Abstracts In Press

The abstracts below are from articles currently ‘in press’ at the JABFM. Content and publication dates are subject to change during the copy editing process; please check back here for weekly updates. In addition, ahead-of-print COVID-19 full articles are now available for download at: COVID-19 Subject Collection.

| SEPTEMBER/OCTOBER 2020 |       | OTHER ACCEPTED ABSTRACTS | 

 

SEPTEMBER / OCTOBER 2020. PRACTICE-BASED RESEARCH SPECIAL ISSUE. VOLUME 33 / ISSUE 5. (Publication Date: September 10, 2020)

 OTHER ABSTRACTS ACCEPTED FOR PUBLICATION (Publication Date: TBD)

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: September 10, 2020

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: September 10, 2020

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

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: September 10, 2020

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

Asthma Care Quality, Language, and Ethnicity in a Multi-State Network of Low-Income Children

John Heintzman, MD, MPH; Jorge Kaufmann, ND, MS; Jennifer Lucas, PhD; Shakira Suglia, PhD; Arvin Garg, MD; Jon Puro, MS; Sophia Giebultowicz, MA; David Ezekiel-Herrera, MS; Andrew Bazemore, MD; Miguel Marino, PhD

Corresponding Author: John Heintzman, MD, MPH; Oregon Health & Science University. Email: heintzma@ohsu.edu

Publication: September 10, 2020

Introduction: Prior research has documented disparities in asthma outcomes between Latino children and non-Hispanic whites, but little research directly examines the care provided to Latino children over time in clinical settings. Methods: We utilized an electronic health record (EHR)-based dataset to study basic asthma care utilization (timely diagnosis documentation and medication prescription) between Latino (Spanish and English-preferring) and Non-Hispanic white children over a thirteen-year study period. Results: In our study population (n=37,614), Latino children were more likely to have Medicaid, be low-income, and be obese than non-Hispanic white children. Latinos (Spanish and Englishpreferring) had lower odds than non-Hispanic whites of having their asthma recorded on their problem list on the first day the diagnosis was noted (odds ratio [OR]=0.83, 95% CI: 0.77-0.89 Spanish-preferring; OR=0.93, 95% CI: 0.87-0.99 English-preferring). Spanish-preferring Latinos had higher odds of ever receiving a prescription for albuterol (OR = 1.96, 95% CI: 1.52-2.52), inhaled corticosteroids (OR=1.45, 95% CI: 1.01-2.09) or oral steroids (OR=1.48, 95% CI: 1.07- 2.04) than non-Hispanic whites. Among those with any prescription, Spanish-preferring Latinos had higher rates of albuterol prescriptions compared to non-Hispanic whites (RR=1.07, 95% CI: 1.01-1.13). Conclusions/Relevance: In a multi-state network of clinics, Latino children were less likely to have their asthma entered on their problem list the first day it was noted than non-Hispanic white children, but otherwise did not receive inferior care to non-Hispanic white children in other measures. Further research can examine other parts of the asthma care continuum to better understand asthma disparities.

ORIGINAL RESEARCH

Patient Safety in Primary Care: Conceptual Meanings to Clinicians, Administrators, Staff, and Patients

Alden Yuanhong Lai; Christina T. Yuan; Jill A. Marsteller; Susan M. Hannum; Elyse Lasser; JaAlah-Ai Heughan; Tyler Oberlander; Zackary D. Berger; Ayse P. Gurses; Hadi H. Kharrazi; Samantha I. Pitts; Sarah H. Scholle; Sydney E. Morss Dy

Corresponding Author: Alden Yuanhong Lai; New York University School of Global Public Health. Email: aldenlai@nyu.edu 

Publication: September 10, 2020

Introduction: Patient safety in primary care is an emerging priority, and experts have highlighted medications, diagnoses, transitions, referrals, and testing as key safety domains. This study aimed to: (1) describe how front line clinicians, administrators, and staff conceptualize patient safety in primary care; and (2) compare and contrast these conceptual meanings from patients’ perspective. Methods: We conducted interviews with 101 front line clinicians, administrators and staff, and focus groups with 65 adult patients at 10 Patient-Centered Medical Homes. We used thematic analysis to approach coding. Results: Findings indicate that front line personnel conceptualized patient safety more in terms of work functions, which reflect the grouping of tasks or responsibilities to guide how care is being delivered. Front line personnel and patients conceptualized patient safety in largely consistent ways. Discussion: Function-based conceptualizations of patient safety in primary care may better reflect front line personnel and patients’ experiences than domain-based conceptualizations, which are favored by experts.

