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Interventions Must Be Realistic to Be Useful and Completed in Family Medicine

2018-01-12T12:43:42-08:00

Being realistic while helping our patients is this issue's theme. Given the volume of tasks required in family medicine, recommendations for improvements in direct care or care measurement cannot just be evidence-based but must also be realistic. On the list of realistic: ordering antipsychotics for symptoms of dementia in the elderly, despite recommendations to not do so; ordering antidepressants without fear that the patient could develop hypertension; mental health care providers in primary care offices; forced choice for opioid management; plus agenda setting for visit efficiency. Not yet realistic: trigger tools to identify adverse events, and pharmacist recommendations related to pain management before opioid visits. Pneumococcal vaccine compliance is only realistic if recommendations are not recurrently changed, are paid for, and if prior immunizations are known. Increasing task delegation to prevent clinician burnout is not realistic if it burns out the nurses, or if the helpful scribes cannot be afforded. Helpful, yet questionably realistic: Primary care clinician involvement for patients in intensive care units and their families, and problem-solving therapy by family physicians. And, let us add ‘frightening’: few international medical school graduates to serve the underserved. The most frequent diagnoses and most critical diagnoses in family medicine are elucidated.







Burnout in Young Family Physicians: Variation Across States

2018-01-12T12:43:42-08:00

Family physicians 3 years out of training report high rates of emotional exhaustion and depersonalization, symptoms of burnout, with considerable variation between states. High rates of burnout among new family physicians is concerning and significant state-level variation suggests that state-related factors may contribute to or reduce burnout.




Primary Care Physician Perspectives about Antipsychotics and Other Medications for Symptoms of Dementia

2018-01-12T12:43:42-08:00

Background:

Guidelines, policies, and warnings have been applied to reduce the use of medications for behavioral and psychological symptoms of dementia (BPSD). Because of rare dangerous side effects, antipsychotics have been singled out in these efforts. However, antipsychotics are still prescribed "off label" to hundreds of thousands of seniors residing in nursing homes and communities. Our objective was to evaluate how and why primary-care physicians (PCPs) employ nonpharmacologic strategies and drugs for BPSD.

Methods:

Semi-structured interviews analyzed via template, immersion and crystallization, and thematic development of 26 PCPs (16 family practice, 10 general internal medicine) in full time primary-care practice for at least 3 years in Northwestern Virginia.

Results:

PCPs described 4 major themes regarding BPSD management: (1) nonpharmacologic methods have substantial barriers; (2) medication use is not constrained by those barriers and is perceived as easy, efficacious, reasonably safe, and appropriate; (3) pharmacologic policies decrease the use of targeted medications, including antipsychotics, but also have unintended consequences such as increased use of alternative risky medications; and (4) PCPs need practical evidence-based guidelines for all aspects of BPSD management.

Conclusions:

PCPs continue to prescribe medications because they meet patient-oriented goals and because PCPs perceive drugs, including antipsychotics and their alternatives, to be more effective and less dangerous than evidence suggests. To optimally treat BPSD, PCPs need supportive verified prescribing guidelines and access to nonpharmacologic modalities that are as affordable, available, and efficacious as drugs; these require and deserve significant additional research and payer support. Community PCPs should be included in BPSD policy and guideline development.




Antidepressants and Incident Hypertension in Primary Care Patients

2018-01-12T12:43:42-08:00

Objective:

Many ADMs can alter blood pressure (BP), but the research on the effect of antidepressant medication (ADMs) on incident hypertension is mixed. We investigated whether the use of ADMs was associated with the subsequent development of hypertension.

Methods:

A retrospective cohort study was conducted using electronic medical record data from 6224 patients with primary care visits from 2008 to 2015. Prescription orders were used to identify ADM use, and hypertension was defined by medical record diagnosis. Using package insert warnings, a 3-level ADM exposure variable was created: ADMs that increase BP (ADM BP+), ADMs that do not increase BP, and no ADM. Unadjusted and adjusted Cox proportional hazard models were computed to estimate the association between the ADM exposure and incident hypertension.

Results:

Unadjusted results revealed that ADM BP+ use compared with the no ADM group was significantly associated with incident hypertension (hazard ratio, 1.30; 95% confidence interval, 1.08–1.57). After adjusting for covariates, ADM BP+ use was no longer significantly associated with incident hypertension (hazard ratio, 1.20; 95% confidence interval, 0.97–1.49).

Conclusions:

Commonly used ADMs were not associated with incident hypertension after controlling for other factors associated with ADM use and hypertension. Research on potential dose and duration effects is warranted.




'The Hand on the Doorknob: Visit Agenda Setting by Complex Patients and Their Primary Care Physicians

2018-01-12T12:43:42-08:00

Background:

Choosing which issues to discuss in the limited time available during primary care visits is an important task for complex patients with chronic conditions.

Design, Setting, and Participants:

We conducted sequential interviews with complex patients (n = 40) and their primary care physicians (n = 17) from 3 different health systems to investigate how patients and physicians prepare for visits, how visit agendas are determined, and how discussion priorities are established during time-limited visits.

Key Results:

Visit flow and alignment were enhanced when both patients and physicians were effectively prepared before the visit, when the patient brought up highest-priority items first, the physician and patient worked together at the beginning of the visit to establish the visit agenda, and other team members contributed to agenda setting. A range of factors were identified that undermined the ability of patient and physicians to establish an efficient working agenda: the most prominent were time pressure and short visit lengths, but also included differing visit expectations, patient hesitancy to bring up embarrassing concerns, electronic medical record/documentation requirements, differences balancing current symptoms versus future medical risk, nonactionable items, differing philosophies about medications and lifestyle interventions, and difficulty by patients in prioritizing their top concerns.

Conclusions:

Primary care patients and their physicians adopt a range of different strategies to address the time constraints during visits. The primary factor that supported well-aligned visits was the ability for patients and physicians to proactively negotiate the visit agenda at the beginning of the visit. Efforts to optimize care within time-constrained systems should focus on helping patients more effectively prepare for visits. Physicians should ask for the patient's agenda early, explain visit parameters, establish a reasonable number of concerns that can be discussed, and collaborate on a plan to deal with concerns that cannot be addressed during the visit.




Changing Patterns of Mental Health Care Use: The Role of Integrated Mental Health Services in Veteran Affairs Primary Care

2018-01-12T12:43:42-08:00

Objective:

Aiming to foster timely, high-quality mental health care for Veterans, VA's Primary Care–Mental Health Integration (PC-MHI) embeds mental health specialists in primary care and promotes care management for depression. PC-MHI and patient-centered medical home providers work together to provide the bulk of mental health care for primary care patients with low-to-moderate-complexity mental health conditions. This study examines whether increasing primary care clinic engagement in PC-MHI services is associated with changes in patient health care utilization and costs.

