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.

JANUARY / FEBRUARY 2020 - SPECIAL OPIOID ISSUE (Publishes Friday, January 3, 2020)

OTHER MANUSCRIPTS ACCEPTED FOR PUBLICATION (Publication Date: TBD)

 

POLICY BRIEF

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

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

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

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

DOI: 10.3122/jabfm.2020.01.190230

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

ORIGINAL RESEARCH

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

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

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

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

DOI: 10.3122/jabfm.2020.01.190090

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

ORIGINAL RESEARCH

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

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

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

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

DOI: 10.3122/jabfm.2020.01.190071

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

ORIGINAL RESEARCH

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

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

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

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

DOI: 10.3122/jabfm.2020.01.190247

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

ORIGINAL RESEARCH

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

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

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

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

DOI: 10.3122/jabfm.2020.01.190233

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

ORIGINAL RESEARCH

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

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

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

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

DOI: 10.3122/jabfm.2020.01.190238

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

ORIGINAL RESEARCH

Factors That Influence Changes to Existing Chronic Pain Management Plans

Julie Diiulio, MS; Laura Militello, MA; Barbara T. Andraka-Christou, JD, PhD; Robert L Cook, MD, MPH; Robert W. Hurley, MD, PhD; Sarah M. Downs, MPH; Shilo Anders, PhD; Burke W. Mamlin, MD; Elizabeth C. Danielson, MA; Christopher A. Harle, PhD

Corresponding Author: Julie Diiulio, MS; Applied Decision Science, LLC. Email:  j.diiulio@applieddecisionscience.com

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

DOI: 10.3122/jabfm.2020.01.190284

Background: The objective of this qualitative study is to better understand primary care clinician decision making for managing chronic pain. Specifically, we focus on the factors that influence changes to existing chronic pain management plans. Limitations in guidelines and training leave clinicians to use their own judgement and experience in managing the complexities associated with treating patients with chronic pain. This study provides insight into those judgments based on clinicians’ first-person accounts. Insights gleaned from this study could inspire innovations aimed at supporting primary care clinicians (PCCs) in managing chronic pain. Methods: We conducted 89 interviews with PCCs to obtain their first-person perspective of the factors that influenced changes in treatment plans for their patients. Interview transcripts were analyzed thematically by a multidisciplinary team of clinicians, cognitive scientists, and public health researchers. Results: Seven themes emerged through our analysis of factors that influenced a change in chronic pain management: (1) change in patient condition, (2) outcomes related to treatment, (3) non-adherent patient behavior, (4) insurance constraints, (5) change in guidelines, laws, or policies, (6) approaches to new patients, and (7) specialist recommendations. Conclusions: Our analysis sheds light on the factors that lead PCCs to change treatment plans for patients with chronic pain. An understanding of these factors can inform the types of innovations needed to support PCCs in providing chronic pain care. We highlight key insights from our analysis and offer ideas for potential practice innovations.

ORIGINAL RESEARCH

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

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

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

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

DOI: 10.3122/jabfm.2020.01.190120

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

ORIGINAL RESEARCH

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

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

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

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

DOI: 10.3122/jabfm.2020.01.190202

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

ORIGINAL RESEARCH

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

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

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

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

DOI: 10.3122/jabfm.2020.01.190154

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

ORIGINAL RESEARCH

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

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

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

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

DOI: 10.3122/jabfm.2020.01.190143

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

ORIGINAL RESEARCH

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

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

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

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

DOI: 10.3122/jabfm.2020.01.190169

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

SPECIAL COMMUNICATION

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

Randi Sokol, MD, MPH, MMedEd; Zev Schuman-Olivier, MD; Maren Batalden, MD, MPH; Laura Sullivan, MD; Allen F. Shaughnessy, PharmD, MMedEd