ORIGINAL RESEARCH

Low-Intensity Intervention Supports Diabetes Registry Implementation: Results from a Cluster-Randomized Trial in the Ambulatory Care Outcomes Research Network (ACORN)

Roy T Sabo, PhD; Rebecca S Etz, PhD; Martha M Gonzalez, BA; Nicole J Johnson, BA; Jonathan P O’Neal, BA; Sarah R. Reves, FNP; Jesse C Crosson, PhD

Corresponding Author: Roy T. Sabo, PhD; Virginia Commonwealth University. Email: roy.sabo@vcuhealth.org

Publication: September 10, 2020

Background: Previous research demonstrated that registries are effective for improving clinical guideline adherence for care of patients with type 2 diabetes. However, registry implementation has typically relied on intensive support (such as practice facilitators) for practice change and care improvement. Objective: To determine whether a remotely-delivered, low-intensity organizational change intervention supports implementation and use of diabetes registries in primary care. Design: Cluster-randomized controlled effectiveness trial of providing limited external support leveraging internal practice resources and problem-solving capacities for driving diabetes registry implementation in 32 practices in Virginia. Intervention: All practices identified local implementation champions who participated in an in-person education session on the value and use of diabetes registries, while intervention practices were also paired with peer mentors and had access to a physician informaticist, who worked remotely to assist practices with implementation. Main Measures: Practice champions reported progress on registry implementation milestone achievement, and reported practice-level organizational capacity using a modified version of the Assessment of Chronic Illness Care (ACIC). Key Results: Intervention practices were significantly more likely to have implemented a registry (44% vs. 6%, p=0.04) and to have achieved more implementation milestones (5.5 vs. 2.6, p<0.0001) than control practices. Baseline ACIC scores indicated room for organizational improvement with regard to chronic illness care (overall median 6.4; range 3.8-10.8) and clinical information systems use (median 6.0; range 0, 11) with no significant differences between intervention and control practices. Conclusions: Remotely-provided guidance paired with limited in-person assistance can support rapid implementation of diabetes registries in typical primary care practices.

ORIGINAL RESEARCH

Impact of Physician-Pharmacist Collaboration for Disease State Management on Diabetes Outcomes and Health Care Use   

Melissa C. Norton, MS, PharmD; Meghan E. Haftman, PharmD, BCPS; Lyndsey N. Buzzard, PharmD, BCACP

Corresponding Author:  Melissa C. Norton, MS, PharmD; Ascension Medical Group. Email: missynorton3@gmail.com

Publication: September 10, 2020

Objective: To evaluate the impact of physician-pharmacist collaboration for disease state management on diabetes outcomes in primary care by comparing outcomes between physician managed care and pharmacist collaborative care. Methods: A retrospective, observational cohort study was conducted at Ascension Medical Group Via Christi from January 1, 2016 to June 30, 2018. Health outcomes were analyzed in 385 patients with diabetes mellitus collaboratively managed by a physician and pharmacist (collaborative care group). Similar patients managed by physician only (usual care group) were matched to the collaborative care group using nearest neighbor matching. The primary outcome compared HbA1c change between collaborative care and usual care groups at 12 months. Results: The mean change in HbA1c decreased by 1.75% in the collaborative care group and 0.16% in the usual care group (p < 0.0001). The usual care group had a larger number of patients with HbA1c less than 8% at follow-up (p = 0.0049). Additional outcomes included decrease in total cholesterol (p = 0.0023), triglycerides (p = 0.0016), and an increase in PPSV23 pneumococcal vaccinations (p = 0.0255) in the collaborative care group. The usual care group had an increase in PCV13 pneumococcal vaccinations (p = 0.0075). Both ED visits (p = 0.0162) and hospitalizations (p = 0.0225) decreased significantly in the collaborative care group, estimating total savings of $633,015. Conclusions: The collaboration of pharmacists and physicians in the primary care setting is associated with improved diabetes outcomes and substantially reduces costs related to decreased health care use.