Methods:

We performed a retrospective longitudinal cohort study of primary care patients with identified mental health needs in 29 Southern California VA clinics from October 1, 2008 to September 30, 2013, using electronic administrative data (n = 66,638). We calculated clinic PC-MHI engagement as the proportion of patients receiving PC-MHI services among all primary care clinic patients in each year. Capitalizing on variation in PC-MHI engagement across clinics, our multivariable regression models predicted annual patient use of 1) non-primary care based mental health specialty (MHS) visits, 2) total mental health visits (ie, the sum of MHS and PC-MHI visits), and 3) health care utilization and costs. We controlled for year- and clinic-fixed effects, other clinic interventions, and patient characteristics.

Results:

Median clinic PC-MHI engagement increased by 8.2 percentage points over 5 years. At any given year, patients treated at a clinic with 1 percentage-point higher PC-MHI engagement was associated with 0.5% more total mental health visits (CI, 0.18% to 0.90%; P = .003) and 1.0% fewer MHS visits (CI, –1.6% to –0.3%; P = .002); this is a substitution rate, at the mean, of 1.5 PC-MHI visits for each MHS visit. There was no PC-MHI effect on other health care utilization and costs.

Conclusions:

As intended, greater clinic engagement in PC-MHI services seems to increase realized accessibility to mental health care for primary care patients, substituting PC-MHI for MHS visits, without increasing acute care use or total costs. Thus, PC-MHI services within primary care clinics may improve mental health care value at the patient population level. More research is needed to understand the relationship between clinic PC-MHI engagement and clinical quality of mental health care.




One Year of Family Physicians' Observations on Working with Medical Scribes

2018-01-12T12:43:42-08:00

Purpose:

The immense clerical burden felt by physicians is one of the leading causes of burnout. Scribes are increasingly being used to help alleviate this burden, yet few published studies investigate how scribes affect physicians' daily work, attitudes and behaviors, and relationships with patients and the workplace.

Methods:

Using a longitudinal observational design, data were collected, over 1 year, from 4 physicians working with 2 scribes at a single academic family medicine practice. Physician experience was measured by open-ended written reflections requested after each 4-hour clinic session. A data-driven codebook was generated using a constant comparative method with grounded theory approach.

Results:

A total of 361 physician reflections were completed, yielding 150 distinct excerpts; 289 codes were assigned. The 11 themes that emerged were further categorized under 4 domains. The most frequently recurring domain was clinic operations, which comprised 51.6% of the codes. Joy of practice, quality of care, and patient experience comprised 22.1%, 16.3%, and 10.0% of the codes, respectively.

Conclusions:

Our study suggests that integrating scribes into a primary care clinic can produce positive outcomes that go beyond reducing clerical burden for physicians. Scribes may benefit patient experience, quality of care, clinic operations, and joy of practice.




Structured Management of Chronic Nonmalignant Pain with Opioids in a Rural Primary Care Office

2018-01-12T12:43:42-08:00

Introduction:

The use of opioid medication for nonmalignant chronic pain (NMCP) increased dramatically during the last 20 years. There have been regulatory changes implemented to reduce the risk of harm to both patients and society. Much of the burden of monitoring these patients is falling on primary care physicians (PCPs), who do not have the time or resources to handle what is entailed in a best-practice approach to NMCP.

Methods:

A retrospective study was conducted with all patients on opioid medication for NMCP who were enrolled onto an individual PCP's practice. All were required to engage with a new care system. Patients had the option to remain on opioids, to wean opioids, or to transfer care. Patients who remained in the practice on opioids were required to have an office visit on a day dedicated solely to NMCP every 3 months. Each visit involved verifying the controlled substance contract, a urine drug screen, board of pharmacy monitoring, pain-targeted history and physical, calculation of the average morphine equivalents used, and evaluations of pain, functional status, and mood. Characteristics more likely to lead to weaning from opioids were monitored, as was the program effect on the patients remaining on opioids.

Results:

With this practice model, 32 patients treated with opioids for NMCP were enrolled. Of these, 38% (n = 12) elected to wean opioids, 53% (n = 17) continued opioid medication, and 9% (n = 3) transferred care. Mean morphine equivalent mg/day was the prime determinant for ability to wean (17.01 mg/day) compared with maintaining (30.61 mg/day) (P = .0397; CI, 0.68 to 26.51). Patients maintaining opioid treatment showed no statistically significant change in any measured data point from beginning until end of the evaluation period.

Conclusion:

Given the choice of following a specific structured care system of opioid medication management or leaving the practice, most patients agreed to the structured system. This approach provided a high degree of compliance with controlled substance regulations and is associated with a reduced number of opioid prescriptions. Patients who were on lower doses of opioid medication are more likely to wean their use with this model.




Primary Care Physician Involvement in Shared Decision Making for Critically Ill Patients and Family Satisfaction with Care

2018-01-12T12:43:42-08:00

Purpose:

An intensive care unit (ICU) patient's primary care physician (PCP) may be able to assist family with certain ICU shared medical decisions. We explored whether families of patients in nonopen ICUs who nevertheless report involvement of a patient's PCP in medical decision making are more satisfied with ICU shared decision making than families who do not.

Methods:

Between March 2013 and December 2015, we administered the Family Satisfaction in the ICU 24 survey to family members of adult neuroscience ICU patients. We compared the mean score for the survey subsection regarding shared decision making (graded on a 100-point scale), as well as individual survey items, between those who reported the patient's PCP involvement in any medical decision making versus those who did not.

Results:

Among 263 respondents, there was no difference in mean overall decision-making satisfaction scores for those who reported involvement (81.1; SD = 15.2) versus those who did not (80.1; SD = 12.8; P = .16). However, a higher proportion reporting involvement felt completely satisfied with their 1) inclusion in the ICU decision making process (75.9% vs 61.4%; P = .055), and 2) control over the care of the patient (73.6% vs 55.6%; P = .02), with no difference regarding consistency of clinical information provided by the medical team (64.8% vs 63.5%; P = 1.00).

Conclusions:

Families who report involvement of a patient's PCP in medical decision making for critically ill patients may be more satisfied than those who do not with regard to specific aspects of ICU decision making. Further research would help understand how best to engage PCPs in shared decisions.




Patient Perspectives on Discussions of Electronic Cigarettes in Primary Care

2018-01-12T12:43:42-08:00

Purpose:

Patient preferences regarding the role of the primary care provider (PCP) in discussing electronic cigarette (e-cigarette) use are unknown.

Methods:

We administered a cross-sectional survey to 568 adult patients in a family medicine clinic to explore e-cigarette use, sources of information on e-cigarettes, perceived knowledge about e-cigarette health effects, views regarding PCP knowledge of e-cigarettes, interest in discussing e-cigarettes with PCPs and preferred format for e-cigarette information. We performed 2 testing with a 2-tailed P < .05 to assess associations between e-cigarette use and these measures.

