccurate diagnoses, even by many experienced dermatologists. Many primary care providers may not be aware of its commonly associated medical and psychiatric co-morbidities or be familiar with new treatment options. Conclusion: In this clinical review, we describe the pathophysiology, epidemiology, diagnosis and treatment of AD, specifically highlighting commonly used therapies and novel medications.

ORIGINAL RESEARCH

Misdiagnosis of Diverticulitis in Patients with prior Diagnosis of Irritable Bowel Syndrome

George F. Longstreth, MD; Carrie Wong, MD; Qiaoling Chen, MS

Corresponding Author: George F. Longstreth, MD;  Kaiser Permanente Southern California. Email: gflongstreth@gmail.com

Publication: TBD

Introduction: Irritable bowel syndrome (IBS) and diverticulitis share clinical features. Misdiagnosed diverticulitis can cause unnecessary antibiotic therapy. Among IBS and non-IBS patients, we compared outpatient, clinically diagnosed (no computed tomography) diverticulitis rates. Among primary-care diverticulitis-diagnosed, IBS patients, we assessed imaged diverticulosis and probable misdiagnosed diverticulitis. Methods: Among 3836-patient IBS and 67,827-patient non-IBS cohorts identified from 2000 to 2002, we retrospectively compared the frequency of outpatient, clinically diagnosed, antibiotic-treated diverticulitis from 2003 to endpoints of December 31, 2017, disenrollment or death. In IBS patients, we reviewed records of initial, primary care-managed episodes for misdiagnosis. Results: In 3,836 clinically diagnosed IBS and 63,991 non-IBS cohorts, follow-up (median [interquartile range]) was 12.4 (3.9-15.0) years versus 10.2 (3.0-15.0) years, respectively (P < .001). The incidence rate/1000 patient-years (95% confidence interval [CI]) of diagnosed diverticulitis was 14.0 (12.1-16.3) and 4.2 (4.0-4.5), respectively, (crude incidence rate ratio [IRR], 3.3 [2.8-3.9]; P <.001). Of examined features, the diagnosis of IBS was most strongly associated with clinically diagnosed diverticulitis (adjusted IRR [95% CI]; 2.64 [2.21-3.15], P <.001). Of initial diverticulitis diagnoses in 189 IBS patients, objective evidence-based diagnosis revision or exclusion occurred in 12 (6.3%), including 6 hospitalized; 29 (15.3%) had colon imaging before and/or afterward without diverticulosis reported; 143 (75.1%) had image-documented diverticulosis; and 6 (3.2%) had no imaging. Conclusions: Outpatient, clinically diagnosed, antibiotic-treated diverticulitis was increased 3-fold in IBS patients. Primary care clinical misdiagnosis of initial episodes occurred in 1 of 5 patients, but additional misdiagnosis due to misattribution of IBS pain to diverticulitis is suggested.

BRIEF REPORT

Family-Oriented Social Service Touchpoints as Opportunities to Enhance Diabetes Screening Among Women with a History of Gestational Diabetes

Maya Venkataramani, MD, MPH; Tina Cheng, MD, MPH; Hsien-Chieh Yeh, PhD; Wendy Bennett, MD, MPH; Nisa M. Maruthur, MD, MHS

Corresponding Author: Maya Venkataramani, MD, MPH; Johns Hopkins University School of Medicine. Email: mvenkat2@jhmi.edu

Publication: TBD

Introduction: Women with a history of gestational diabetes (GDM) are at increased risk for type 2 diabetes and thus require regular follow-up screening for diabetes; however, many women do not receive this screening, and in particular low-income women face disparities in receipt of recommended follow-up care. While these women may have limited access to healthcare following pregnancy, they may more regularly access social service programs that serve themselves or their young children. Leveraging these social service touchpoints could broaden opportunities to improve follow-up care receipt among women with a history of GDM. To describe these potential opportunities, we used nationally -representative data to characterize diabetes screening needs among women with a history of GDM who access the child-oriented social service programs WIC and Head Start. Methods: We analyzed nationally-representative data from the National Health Interview Survey from calendar years 2016 and 2017. Our analytic sample included women aged 18-45 years, who were linked to at least one of their children in the dataset, and had a self-reported history of GDM but did not have prediabetes or diabetes. We examined the proportion of these women who accessed WIC or Head Start who did not report having testing for diabetes within the past 3 years. Results: Of 432 (representing 2,002,675 weighted) women meeting inclusion criteria, 21.7% had accessed WIC and 8.7% Head Start. Nearly 1 in 10 women with a history of GDM in either group did not report recent diabetes screening. In sensitivity analyses that excluded likely pregnancy-related testing, 35.0% of women accessing WIC and 21.2% of those accessing Head Start had not had recent screening. Discussion: There is an unmet need for follow-up diabetes screening among women with a history of GDM who access WIC or Head Start services for themselves or their young children. Leveraging women’s touchpoints with these programs could enhance opportunities to improve recommended diabetes screening among a high-risk population. 

 

 

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