ORIGINAL RESEARCH

Identifying Significant Practice Facilitation Delays and Barriers in Primary Care Quality Improvement  

Jiancheng Ye; Renwen Zhang; Jennifer E. Bannon; Ann A. Wang; Theresa L. Walunas; Abel N. Kho; Nicholas D. Soulakis

Corresponding Author:  Nicholas D. Soulakis; Northwestern University Feinberg School of Medicine. Email: nicholas.soulakis@northwestern.edu

Publication: September 10, 2020

Objective: Practice facilitation is an effective approach to implementing quality improvement (QI) interventions in practice-based research networks (PBRNs). Regular facilitator-practice interactions are necessary for successful facilitation. We use time series analysis to characterize the tempo of facilitation activities among 226 primary care practices in a PBRN-based quality QI initiative. We identified significant delays between facilitation activities and evaluated the relationship between the delays, QI intervention completion, and facilitator-documented barriers to implementation. Methods: We performed a secondary analysis of data from the H3 (Healthy Hearts in the Heartland) initiative. Time series analysis was performed to identify significant delays in practice facilitation. Qualitative content analysis was conducted to categorize the barriers to facilitation documented in facilitators’ notes. Regression analyses were used to examine the association between delays, barriers, and QI intervention completion. Results: While most facilitation activities occurred at regular practice-specific tempos, nearly all practices experienced at least one delay. Practices with more delays had lower QI intervention completion. Practices with more delays were more likely to have challenges such as lack of time and staff, lack of staff engagement, technical issues, and staff turnover. These barriers were also associated with lower QI intervention completion. Discussion and Conclusion: Interruptions in the practice-specific tempo of facilitation activities is associated with less QI intervention completion and with the presence of significant challenges such as clinic staffing and technical issues. Our time series-based algorithm for detecting practice-specific delays can be applied to a decision support system that notifies facilitators which practices within PBRN-based initiatives may benefit from additional attention and resources.

ORIGINAL RESEARCH

Obesity in Primary Care: Motivations for Participating in a Pragmatic Clinical Obesity Trial among Rural Family Medicine Clinicians  

Joanna Veazey Brooks, PhD; Kim Kimminau; Stacy McCrea-Robertson; Christie Befort, PhD

Corresponding Author:  Joanna Veazey Brooks, PhD, MBE; University of Kansas School of Medicine. Email:  jbrooks6@kumc.edu

Publication: September 10, 2020

Purpose: To understand the motivations for rural-practicing primary care clinicians to participate in an intensive multi-year pragmatic randomized behavioral obesity intervention trial, Rural Engagement in Primary Care for Optimizing Weight Reduction (RE-POWER). Methods: Structured interviews were conducted with 21 Family Medicine clinicians who were study leads at participating rural practices. Themes emerged through analysis of transcripts and interview notes using the constant comparative method. Results: Analysis revealed three main themes. First, primary care clinicians participated in REPOWER because it provided a concrete plan to address their recurring clinical care need for effective obesity treatment and management. In addition, two other less apparent needs emerged. Participation offered help to frustrated physicians who felt a deep professional duty to care for all of their patients’ problems but were dissatisfied with current obesity management. Participation was also attractive to rural primary care clinicians because it provided a visible and sustainable way to demonstrate their commitment to improving the health of patients and the broader community. Conclusions: Our findings show that clinicians are motivated to try solutions for a clinical problem—in this case obesity—when that clinical problem is also closely connected to a particularly frustrating area of clinical care that challenges their professional identity. Our data suggest that motivation to close the gap between ideal and real practice can become such a high priority that clinicians are sometimes willing to try potential solutions, like engagement in research, that they otherwise would not consider.