Results:

The prevalence of e-cigarette use was 10% for recent (≤30 days) use and 29% for nonrecent (>30 days) use. Prevalence was significantly higher among those who were younger, less educated, or smoked cigarettes, but did not vary by sex or self-reported health status. Roughly one quarter of participants believed they were knowledgeable about the health effects of e-cigarettes, secondhand smoke, and quitting cigarettes. Sources of e-cigarette information included television advertisements (56.6%), friends and family (49.9%), or e-cigarette shops (25.5%), but included physician offices much less frequently (6.0%). Although 30.2% disagreed that their PCP knew a lot about e-cigarettes, 62.0% were comfortable discussing e-cigarettes with their PCP. However, only 25% of all patients wanted their PCP to discuss e-cigarettes with them, but 62.0% of recent e-cigarette users wanted such a discussion. Most preferred a brief discussion or handout to a lengthy discussion.

Conclusion:

PCPs were infrequent sources of information for patients regarding e-cigarette use. PCPs need evidence-based strategies to help them address e-cigarettes in primary care.




Task Delegation and Burnout Trade-offs Among Primary Care Providers and Nurses in Veterans Affairs Patient Aligned Care Teams (VA PACTs)

2018-01-12T12:43:42-08:00

Purpose:

Appropriate delegation of clinical tasks from primary care providers (PCPs) to other team members may reduce employee burnout in primary care. However, (1) the extent to which delegation occurs within multidisciplinary teams, (2) factors associated with greater delegation, and (3) whether delegation is associated with burnout are all unknown.

Methods:

We performed a national cross-sectional survey of Veterans Affairs (VA) PCP-nurse dyads in Department of VA primary care clinics, 4 years into the VA's patient-centered medical home initiative. PCPs reported the extent to which they relied on other team members to complete 15 common primary care tasks; paired nurses reported how much they were relied on to complete the same tasks. A composite score of task delegation/reliance was developed by taking the average of the responses to the 15 questions. We performed multivariable regression to explore predictors of task delegation and burnout.

Results:

Among 777 PCP-nurse dyads, PCPs reported delegating tasks less than nurses reported being relied on (PCP mean ± standard deviation composite delegation score, 2.97± 0.64 [range, 1–4]; nurse composite reliance score, 3.26 ± 0.50 [range, 1–4]). Approximately 48% of PCPs and 35% of nurses reported burnout. PCPs who reported more task delegation reported less burnout (odds ratio [OR], 0.62 per unit of delegation; 95% confidence interval [CI], 0.49–0.78), whereas nurses who reported being relied on more reported more burnout (OR, 1.83 per unit of reliance; 95% CI, 1.33–2.5).

Conclusions:

Task delegation was associated with less burnout for PCPs, whereas task reliance was associated with greater burnout for nurses. Strategies to improve work life in primary care by increasing PCP task delegation must consider the impact on nurses.




Primary Care Physicians' Struggle with Current Adult Pneumococcal Vaccine Recommendations

2018-01-12T12:43:42-08:00

Introduction:

In 2012, the Advisory Committee on Immunization Practices recommended 13-valent pneumococcal conjugate vaccine (PCV13) in series with 23-valent pneumococcal polysaccharide vaccine (PPSV23) for at-risk adults ≥19; in 2014, it expanded this recommendation to adults ≥65. Primary care physicians' practice, knowledge, attitudes, and beliefs regarding these recommendations are unknown.

Methods:

Primary care physicians throughout the U.S. were surveyed by E-mail and post from December 2015 to January 2016.

Results:

Response rate was 66% (617 of 935). Over 95% of respondents reported routinely assessing adults' vaccination status and recommending both vaccines. A majority found the current recommendations to be clear (50% "very clear," 38% "somewhat clear"). Twenty percent found the upfront cost of purchasing PCV13, lack of insurance coverage, inadequate reimbursement, and difficulty determining vaccination history to be "major barriers" to giving these vaccines. Knowledge of recommendations varied, with 83% identifying the PCV13 recommendation for adults ≥65 and only 21% identifying the recommended interval between PCV13 and PPSV23 in an individual <65 at increased risk.

Conclusions:

Almost all surveyed physicians reported recommending both pneumococcal vaccines, but a disconnect seems to exist between perceived clarity and knowledge of the recommendations. Optimal implementation of these recommendations will require addressing knowledge gaps and reported barriers.




Impact of Pharmacist Previsit Input to Providers on Chronic Opioid Prescribing Safety

2018-01-12T12:43:42-08:00

Introduction:

Primary care providers (PCPs) account for half of opioid prescriptions, often feel chronic pain patients are challenging to manage, and there is wide variability in practice patterns. The purpose of this pilot study was to evaluate the impact of a previsit pharmacist review of high-risk patients treated with opioids for chronic pain on compliance to guideline recommendations at a family medicine residency clinic.

Methods:

All adult patients with an appointment for chronic pain who were prescribed >50 morphine milligram equivalents (MMEs)/day had charts reviewed by a pharmacist before each appointment; recommendations were sent electronically to the provider before the appointment. After 4 months of implementation, each patient's chart was manually reviewed to gather outcome variables. The primary outcomes were the mean MMEs/day and pain scores.

Results:

Pharmacist previsit recommendations were provided for 45 patients. When comparing outcomes before and after intervention, the mean MMEs/day decreased by 14% (P < .001), with no change in pain scores (P = .783). Statistically significant improvements were noted in multiple other secondary opioid safety outcomes.

Conclusion:

Clinical pharmacists providing previsit recommendations was associated with decreased opioid utilization with no corresponding increase in pain scores and increased compliance to guideline recommendations.




The Accuracy of Trigger Tools to Detect Preventable Adverse Events in Primary Care: A Systematic Review

2018-01-12T12:43:42-08:00

Purpose:

To understand the ability of trigger tools to detect preventable adverse events (pAEs) in the primary care outpatient setting using the Institute for Healthcare Improvement's (IHI) Outpatient Adverse Event Trigger Tool (IHI Tool).

Methods:

The OVID MEDLINE and OVID MEDLINE In-process and non-Indexed citations databases were queried using controlled vocabulary and Medical Subject Headings related to the concepts "primary care" and "adverse events." Included articles were conducted in the outpatient setting, used at least 1 of the triggers identified in the IHI Tool, and identified pAEs of any type. Articles were selected for inclusion based first on assessment of titles then abstracts by 2 trained reviewers independently, followed by full text review by 2 authors.

Results:

Our search identified 6435 unique articles, and we included 15 in our review. The most common studied trigger was laboratory abnormalities. The most common pAEs were medication errors followed by unplanned hospitalizations. The effectiveness of triggers in identifying AEs varied widely.

Conclusion:

There is insufficient data on the IHI Tool and its use to identify pAEs in the general real-world outpatient setting. Health care providers of the primary care setting may benefit from better trigger tools and other methods to help them detect pAEs. More research is needed to further evaluate the effectiveness of trigger tools to reduce barriers of cost and time and improve patient safety.




