Women’s Health, Social Issues, and Quality of Care in Family Medicine

Women’s Health - Period Poverty, Contraception, and Prenatal Care

Are you aware of the term ‘period poverty’ and its implications? Mulki et al.¹ provide a sobering report that three-quarters of responding adolescent and adult women in their geographic area reported missing important life events or schooling, and/or engaging in at-risk hygiene behavior due to lack of adequate hygiene supplies for menses. It is highly unlikely that this problem would be limited to their city or local area alone. Their results suggest that period poverty events can have long-term impacts, such as poor school attendance.

Dehlendorf et al.² tackle the development of contraceptive performance measures that can be used in clinical practice. Given that reproductive decision making is personal to each patient, the authors ask how quality should be defined in contraceptive care. Toward this end, they provide actionable tools to enhance contraceptive care that were developed through the Person-Centered Reproductive Health Program endorsed by the Centers for Medicare and Medicaid Services Consensus-Based Entity. The answers to 3 questions provide measures of quality related to contraceptive needs, counseling, and access to contraceptive methods. A provided graphic figure summarizes the quality measures well.

Nine Community Health Centers undertook a project to improve contraceptive care through counseling.³ Multiple outcomes were measured and most centers were able to improve their care. More information on their process toward improvement is provided in the article. Further, Nexplanon, a Long-Acting Reversible Contraception (LARC) is highly effective, such that a rapid repeat pregnancy after a childbirth is 3 times more likely in those not receiving LARC in the postpartum period.⁴ The challenge is that either Nexplanon or long-acting contraception might not be of interest to the patients, highlighting the importance of understanding how patients’ preferences inform their decisions for broader intervention uptake.

Jean et al.⁵ explore how patient preferences and values inform decisions around seeking prenatal care. In this study, the authors identify reasons why Black women choose to seek prenatal care at a free, faith-based clinic. The report describes 4 key aspects of care that were meaningful to patients, highlighting areas that health care teams could focus on to attract and retain this population.

Improving the Quality and Experience of Family Medicine Care

Here is more evidence supporting a common belief and practice goal in family medicine: continuity between the patient and physician makes a difference. Specifically, this study shows that continuity makes a major financial difference.⁶ Compared with the lower quintile, the higher quintile of patient-to-clinician continuity was associated with about 10% lower total expenditures and fewer hospitalization and emergency department visits. We knew it, but that data has been difficult to find in the literature. Now it is time for family medicine to Advocate Loudly for care practices than enhance continuity. Further, primary care practices with highly integrated behavioral health providers had better outcomes for patients with multiple chronic and behavioral health conditions.⁷ The authors highlight a scoring system and specific target score that should be the goal for practices to attain these outcomes.

The average family physicians completing the American Board of Family Medicine Continuing Certification Questionnaire had about 2000 patients assigned to them (ie, ‘in their panel’).⁸ The authors also provide information on association with other factors, such as presence of nurse practitioners or physicians assistants, and the provision of inpatient care. Panel size was also associated with the number of vulnerable patients in the practice.

To assist family practices, Fennelly et al.⁹ compare 3 health-related social needs screening tools and find great similarity in performance, such as identifying a similar number of social needs for patients. Five items have been identified by the Centers for Medicare and Medicaid Services as appropriate for screening: food, housing, transportation, safety, & utility insecurities. Anderi et al.¹⁰ tackle another concern of many family physicians – patient portal use. The authors specifically look at portal use by patients with hypertension and/or diabetes (ie, patients with chronic illness and usually multiple concurrent medications), and ask how portal use impacts disease management.

It can be a challenge to agree and make changes in how a clinical practice functions. Then after a significant change, sustainability is key. Paul et al.¹¹ report the experience in the Mayo Clinic system that designated one practice as the Family Medicine Learning and Experience (FLEX) Lab to try out new methods of managing care. Their experiences may feel familiar to many, representing both the challenges and hopes for continuous improvement. Sohn et al.¹² find that only a minority of primary care physicians working in the Veterans Health Administration in the upper Midwest prescribed buprenorphine, even though most expressed interest in doing so. The reported reasons for nonuse could be addressed, starting with additional education, and an easily available and responsive eConsult platform. Further, what happens after the research trial is completed? In this case, the authors examine sustainability of shared medical appointments for diabetes self-management and support.¹³

National Social Issues Important in Family Medicine

Primary care often intersects with larger social issues, including those with high stakes. Firearm violence is a leading cause of death in the pediatric population.¹⁴ Batish et al.¹⁴ investigate the topic of screening for potential firearm violence exposure in adolescents and young adults during routine visits, and what to do if the answer to the screening question is “yes.” The baseline questionnaire was repeated at 6 months. Of note, this was a study done in a nonurban primary care setting. A key finding was the willingness of respondents to disclose this potentially sensitive information, and a second finding was the frighteningly high numbers of those who reported gun violence exposure. The use of 3 different means of responding to the questions probably assisted with the nice response rates the researchers attained.

Liu-Galvin and coauthors¹⁵ tackle the (large and concerning) economic burden of Long Covid through lost labor – definitely in the billions. The authors’ real-world estimates for 1 year alone far exceed prior estimates of lost labor costs, highlighting the importance of prevention and vaccination.