ORIGINAL RESEARCH

Bringing Parent Voices into a Pediatric Research Network Through a Virtual Parent Panel

Stacey A. Engster, MD, MS; Carrie Fascetti, LSW; Alexandra Mykita, MA; Kate Pompa, MSCP, LPC; Evelyn Cohen Reis, MD

Corresponding Author:  Stacey A. Engster, MD, MS; University of Pittsburgh School of Medicine. Email: engstersa2@upmc.edu

Publication: September 10, 2020

Background: Additional strategies are needed for longitudinal engagement of parents as key stakeholders in PBRNs. Our objective was to create a virtual Parent Panel for our PBRN to engage parents remotely and utilize their input on child health research. Methods: We utilized an existing online parent survey study to invite parents to participate longitudinally by completing brief, monthly online questionnaires about child health research topics. The existing survey assessed perceptions and preferences for pain management of routine child vaccinations. Results: Of 412 parents who completed the existing online survey, 233 parents expressed interest in participating in our Parent Panel and 131 parents confirmed interest. Of those, 105 parents provided demographic information: most were female (96%), married (83%), white (84%), between 31-40 years (61%), and college degreed (83%). Parents were motivated to participate in our Parent Panel for a variety of reasons: altruism, a unique perspective, having a voice within child health research, a personal history of working within healthcare/research, and previous healthcare experiences with their children. Parents thought their participation could help research, parents, and children. We sent monthly electronic surveys with increasing parent enrollment to up to 131 parents, with monthly response rates ranging from 35-80%. Multiple changes have been implemented in our PBRN based on parent feedback. Conclusion: We successfully created and longitudinally maintained a virtual Parent Panel, using valuable parent feedback to make changes in our PBRN. PBRNs could adapt a similar strategy to virtually engage parents as key stakeholders to improve child health research.

ORIGINAL RESEARCH

Adaptations to Diabetes Shared Medical Appointments for Practice-Based Research: Optimizing Intervention Fit to Context in the Invested in Diabetes Pragmatic Trial

Bethany M. Kwan; Jenny Rementer; Natalie Richie; Andrea L. Nederveld; Phoutdavone Phimphasone-Brady; Martha Sajatovic Donald E. Nease, Jr.; Jeanette A. Waxmonsky

Corresponding Author:  Bethany M. Kwan; University of Colorado Anschutz Medical Campus. Email: bethany.kwan@ucdenver.edu

Publication: September 10, 2020

Introduction: Complex behavioral interventions such as diabetes shared medical appointments (SMAs) should be tested in pragmatic trials. Partnerships between dissemination and implementation scientists and Practice-Based Research Networks (PBRNs) can support adaptation and implementation to ensure such interventions fit the context. This paper describes adaptations to and implementation of the Targeted Training for Illness Management (TTIM) intervention to fit the primary care diabetes context. Methods: The Invested in Diabetes pragmatic trial engaged 22 PBRN practices to compare two models of diabetes SMAs, based on TTIM. We used surveys, interviews, and observation to assess practice contextual factors, such as practice size, location, payer mix, change and work culture, motivation to participate, and clinical and administrative capacity. The Enhanced Replicating Effective Programs (REP) framework was used to guide adaptations to TTIM and implementation in participating practices. Results: Practices varied in size and patient demographics. All had integrated behavioral health, but limited health educators or prescribing providers. Adaptations to SMA delivery accommodated the need for flexibility in personnel and reduced scheduling burden. Adaptations to TTIM content were designed to fit general primary care diabetes and Spanish-speaking patients. Conclusion: Enhanced REP is a useful process framework for adaptation, implementation, and testing of diabetes SMAs in primary care. Adapting intervention content, delivery, and training to fit context can help ensure pragmatic trials have both internal and external validity. Attention Abstract 2 to intervention fit to context can support continued practice engagement in research and sustainability of evidence-based interventions.