Frequency and Criticality of Diagnoses in Family Medicine Practices: From the National Ambulatory Medical Care Survey (NAMCS)

2018-01-12T12:43:42-08:00

Background:

Family medicine is a specialty of breadth, providing comprehensive health care for the individual and the family that integrates the broad scope of clinical, social, and behavioral sciences. As such, the scope of practice (SOP) for family medicine is extensive; however, over time many family physicians narrow their SOP. We sought to provide a nationally representative description of the most common and the most critical diagnoses that family physicians see in their practice.

Methods:

Data were extracted from the 2012 National Ambulatory Medical Care Survey (NAMCS) to select all ICD-9 codes reported by family physicians. A panel of family physicians then reviewed 1893 ICD-9 codes to place each code into an American Board of Family Medicine Family Medicine Certification Examination test plan specifications (TPS) category and provide a rating for an Index of Harm (IoH).

Results:

An analysis of all 1893 ICD-9 codes seen by family physicians in the 2012 NAMCS found that 198 ICD-9 codes could not be assigned a TPS category, leaving 1695 ICD-9 codes in the dataset. Top 10 lists of ICD-9 codes by TPS category were created for both frequency and IoH.

Conclusions:

This study provides a nationally representative description of the most common diagnoses that family physicians are seeing in their practice and the criticality of these diagnoses. These results provide insight into the domain of the specialty of family medicine. Medical educators may use these results to better tailor education and training to practice.




The Effectiveness of Problem-Solving Therapy for Primary Care Patients' Depressive and/or Anxiety Disorders: A Systematic Review and Meta-Analysis

2018-01-12T12:43:42-08:00

Background:

There is increasing demand for managing depressive and/or anxiety disorders among primary care patients. Problem-solving therapy (PST) is a brief evidence- and strength-based psychotherapy that has received increasing support for its effectiveness in managing depression and anxiety among primary care patients.

Methods:

We conducted a systematic review and meta-analysis of clinical trials examining PST for patients with depression and/or anxiety in primary care as identified by searches for published literature across 6 databases and manual searching. A weighted average of treatment effect size estimates per study was used for meta-analysis and moderator analysis.

Results:

From an initial pool of 153 primary studies, 11 studies (with 2072 participants) met inclusion criteria for synthesis. PST reported an overall significant treatment effect for primary care depression and/or anxiety (d = 0.673; P < .001). Participants' age and sex moderated treatment effects. Physician-involved PST in primary care, despite a significantly smaller treatment effect size than mental health provider only PST, reported an overall statistically significant effect (d = 0.35; P = .029).

Conclusions:

Results from the study supported PST's effectiveness for primary care depression and/or anxiety. Our preliminary results also indicated that physician-involved PST offers meaningful improvements for primary care patients' depression and/or anxiety.




Is It Idiopathic Pulmonary Fibrosis or Not?

2018-01-12T12:43:42-08:00

Pulmonary fibrosis is not uncommon. Usual interstitial pneumonitis (UIP)/idiopathic pulmonary fibrosis (IPF) is the most common of the idiopathic pulmonary fibrotic diseases and has the worst prognosis with a mean life expectancy of 3.8 years. The American Thoracic Society has provided guidelines for the accurate diagnosis of IPF.

In 2014, 2 antifibrotic medications were approved in the United States that target the multiple fibrotic pathways of UIP, which increased the need for early and accurate diagnosis of IPF. The early and correct diagnosis is hampered by mimickers that include nonspecific interstitial pneumonitis, chronic hypersensitivity pneumonitis, and fibrotic sarcoidosis. Careful history taking, serologic testing, and Computer Tomography (CT) inspection can frequently make the correct diagnosis without need of invasive procedure. The purpose of this article is to share the most important aspects of the clinical and radiology presentation of IPF and its mimickers to enhance primary care clinician's ability to correctly and noninvasively diagnose UIP/IPF.




The Intersection of National Immigration and Healthcare Policy

2018-01-12T12:43:42-08:00

Immigration policy and health care policy remain principal undertakings of the federal government. The two have recently been pursued independently in the judicial and legislative arenas. Unbeknownst to many policymakers, however, national immigration policy and health care policy are linked in ways that, if unattended, could undermine the well-being of a significant portion of the US population, specifically medically underserved rural and urban populations. Using current data from a workforce report of the Association of American Colleges and the published literature, we demonstrate the significant impact that contemporary immigration policy directives may have on the number and distribution of international medical graduates who currently provide—and by the year 2025 will provide—a significant portion of primary health care in the United States, especially in underserved small urban and rural communities.




Diplomate Status: A Matter of Distinction

2018-01-12T12:43:42-08:00













Multiple Practical Facts and Ideas to Improve Family Medicine Care

2017-11-27T08:01:19-08:00

Seconds count in a study on the best electronic health note format to reduce medical record charting time and increase accuracy. Directly observed family physician work is compared with Current Procedural Terminology (CPT) coding examples and notably under-recognized. This issue contains articles from single practices that that implemented new methods of care and other reports on practice innovations that can be more broadly implemented. We have articles on opioid medication use for acute low back pain in primary care, an electronic chronic pain consult service, a key question to identify potential opioid misuse risk, and newly implemented screening for other substances of abuse. Omissions (or gaps) in care are also highlighted: from the common types of omissions identified by primary care clinicians, self-reported low levels of substance use screening by family medicine prenatal care providers, and inadequate and inadequately available hospital discharge summaries. In addition, the most important alarm symptoms for a cancer diagnosis are reported.




Dynamic Electronic Health Record Note Prototype: Seeing More by Showing Less

2017-11-27T08:01:19-08:00

Introduction:

Cluttered documentation may contribute adversely to physician readers’ cognitive load, inadvertently obscuring high-value information with less valuable information. We test the hypothesis that a novel, collapsible assessment, plan, subjective, objective (APSO) note design would be faster, more accurate, and more satisfying to use than a conventional electronic health record (EHR) subjective, objective, assessment, plan (SOAP) note for finding information needed for ambulatory chronic disease care.

Methods:

We iteratively developed physician clinic note prototypes with features designed to emphasize more important information and de-emphasize less clinically relevant information. Sixteen primary care physicians reviewed comparable clinic notes with the 4 note styles presented in random order to find key information in the notes during timed tasks. The 4 note styles were denoted A (traditional SOAP note), B (2-column APSO note), C (collapsible APSO note), and D (2-column collapsible APSO note). The 4 unique note styles were designed to have equal amounts of information in each section. We simulated their utility for clinical practice by imposing time limits and by interrupting 1 of the tasks with a typical clinical interruption. For each session, we recorded audio, computer-screen activity, eye tracking, and made field notes. We obtained usability ratings (System Usability Scale), new feature preference ratings, and performed semistructured post-task interviews with subsequent content analysis. We compared the effectiveness of the 4 note styles by measuring time on task, task success (accuracy), and effort as measured by NASA Task Load Index.