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

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

DOI: 10.3122/jabfm.2020.01.190223

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

BRIEF REPORT

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

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

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

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

DOI: 10.3122/jabfm.2020.01.190228

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

BRIEF REPORT

Practice Predictors of Buprenorphine Prescribing by Family Physicians

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

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

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

DOI: 10.3122/jabfm.2020.01.190235

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

RESEARCH LETTER

Variability in Opioid Prescribing Practices for New Low Back Pain in the Primary Care Setting

Micheal Raad, MD; Jina Pakpoor, MD; Andrew Harris, BS; Varun Puvanesarajah, MD; Majd Marrache, MD; Joseph K. Canner, MHS; Amit Jain, MD

Corresponding Author: Amit Jain, MD;  Johns Hopkins Hospital. Email: amitjain@jhmi.edu

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

DOI: 10.3122/jabfm.2020.01.190254 

Background: The United States is facing a widespread opioid epidemic that disproportionately affects the working-age population. In the clinical setting, new low back pain is one of the most common reasons for opioid prescriptions, despite national recommendations advising against their use until non-opioid treatments have been trialed. In this study we aimed to examine national opioid prescribing practices among primary care physicians after the evaluation of low back pain in working-age patients. Method: This study used a national claims database’s billing codes to identify patients in the outpatient setting with a new encounter for isolated low back pain following a 1-year look-back period. The primary outcome was whether an opioid prescription was filled within 30 days after the encounter. Patients with a daily morphine milligram equivalence (MME/day) known to be associated with a higher risk of over-dose was also analyzed. Results: 418,565 patients between January 1 2011 and November 30, 2016 were included. The proportion of patients with filled opioid prescriptions declined significantly between 2011 and 2016 (p<0.01: 28.5% in 2011, 27.6% in 2012, 26.3% in 2013, 25.5% in 2014, 23.5% in 2015, 20.4% in 2016). Nationally, the proportion of patients with a filled opioid prescription varied significantly between the various states (p<0.01), ranging from 12.9% in Hawaii to 33.6% in Arkansas Discussion: We found that the overall frequency of opioid prescriptions for low back pain is decreasing nationally, speaking favorably for future initiatives to change physician prescribing patterns. However, we identified that there is large variation in prescribing patterns among physicians of different states.

RESEARCH LETTER

Anti-Hypertensive Medication Combinations in the United States   

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

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

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

DOI: 10.3122/jabfm.2020.01.190134

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

ETHICS FEATURE

An Ethical Framework to Manage Patient Requests for Medical Marijuana   

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

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

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

DOI: 10.3122/jabfm.2020.01.190216

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

ORIGINAL RESEARCH

Improved Prenatal Counseling per Pregnancy Weight Gain Guideline Lowered Gestational Diabetes

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

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

Publication: TBD

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

ORIGINAL RESEARCH

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

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

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

Publication: TBD

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

RESEARCH LETTER

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

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

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

Publication: TBD

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

BRIEF REPORT

Thyroid Hormone Use in the United States, 1997-2016     

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

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

Publication: TBD

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

BRIEF REPORT

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

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

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

Publication: TBD

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

BRIEF REPORT

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

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

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

Publication: TBD

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

RESEARCH LETTER

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

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

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

Publication: TBD

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

CLINICAL REVIEW

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

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

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

Publication: TBD

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

CLINICAL REVIEW

Cervical Spondylotic Myelopathy: A Guide to Diagnosis and Management   

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

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

Publication: TBD

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

REFLECTIONS IN FAMILY MEDICINE

Crashing Out of a Career   

Brenda Neufeld, MD

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

Publication: TBD

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

ORIGINAL RESEARCH

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

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

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

Publication: TBD

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

ORIGINAL RESEARCH

Marketing Messages in Continuing Medical Education Modules on Binge Eating Disorder 

Jin Jung, BS; Adriane Fugh-Berman, MD

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

Publication: TBD

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

ORIGINAL RESEARCH

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

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

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

Publication: TBD

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

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