FAMILY MEDICINE AND THE HEALTH CARE SYSTEM

A Project ECHO (Extension for Community Healthcare Outcomes) Network Within a Practice-Based Research Network: Report of a Success Story in Oregon  

Margaret McLain McDonnell, MPH; Nancy C. Elder, MD, MSPH; Ron Stock, MD, MA; Miriam Wolf, BS; Anna Steeves-Reece, MPH; Tuesday Graham, BS

Corresponding Author:  Margaret McLain McDonnell, MPH; Oregon Rural Practice-based Research Network. Email:  mclainma@ohsu.edu

Publication: September 10, 2020

Two key advancements in improving the quality of primary care have been Practice Based Research Networks (PBRNs) and Project ECHO (Extension for Community Healthcare Outcomes). PBRNs advance quality through research and transformation projects, often utilizing practice facilitation. Project ECHO uses case-based telementoring to support community clinicians to deliver best-practice care. While some PBRNs sponsor ECHO programs, the Oregon Rural Practice-based Research Network (ORPRN) has created a statewide network for ECHO programs (Oregon ECHO Network, OEN). We facilitated a unique funding stream for the OEN by partnering with payers and health systems. The purpose of this paper is to share our experience of how OEN programs and ORPRN research and transformation projects enhance practice recruitment and retention and improve financial stability. We describe the synergy between ORPRN projects and ECHO programs using three examples, tobacco cessation, chronic pain and opioid prescribing, and diabetes management. We highlight challenges and opportunities in these examples beginning with their development, their implementation and their ultimate alignment, despite varied funding streams and timelines. We believe that incorporating the OEN within ORPRN has been a success for both PBRN research and Project ECHO programs, allowing us to better support primary care practices across the state.

BRIEF REPORT

A PBRN Research Roadmap for Evaluating COVID-19 in Community Health Centers  

Jennifer E. DeVoe, MD, DPhil; Sonja Likumahuwa-Ackman, MID, MPH; Heather E. Angier, PhD, MPH; Nathalie Huguet, PhD; Deborah J. Cohen, PhD; Susan A. Flocke, PhD; Miguel Marino, PhD; Rachel Gold, PhD, MPH

Corresponding Author:  Sonja Likumahuwa-Ackman, MID, MPH; Oregon Health & Science University. Email: likumahu@ohsu.edu

Publication: September 10, 2020

Background: Primary care Practice-based Research Networks (PBRNs) are critical laboratories for generating evidence from real-world settings, including studying natural experiments. Primary care’s response to the novel coronavirus-19 (COVID-19) pandemic is arguably the most impactful natural experiment in our lifetime. The OCHIN PBRN and the BRIDGE-C2 Center: Evaluating the Impact of COVID-19: We briefly describe the OCHIN PBRN of community health centers (CHCs), its partnership with implementation scientists, and how we are leveraging this infrastructure and expertise to create a rapid research response evaluating how CHCs across the country responded to the COVID-19 pandemic. COVID-19 Research Roadmap: Our research agenda focuses on asking: How has care delivery in CHCs changed due to COVID-19? What impact has COVID-19 had on the delivery of preventive services in CHCs? What PBRN services (e.g., data surveillance, training, evidence synthesis) are most impactful to real-world practices? What decision-making strategies were used in the PBRN and its practices to make real-time changes in response to the pandemic? What critical factors in successfully and sustainably transforming primary care are illuminated by pandemic-driven changes? Discussion & Conclusions: PBRNs enable real-world evaluation of practice change and natural experiments, and thus are ideal laboratories for implementation science research. We present a realtime example of how a PBRN ‘Implementation Laboratory’ activated a response to study an historic natural experiment, to help other PBRNs charting a course through this pandemic. 

Ahead-of-Print Version: | FULL PDF |

BRIEF REPORT

Patient, Clinician, and Communication Factors Associated with Colorectal Cancer Screening  

Alex H Krist, MD, MPH; Camille J Hochheimer, PhD; Roy T Sabo, PhD; Jon Puro, MHA; Eric Peele; Paulette Lail-Kashiri, MPH; Sally W Vernon, PhD

Corresponding Author:  Alex H Krist, MD, MPH; Virginia Commonwealth University. Email: ahkrist@vcu.edu