Results:

Note styles C and D were significantly faster than A and B for the Review of Systems and Physical Examination tasks, as we expected. Notes B and C had the best success (finding requested data) scores. Users strongly endorsed all the new note features incorporated into the new note prototypes. Previously expressed concerns about temporarily hiding parts of the note (using the accordion display design pattern) were allayed. Usability ratings for note A were worst but comparably better for note styles B, C, and D.

Discussion:

The new APSO note prototypes performed better than the traditional SOAP note format for speed, task success (accuracy), and usability for physician users acquiring information needed for a typical chronic disease visit in primary care. Moving Assessment and Plan to the top is 1 easily accomplished feature change. Innovative documentation displays of EHR data can safely improve information display without eliminating data from the record of the visit.




Implementation of a Standardized Medication Therapy Management Plus Approach within Primary Care

2017-11-27T08:01:19-08:00

Purpose:

The purpose of this study was to implement a clinical pharmacist-led medication therapy management (MTM) service within a primary-care setting that is enhanced by 1) a clinical decision support system (CDSS) that includes a unique combination of medication risk mitigation factors, which aids the pharmacist in interpreting the medication profile, and 2) pharmacogenomics (PGx) testing.

Methods:

This was a service implementation study, whereby Medicare beneficiaries were eligible if they were patients of Elmwood Family Physicians, a private family, primary care practice with 2 locations in New Jersey, and were on at least 7 medications. Patients had a medication reconciliation completed by a pharmacist and performed a PGx buccal swab. Patient information was run through a CDSS to aid the pharmacist with screening for multidrug interactions and assessing patient’s medication-related risks. The output of the CDSS was used to create recommendations and provide a consult to the physicians. Recommendations were followed up by return of the consult.

Results:

Enrolled patients used a mean (± standard deviation) of 12.1 (± 4.6) medications. The turnaround time for the MTM Plus consults was 11.7 (± 6.2) days. During the consults, the pharmacist identified 138 medication-related problems (MRPs). The most common MRPs were drug-drug interactions (29.0%) and drug-gene interactions (DGIs; 24.6%).

Conclusion:

Implementing a clinical pharmacist-led MTM Plus service in the primary care setting is feasible. This study highlights that DGIs are common in older adults in family practice and indicates that PGx testing identifies additional MRPs that may otherwise go unnoticed in these patients. The experiences we shared can aid other clinicians in establishing successful MTM Plus services. Future studies should also measure the impact of such personalized medicine services on economic, clinical, and humanistic outcomes. This study has been registered with ClinicalTrials.gov (study No. NCT02748148).




Impact of a Novel Wellness Group Visit Model on Obesity and Behavior Change

2017-11-27T08:01:19-08:00

Background:

Increasing weight-related illness in the United States has led to 120,000 preventable deaths annually and soaring medical costs. Treating patients in a group setting may be more effective than traditional care (TC) in achieving behavioral change. We studied a wellness-group (WG) model to determine whether it could generate sustained behavioral change and weight loss in a subset of patients.

Methods:

99 patients with a body mass index (BMI) >30 kg/m2 from 1 family practice volunteered to participate in a 15-visit WG co-led by a family physician and dietitian. We compared these WG patients with 190 patients who had a BMI >30 kg/m2 and who received TC in the form of an annual physical during the same time period. The patients were mostly white, highly educated, and of middle-to-high-income households. All patients were surveyed on their ability to sustain 12 wellness behaviors 3 months after completing their WG or physical. Patients were not paid to complete the survey. We reviewed medical charts for weight, BMI, blood pressure, lipids, and glycohemoglobin before and at least 1 year after the WG or physical. WG patients’ weights were recorded at the beginning and end of the WG as was the weight from their most recent office visit.

Results:

WG patients were more likely to report sustaining 12 of 12 wellness behaviors than patients who received TC with an annual physical. At 1 year, WG patients also lost more weight than TC patients (–13.21 pounds for WG vs +1.94 pounds for TC) and achieved greater reduction in their systolic blood pressure (–6.96 mm Hg for WG vs –1.13 mm Hg for TC). Average weight gained after the WG was 6.9 pounds. Among WG patients, 61% lost a clinically relevant amount of weight (>5%). Of the WG patients who lost clinically relevant weight, 71% were able to maintain at least half of their weight loss 3 years later.

Conclusions:

An observational study of a novel WG model showed that WG patients sustained wellness behaviors and weight loss over time when compared with patients who received TC.




The Full Scope of Family Physicians Work Is Not Reflected by Current Procedural Terminology Codes

2017-11-27T08:01:19-08:00

Background:

The purpose of this study was to characterize the content of family physician (FP) clinic encounters, and to count the number of visits in which the FPs addressed issues not explicitly reportable by 99211 to 99215 and 99354 Current Procedural Terminology (CPT) codes with current reimbursement methods and based on examples provided in the CPT manual.

Methods:

The data collection instrument was modeled on the National Ambulatory Medical Care Survey. Trained assistants directly observed every other FP-patient encounter and recorded every patient concern, issue addressed by the physician (including care barriers related to health care systems and social determinants), and treatment ordered in clinics affiliated with 10 residencies of the Residency Research Network of Texas. A visit was deemed to include physician work that was not explicitly reportable if the number or nature of issues addressed exceeded the definitions or examples for 99205/99215 or 99214 + 99354 or a preventive service code, included the physician addressing health care system or social determinant issues, or included the care of a family member.

Results:

In 982 physician-patient encounters, patients raised 517 different reasons for visit (total, 5278; mean, 5.4 per visit; range, 1 to 16) and the FPs addressed 509 different issues (total issues, 3587; mean, 3.7 per visit; range, 1 to 10). FPs managed 425 different medications, 18 supplements, and 11 devices. A mean of 3.9 chronic medications were continued per visit (range, 0 to 21) and 4.6 total medications were managed (range, 0 to 22). In 592 (60.3%) of the visits the FPs did work that was not explicitly reportable with available CPT codes: 582 (59.3%) addressed more numerous issues than explicitly reportable, 64 (6.5%) addressed system barriers, and 13 (1.3%) addressed concerns for other family members.

Conclusions and relevance:

FPs perform cognitive work in a majority of their patient encounters that are not explicitly reportable, either by being higher than the CPT example number of diagnoses per code or the type of problems addressed, which has implications for the care of complex multi-morbid patients and the growth of the primary care workforce. To address these limitations, either the CPT codes and their associated rules should be updated to reflect the realities of family physicians’ practices or new billing and coding approaches should be developed.




Primary Care Providers Perspectives on Errors of Omission

2017-11-27T08:01:19-08:00

Background:

Despite recent focus on patient safety in primary care, little attention has been paid to errors of omission, which represent significant gaps in care and threaten patient safety in primary care but are not well studied or categorized. The purpose of this study was to develop a typology of errors of omission from the perspectives of primary care providers (PCPs) and understand what factors within practices lead to or prevent these omissions.