Publication: September 10, 2020

Introduction: Screening for colorectal cancer is beneficial. Yet screening remains suboptimal and underserved populations are at greater risk for not being appropriately screened. While many barriers to screening are understood, less is known about the decision-making process on whether to receive colonoscopy or stool testing influences screening. Methods: As part of a randomized controlled trial to test engaging underserved populations in preventive care through online, personalized, educational material, 2,417 patients age 50 to 74 years were randomly selected from the 70,998 patients with an office visit the year prior and mailed a survey to assess decision-making for colorectal cancer screening. Twenty practices in practice-based research networks from five diverse states participated. Survey data was supplemented with electronic health record data. Results: Among respondents, 64% were or became up to date with screening within three months of their office visit. The main factor associated with being up to date was the length of the patient-clinician relationship (<6 months vs. 5+ years: OR=0.49; 95% CI 0.30-0.80). Sharing the decision about screening options with the clinician was a predictor for being up to date compared to patients who made the decision for themselves (OR 1.75; 95% CI: 1.27-2.44). Only 36% of patients reported being given a choice about screening options. Traditional factors like race, employment, insurance, and education were not associated with screening. Conclusions: Having a long-term relationship with a primary care clinician and sharing decisions may be key drivers to ensure evidence-based preventive care for underserved populations. 

POLICY BRIEF

Gender Differences in Reported Weekly Work Hours among Family Physicians

Elizabeth Wilkinson, BA; Megan Coffman, MS; Stephen Petterson, PhD; Yalda Jabbarpour, MD

Corresponding Author: Elizabeth Wilkinson, BA; Robert Graham Center for Policy Studies in Family Medicine and Primary Care. Email: ewilkinson@aafp.org 

Publication: September 10, 2020

While women are entering family medicine at higher rates than men, little is known about the present differences in practice patterns between male and female family physicians. We used 2017 and 2018 American Board of Family Medicine Family Medicine Certification Examination practice demographic questionnaires to assess average weekly total hours and direct patient care hours by age and gender reported by family physicians. We found a gender gap between both overall hours worked and direct patient care hours, with female family physicians reporting fewer hours across age groups.

COMMENTARY

How We Talk About "Perpetration of Intimate Partner Violence" Matters

Joan Tu, MA; Brian Penti, MD

Corresponding Author: Joan Tu, MA; University of Calgary. Email: joan.tu@ucalgary.ca

Publication: September 10, 2020

Many partners and children who are affected by intimate partner violence (IPV) are unable to leave abusive situations that put their health and safety at risk. Family physicians provide care for people who perpetrate IPV and are in a role that may allow them to recognize and counsel patients who are using violence. Appropriate referrals can potentially help these patients access effective interventions such as certified battering intervention programs in a manner that prevents violence for their families. The language used by physicians can facilitate or impede disclosures among patients perpetrating IPV who may be open or willing to discuss their use of violence. Talking about their behavior in ways that patients perceive as derogatory or confrontational may alienate people who use violence from initiating or engaging in meaningful discussions about their abusive behaviors in clinical settings and getting the help they need to stop their violence. To enable patients to safely talk about their own perpetration of violence, physicians need to develop appropriate language and a nuanced, evidence-based approach to broaching and discussing this issue with patients. As with other patient populations, being labeled may not accurately describe their identity, behavior, nor experiences, and result in them avoiding care. We provide possible examples of respectful non-judgmental language and non-threatening clinically appropriate questions for people who use violence in keeping with trauma-informed approaches. Additional research is needed to identify how best to discuss perpetration of IPV with patients to help initiate change in their behavior while maintaining victim safety.

ORIGINAL RESEARCH

Patient Interest in Video Integration for After-Hours Triage Calls

Janani Sankaran, MD; Sherin M. Menachery; Robert D. Bradshaw, MD, MPH

Corresponding Author: Janani Sankaran, MD; San Joaquin General Hospital. Email: jsankaran@sjgh.org

Publication: September 10, 2020

Purpose: To understand patient attitudes, access towards video calling to enhance efficiency of after-hours triage calls. Methods: We surveyed patients aged 18-89 years. Questions included demographics, preferences, access to video calling devices, perceived advantages and disadvantages of this technology. Answers were entered into Qualtrics database and analyzed using JMP 11. Results: 298 patients agreed to participate, mean age was 47.9 years; 71.6% were female; and 75.1% had access to video calling device. Device proficiency was inversely related to age and greatest in 18-32 years group. 71% of patients enjoyed video communication directly proportional to education (trend test Z = 2.78, p < 0.005). Adjusted for both age and education, respondents with college education or above were 3 times more likely to self-identify as “good’ with video (OR 3.11, 95% CI 1.48-6.64); those under age 48 had even higher proficiency (OR 13.9, 95% CI 4.79-59.34). Patients with prior video experience were 3 times more likely to prefer video calling (RR = 3.46, 95% CI 1.95-6.11). Patients calling their doctor 5 or more times annually preferred video calling significantly more than calling by telephone (RR 1.61, 95% CI 1.31-1.97). Faster contact with the primary care provider (19.8%) was the most perceived advantage. Loss of in-person interaction with doctor (37.1%) was the greatest perceived disadvantage. Conclusions: Patients appear to have access and interest in video communication for afterhour calls. Further studies are needed to evaluate if addition of video component to after-hours triage calls will help reduce unnecessary ED visits.

BRIEF REPORT

Case Report on Anti-HMGCR Myopathy: A Rare and Serious Side Effect of Statins

LT Nathaniel Irvine, MD

Corresponding Author: LT Nathaniel Irvine, MD; Naval Health Clinic New England. Email: nathaniel.j.irvine.mil@mail.mil 

Publication: September 10, 2020

Cardiovascular disease is a leading cause of morbidity and mortality in the United States. Since their initial discovery statins have become the first line treatment in decreasing the risk of cardiovascular disease. While typically well tolerated side effects do occur and tend to affect the musculature. Most are benign and resolve after discontinuing the statin. A subset of immune mediated necrotizing myositis, anti-3-hydroxy-3-methylglutaryl coenzyme A reductase (HMGCR) myopathy is a rare disease that occurs in 0.9 to 1.4 cases per 100,000 people. It causes significant muscle weakness that does not resolve with discontinuation of the statin. Unlike other known complications it has a late onset occurring years after the statin was initially prescribed. It can also present in patients previously treated with statins who have not taken them for several years. This case report details the case of a 54-year old woman who developed anti-HMGCR myopathy after several years of uncomplicated statin use. Differences between other reported cases and this one are discussed including the patient’s strong response to steroid therapy which resulted in the normalization of her serum creatinine kinase (CK) and alleviation of her muscle weakness. This case highlights the need for clinicians to be aware of anti-HMGCR myopathy and to consider it as a potential cause of proximal muscle weakness and persistent serum CK elevations in patients exposed to statins even if they were previously well tolerated by the patient.

RESEARCH LETTER

Primary Care Clinician Decision-Making Around Surveillance Colonoscopies in Older Adults with Prior Adenomas

Nancy L. Schoenborn, MD, MHS; Cynthia M. Boyd, MD, MPH; Jacqueline Massare, BS; Reuben Park; Youngjee Choi, MD; Craig E. Pollack, MD, MHS

Corresponding Author: Nancy L. Schoenborn, MD;  The Johns Hopkins University School of Medicine. Email: nancyli@jhmi.edu

Publication: September 10, 2020

Introduction: While guidelines recommend against routine colorectal cancer screening in adults >75 years and/or those with limited life expectancies, there is no clear guidance on when surveillance colonoscopies following prior adenoma detection should stop. How primary care clinicians weigh the potential risks and benefits of surveillance colonoscopies in older adults with prior adenomas is unknown. Methods: We conducted semi-structured in-person interviews with 30 primary care clinicians from 21 clinics in Maryland. We asked how clinicians decided whether to continue or stop surveillance colonoscopies in older patients with prior adenomas. Interview transcripts were independently coded by two investigators using qualitative content analysis. Results: Participants described a range of decision-making approaches. Some deferred to specialists because they did not feel confident making decisions about stopping surveillance in light of the higher cancer risk involved. Some took a more active role and discussed the decision with patients and/or specialists. Other clinicians felt comfortable stopping surveillance colonoscopies and made these decisions based on patient age, comorbidities, or life expectancy. Discussion: We found a range of decision-making approaches among primary care clinicians on whether to continue surveillance colonoscopies in older adults with prior adenomas. Separate bodies of evidence currently exist on how prior adenoma characteristics influence colorectal cancer risk and on how older age and declining health influence the benefit/harm balance of screening. Information is lacking on the benefits and harms of surveillance in older adults with prior adenomas. Developing the evidence to address this knowledge gap is critically needed to inform clinical decision-making.