Methods:

A qualitative descriptive design was used to collect data from 26 PCPs, both physicians and nurse practitioners, from the New York State through individual interviews. One researcher conducted all interviews, which were audiotaped, transcribed verbatim, and analyzed in ATLAS.ti, Berlin by 3 researchers using content analysis. They immersed themselves into data, read transcripts independently, and conducted inductive coding. The final codes were linked to each other to develop the typology of errors of omission and the themes. Data saturation was reached at the 26th interview.

Results:

PCPs reported that omitting patient teaching, patient followup, emotional support, and addressing mental health needs were the main categories of errors of omission. PCPs perceived that time constraints, unplanned patient visits and emergencies, and administrative burden led to these gaps in care. They emphasized that organizational support and infrastructure, effective teamwork and communication, and preparation for the patient encounter were important safeguards to prevent errors of omission within their practices.

Discussion:

Errors of omission are common in primary care and could threaten patient safety. Efforts to eliminate them should focus on strengthening organizational attributes of practices, improving teamwork and communication, and assigning manageable workload to PCPs.

Conclusions:

Practice and policy change is necessary to address gaps in care and prevent them before they result in patient harm.




Family Physicians Perceived Prevalence, Safety, and Screening for Cigarettes, Marijuana, and Electronic-Nicotine Delivery Systems (ENDS) Use during Pregnancy

2017-11-27T08:01:19-08:00

Objective:

Assess perceptions of prevalence, safety, and screening practices for cigarettes and secondhand smoke exposure (SHSe), marijuana (and synthetic marijuana), electronic nicotine delivery systems (ENDS; eg, e-cigarettes), nicotine-replacement therapy (NRT), and smoking-cessation medications during pregnancy, among primary care physicians (PCPs) providing obstetric care.

Methods:

A web-based, cross-sectional survey was e-mailed to 3750 US physicians (belonging to organizations within the Council of Academic Family Medicine Educational Research Alliance). Several research groups’ questions were included in the survey. Only physicians who reported providing "labor and delivery" obstetric care responded to questions related to the study objectives.

Results:

A total of 1248 physicians (of 3750) responded (33.3%) and 417 reported providing labor and delivery obstetric care. Obstetric providers (N = 417) reported cigarette (54%), marijuana (49%), and ENDS use (24%) by "Some (6% to 25%)" pregnant women, with 37% endorsing that "Very Few (1% to 5%)" pregnant women used ENDS. Providers most often selected that very few pregnant women used NRT (45%), cessation medications (ie, bupropion or varenicline; 37%), and synthetic marijuana (23%). Significant proportions chose "Do not Know" for synthetic marijuana (58%) and ENDS (27%). Over 90% of the sample perceived that use of or exposure to cigarettes (99%), synthetic marijuana (99%), SHS (97%), marijuana (92%), or ENDS (91%) were unsafe during pregnancy, with the exception of NRT (44%). Providers most consistently screened for cigarette (85%) and marijuana use (63%), followed by SHSe in the home (48%), and ENDS (33%) and synthetic marijuana use (28%). Fewer than a quarter (18%) screened consistently for all substances and SHSe. One third (32%) reported laboratory testing for marijuana and 3% reported laboratory testing for smoking status.

Conclusion:

This sample of PCPs providing obstetric care within academic settings perceived cigarettes, marijuana, and ENDS use to be prevalent and unsafe during pregnancy. Opportunities for increased screening during pregnancy across these substances were apparent.




Information Transfer and the Hospital Discharge Summary: National Primary Care Provider Perspectives of Challenges and Opportunities

2017-11-27T08:01:19-08:00

Purpose:

The hospital discharge summary (HDS) serves as a critical method of patient information transfer between hospitalist and primary care provider (PCP). This study was designed to increase our understanding of PCP preferences for, and perceived deficiencies in, the discharge summary.

Methods:

We designed a mail survey that was sent to a random sample of 800 American Academy of Family Physicians members nationally. The survey response rate was 59%. We analyzed the availability of summaries at hospital followup, whether all desired information was contained in the summary and whether certain specific items were completed. Provider subgroup analysis was performed.

Results:

The strongest predictor of discharge summary availability at posthospital followup is direct access to inpatient data. Respondents (27.5%) had a summary available 0% to 40% of the time, 41.4% noted availability 41% to 80% of the time and 31.1% >80% of the time; if a provider had access to inpatient data they tended to have a discharge summary available to them (P < .0001). Providers also described significant content deficits: 26.5% of providers noted the summary contained all information needed 0% to 40% of the time, 48.5% of providers noted this 41% to 80% of the time and only 25% >80% of the time. Specific summary items considered "very important" by providers included medication list (94% of respondents), diagnosis list (89%), and treatment provided (87%).

Conclusions:

Opportunities remain in timely delivery of a complete HDS to the PCP. Further multifaceted practice redesign should be directed at optimizing this critical information transfer tool, potentially encompassing electronic medical record utilization and specific training for clinicians preparing summaries. Initial efforts should focus on ensuring availability of a complete summary (containing items deemed important by PCPs including medication list, diagnosis list, and treatment provided) at the posthospital follow-up visit.




Supporting Better Access to Chronic Pain Specialists: The Champlain BASE™ eConsult Service

2017-11-27T08:01:19-08:00

Introduction:

Excessive wait times for chronic pain are associated with significant reductions in quality of life and worse health outcomes. The Champlain BASE (Building Access to Specialists through eConsultation) eConsult service can improve access to specialist care for patients with chronic pain by facilitating electronic communication between primary care providers (PCPs) and specialists. We explored the content of eConsult cases sent to chronic pain specialists to identify the major themes emerging from exchanges between PCPs and specialists regarding patients with chronic pain.

Methods:

We conducted a thematic analysis of eConsult cases submitted to chronic pain specialists between April 1, 2011 and October 31, 2014, using a constant comparison approach.

Results:

PCPs submitted 128 cases to chronic pain specialists during the study period. The study team coded 48 cases before data saturation was reached. PCPs sought advice for treating patients with chronic pain arising from a range of medical problems, and who frequently struggled with issues of mental health, substance dependence, and social complexity. Specialists responded with advice on pain management and treatment, directed PCPs to published guidelines and community resources, and validated the PCPs’ frustration or concerns. Specialists provided instruction on safe opioid prescribing and how to identify and manage potential cases of substance dependence.

Conclusion:

Providing care to patients with chronic pain is a challenge for PCPs, who often experience frustration at their inability to provide a definitive solution for patients. Specialists offered invaluable feedback not only through guidance and advice, but also with sympathy and encouragement.




Neighborhood Socioeconomic Status and Receipt of Opioid Medication for New Back Pain Diagnosis

2017-11-27T08:01:19-08:00

Background:

Although treatment for new back pain is heavily guideline driven, deviations occur frequently. Neighborhood socioeconomic status (nSES) may contribute to these deviations.

Objective:

Determine whether nSES is associated with type of treatment provided for patients seeking treatment for new back pain in primary care clinics.

Methods:

This retrospective cohort was conducted in academic internal and family medicine practices. Data were examined from the Primary Care Patient Data Registry. Eligibility criteria included age ≥18 years, free of HIV and cancer, and presenting to primary care with a new diagnosis of back pain, resulting in1646 patients included. Patients’ nSES was determined using ZIP code and calculating a validated index of 7 census-tract variables. Multinomial logistic regression was used to measure the association between nSES and 3 treatment outcomes compared with no pharmacologic management. Outcomes included opioid prescription, nonsteroidal anti-inflammatory (NSAID)/muscle relaxant prescription, or combined opioid/nonopioid treatment within 90 days of initial presentation. Covariates included age, sex, race, high clinic utilization (HCU), depression, anxiety, substance use, obesity, comorbidities, smoking, number of pain conditions, and physical therapy (PT) referral.

Results:

The cohort was 67.9% female with an average age of 55.72 years (Standard Error [SE] = 0.387). Compared with no pharmacologic treatment, individuals in the low nSES group had 63% higher odds of receiving an opioid only compared with the high nSES group (odds ratio [OR], 1.63; 95% confidence interval [CI], 1.01 to 2.62). There was no significant association between nSES and odds of nonopioid or combined treatment compared with no pharmacotherapy (OR, 1.17; 95% CI, 0.97 to 1.50), (OR, 1.09; 95% CI, 0.67 to 1.78), respectively. Covariates associated with increased odds of opioid only included HCU, ever smoker, and increasing comorbidity index. PT referral was associated with NSAID/muscle relaxant only, and increasing age and comorbidity index were inversely associated with odds of NSAID/muscle relaxant only. Finally, covariates associated with increased odds of receiving both therapies included high clinic utilizusation, ever smoking, and PT referral.

Conclusions:

These data characterize a possible association between low nSES and increased risk of receiving an opioid only when being treated for new back pain. This may be evidence that patients of low nSES are at increased risk of receiving guideline-noncompliant treatment for new back pain.




Relationship of Opioid Prescriptions to Physical Therapy Referral and Participation for Medicaid Patients with New-Onset Low Back Pain

2017-11-27T08:01:19-08:00

Introduction:

Physical therapy (PT) early in the management of low back pain (LBP) is associated with reductions in subsequent health care utilization and LBP-related costs. The objectives of this study were to 1) Examine differences among newly consulting patients with LBP who received a PT referral and those who did not, 2) examine differences between patients who participated in PT to those who did not, and 3) compare the impact of a PT referral and PT participation on LBP-related health care utilization and costs over 1 year.

Methods:

This was a retrospective cohort study using electronic medical records and claims data. Participants were 454 Medicaid enrollees with new LBP consultations (mean age, 40.4 years; SD = 12.0; 70% women). Outcomes included advanced imaging, injections, emergency department visits, opioid prescriptions, surgery and LBP-related costs. Variables associated with a PT consult, PT participation, and subsequent outcomes were evaluated with multivariate models.

Results:

A total of 251 (55%) participants received a PT consult within 7 days of the index LBP visit and 81 (19%) participated in PT. The odds of a PT consult were increased if patients were prescribed non-steroidal anti-inflammatories (aOR = 1.81; 95% confidence interval [CI], 1.0 to 3.27; P = .05) or muscle relaxers (adjusted odds ratio [aOR] = 2.24; 95% CI, 1.03 to 4.87; P = .04). Whereas tobacco users and individual with multiple comorbidities were less likely to receive a PT consult (aOR = 0.52; 95% CI, 0.20 to 0.91) and 0.42 (95% CI, 0.23 to 0.78), respectively). Odds of participating in PT were higher for patients receiving an radiograph at baseline (odds ratio [OR] = 2.63; 95% CI, 1.25 to 5.53) or having multiple comorbidities (OR = 2.96; 95% CI, 1.20 to 7.20). The odds of receiving an opioid prescription over the year following the index visit reduced with a PT consult (aOR = 0.65; 95% CI, 0.43 to 1.00) and with PT participation (aOR = 0.47; 95% CI, 0.24 to 0.92). No differences in LBP related costs over 1 year were noted between any of the groups.

Conclusions:

Among Medicaid recipients with new-onset LBP, the index provider’s prescription and imaging decisions and patient demographics were associated with PT referrals and participation. A referral to PT and subsequent PT participation was associated with reduced opioid prescriptions during follow-up. There was no difference in overall LBP-related health care costs.




Frequency of Cannabis Use Among Primary Care Patients in Washington State

2017-11-27T08:01:19-08:00

Introduction:

Over 12% of US adults report past-year cannabis use, and among those who use daily, 25% or more have a cannabis use disorder. Use is increasing as legal access expands. Yet, cannabis use is not routinely assessed in primary care, and little is known about use among primary care patients and relevant demographic and behavioral health subgroups. This study describes the prevalence and frequency of past-year cannabis use among primary care patients assessed for use during a primary care visit.

Methods:

This observational cohort study included adults who made a visit to primary care clinics with annual behavioral health screening, including a single-item question about frequency past-year cannabis use (March 2015 to February 2016; n = 29,857). Depression, alcohol and other drug use were also assessed by behavioral health screening. Screening results, tobacco use, and diagnoses for past-year behavioral health conditions (e.g., mental health and substance use disorders) were obtained from EHRs.

Results:

Among patients who completed the cannabis use question (n = 22,095; 74% of eligible patients), 15.3% (14.8% to 15.8%) reported any past-year use: 12.2% (11.8% to 12.6%) less than daily, and 3.1% (2.9%–3.3%) daily. Among 2228 patients age 18 to 29 years, 36.0% (34.0% to 38.0%) reported any cannabis use and 8.1% (7.0% to 9.3%) daily use. Daily cannabis use was common among men age 18 to 29 years who used tobacco or screened positive for depression or used tobacco: 25.5% (18.8% to 32.1%) and 31.7% (23.3% to 40.0%), respectively.

Conclusions:

Cannabis use was common in adult primary care patients, especially among younger patients and those with behavioral health conditions. Results highlight the need for primary care approaches to address cannabis use.




The Diagnostic Value of the Patients Reason for Encounter for Diagnosing Cancer in Primary Care

2017-11-27T08:01:19-08:00

Purpose:

Family physicians (FPs) have to recognize alarm symptoms and estimate the probability of cancer to manage these symptoms correctly. Mostly, patients start the consultation with a spontaneous statement on why they visit the doctor. This is also called the reason for encounter (RFE). It precedes the interaction and interpretation by FPs and patients. The aim of this study is to investigate the predictive value of alarm symptoms as the RFE for diagnosing cancer in primary care.

Design and setting:

Retrospective cohort study in a Dutch practice-based research network (Family Medicine Network).