CLINICAL REVIEW

Management of Common Skin Injuries, Lacerations, Wounds, Trigger Fingers, and Burns in Primary Care

Ronald Akiki, BS; Raman Mehrzad, MD, MHL, MBA

Corresponding Author: Raman Mehrzad, MD, MHL, MBA; Rhode Island Hospital. Email: raman_m1@hotmail.com

Publication: September 10, 2020

Primary care clinicians encounter many conditions during their day-to-day visits with patients. A few of these common presentations include burns, lacerations, trauma to the hand and wounds, some of which do not require an evaluation by a specialist and can be managed outpatient by primary care clinicians. In this article, we share evidence-based tips to avoid common pitfalls in primary care recognition and management of such presentations as well as guide them to manage many of these conditions themselves. We also provide guidance in the decision to refer the patient to a plastic surgeon or other specialists. 

REFLECTIONS IN FAMILY MEDICINE

Asylum Body Work

Lucy M. Candib, MD

Corresponding Author: Lucy M. Candib, MD; University of Massachusetts Medical School. Email: lcandib@massmed.org

Publication: September 10, 2020

This poem describes how minor injuries to my body repeatedly called to my mind the devastating torture experienced by a man who is seeking asylum in the USA. 

POLICY BRIEF

Proportion of Family Physicians Caring for Children is Declining

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

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

Publication: TBD

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

BRIEF REPORT

Electronic Health Record Reminder Effect on Hepatitis C Antibody Screening

Elie Mulhem; Indigo Brown; Ke Song

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

Publication: TBD

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

ORIGINAL RESEARCH

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

Daniel J. Parente, MD, PhD

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

Publication: TBD

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

POLICY BRIEF

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

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

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

Publication: TBD

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

ORIGINAL RESEARCH

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

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

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

Publication: TBD

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

ORIGINAL RESEARCH

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

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

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

Publication: TBD

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

ORIGINAL RESEARCH

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

V Fitzpatrick; A Rivelli; K Bria; B Chicoine

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

Publication: TBD

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

ORIGINAL RESEARCH

Glucosamine Chondroitin and Overall Mortality in a US NHANES Cohort

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

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

Publication: TBD

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

ORIGINAL RESEARCH

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

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

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

Publication: TBD

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

ORIGINAL RESEARCH

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

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

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

Publication: TBD

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

ORIGINAL RESEARCH

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

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

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

Publication: TBD

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

ORIGINAL RESEARCH

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

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

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

Publication: TBD

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

BRIEF REPORT

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

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

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

Publication: TBD

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

BRIEF REPORT

The Golden Letter: Innovation Collaboration to Reduce Avoidable Hospital Admissions

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

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

Publication: TBD

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

BRIEF REPORT

An Evidence-Based, Systematic Approach to Opioid Prescribing

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

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

Publication: TBD

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

BRIEF REPORT

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

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

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

Publication: TBD

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

BRIEF REPORT

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

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

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

Publication: TBD

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

RESEARCH LETTER

A Proposed Opioid Tapering Tool

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

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

Publication: TBD

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

EVIDENCE-BASED CLINICAL MEDICINE

Current Indications for Tonsillectomy and Adenoidectomy

David A. Randall, MD

Corresponding Author: David A. Randall, MD; Email: davidarandallmd@gmail.com

Publication: TBD

This paper reviews current indications for otolaryngology consultation for tonsillectomy and adenoidectomy (T&A). Despite often being performed concurrently, these procedures should be considered separate surgeries done for different indications. The American Academy of Otolaryngology – Head and Neck Surgery published T&A guidelines for children in 2019. These recommendations are often extrapolated to adults in clinical practice despite less robust literature support for this age group. T&A should be recommended for pediatric obstructive sleep apnea. Specific frequencies of tonsillitis have been identified that indicate benefit from tonsillectomy in normal children; certain modifying health factors warrant consideration of surgery with fewer infections. The Guidelines include consideration of tonsillectomy for poorly validated indications such as halitosis, febrile seizure, dental malocclusion, dysphagia, dysphonia, and psoriasis.

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