Method:

We analyzed all patients >45 years of age listed in the practice-based research network, FaMe-net, in the period 1995 to 2014 (118.219 patient years). We focused on a selection of alarm symptoms as defined by the Dutch Cancer Society and Cancer Research UK. We calculated the positive predictive value (PPV) of alarm symptoms, spontaneously mentioned in the beginning of the consultation by the patient (RFE), for diagnosing cancer.

Results:

The highest PPVs were found for patients spontaneously mentioning a breast lump (PPV 14.8%), postmenopausal bleeding (PPV 3.9%), hemoptysis (PPV 2.7%), rectal bleeding (PPV 2.6%), hematuria (PPV 2.2%) and change in bowel movements (PPV 1.8%).

Conclusion:

Patients think about going to their physician and think about their first uttered statements during the consultation. In the case of cancer, the diagnostic workup during the consultation on alarm symptoms will add to the predictive value of these reasons for encounter. However, it is important to realize that the statement made by the patient entering the consultation room has a significant predictive value in itself.




Older Adults Preferences for When and How to Discuss Life Expectancy in Primary Care

2017-11-27T08:01:19-08:00

Introduction:

Life expectancy is important to inform a number of clinical decisions in primary care but its communication is challenging for clinicians.

Methods:

This qualitative interview study with 40 community-dwelling older adults explored their perspectives on how and when to discuss life expectancy in primary care.

Results:

Most participants did not want to discuss life expectancy longer than 1 year but were open to being offered discussion by clinicians. Suggestions included using health decline as trigger for discussion and discussing with family members instead of patient.

Discussion:

Although older adults have varied preferences for the timing and content of life expectancy discussions in primary care, it was generally acceptable for clinicians to offer the opportunity for this type of discussion.




Worsening Rural-Urban Gap in Hospital Mortality

2017-11-27T08:01:19-08:00

Background:

One out of every 5 Americans live in rural communities. Rural Americans have higher rates of early and preventable deaths outside of the hospital than their urban counterparts. How rurality relates to hospital mortality is unknown. We sought to determine the association between rural versus urban residence and hospital mortality.

Methods:

This is a retrospective observational study of 4,412,942 nonmaternal, nonneonatal hospitalizations in 2008, and 3899,464 nonmaternal, nonneonatal hospitalizations in 2013 using all-payer, all-age data from the National Inpatient Sample of the Health care Cost and Utilization Project. Using multivariable logistic regression, we report the association between rural versus urban location of residence and hospital mortality, adjusting for chronic disease burden, age, income, and insurance status.

Results:

The unadjusted probability of hospital mortality for urban patients decreased from 2.51% (95% CI, 2.40 to 2.62) in 2008 to 2.27% (95% CI, 2.22 to 2.32) in 2013 (P < .001). Hospital mortality did not change for rural patients over this same time period (2008: 2.66% [95% CI, 2.57 to 2.74], 2013: 2.66% [95% CI, 2.60 to 2.72]; P = .99). Adjusting for covariates accounted for the rural-urban hospital mortality difference in 2008 (rural: 2.13% [95% CI, 2.05 to 2.21], urban: 2.11% [95% CI, 2.02 to 2.20]; P = .67), but did not fully explain the difference in 2013 (rural: 1.92% [95% CI, 1.87 to 1.97]; urban: 1.76% [95% CI, 1.72 to 1.80], P < .001), resulting in 8416 excess deaths among hospitalized patients from rural areas.

Conclusion and Relevance:

In 2013, patients living in rural areas of the United States had a greater probability of hospital mortality than their urban counterparts. Explaining excess rural hospital deaths will require further attention to the patient, community, and health system factors that distinguish rural from urban populations.




Using Drug Prescribing Patterns to Identify Stewards of Cost-Conscious Care

2017-11-27T08:01:19-08:00

Purpose:

To characterize family physicians (FPs) who are stewards of care by consistently prescribing omeprazole over esomeprazole.

Methods:

Cross-sectional analysis of physicians prescribing omeprazole or esomeprazole under Medicare Part D in 2014.

Results:

There was a regional trend with 49% of Western FPs but only 6% of Southern FPs rarely prescribing esomeprazole. Physicians had increased odds of being a steward if they worked with a care coordinator (P < .001), at a patient-centered medical home (P < .001), or in a large practice (P < .001).

Conclusions:

If these findings are replicated across multiple drugs, future outreach could be conducted based on provider prescribing patterns.




Predicting Risk for Opioid Misuse in Chronic Pain with a Single-Item Measure of Catastrophic Thinking

2017-11-27T08:01:19-08:00

Background:

Chronic pain patients are frequently treated with opioid medications in primary care, where brief measures of risk for opioid misuse have great utility. Catastrophic thinking is a clinically relevant and potentially modifiable factor associated with several chronic pain outcomes, including risk for opioid misuse. This study examined the utility of a single-item measure of pain-related catastrophizing in predicting risk of opioid misuse.

Method:

119 chronic pain patients completed the Coping Strategies Questionnaire catastrophizing item, Pain Catastrophizing Scale (PCS), and Screener and Opioid Assessment for Patients with Pain–Revised (SOAPP-R). Area under the receiver operator curve (AUC) and linear regression were used to examine predictive utility of the catastrophizing item.

Results:

The catastrophizing item demonstrated a fair ability to discriminate those with high risk for opioid misuse on the SOAPP-R (AUC = 0.74), whereas the PCS demonstrated good discrimination (AUC = 0.85). The single item alone accounted for 30% of variance in SOAPP-R scores.

Conclusion:

A single question assessing pain catastrophizing has utility for predicting risk for opioid misuse. In addition, it provides the primary care provider with information on a potentially modifiable risk factor that can be addressed within the context of a brief clinical visit.




Dysrhythmias with Loperamide Used for Opioid Withdrawal

2017-11-27T08:01:19-08:00

The antidiarrheal loperamide has had a recent, drastic increase in off-label use as an alternative treatment for symptoms of opioid withdrawal. The concept of this is easily discovered on the Internet and social media, where there are multiple blogs and forums promoting loperamide use at doses of 70 to 200 mg per day. Unfortunately, the serious side effects are not well recognized. Multiple cases of cardiac dysrhythmias contributing to death have been highlighted in recent literature. In November 2016, the US Food & Drug Administration released a statement highlighting the potential heart effects and risk of death with high doses of loperamide.1 This case regards a 22-year-old who took 200 mg of loperamide per day for 2 years as an alternative to methadone in her attempts to wean off heroin. Her subsequent spontaneous collapse, dysrhythmias, and acute hospital treatment are reviewed in detail as they were contradictory to standard therapy and required a multidisciplinary approach. Her outpatient management addressed the complex biological, psychological, and social aspects of her addiction.




Notalgia Paresthetica Relieved by Cervical Traction

2017-11-27T08:01:19-08:00

Notalgia paresthetica is a syndrome of unilateral, chronic pruritis that is associated with burning pain, paresthesia, numbness, and hyperesthesia localized to the medial and inferior scapula. The condition does not respond to anti-inflammatory drugs or traditional antipruritic agents and has variable responses to numerous other reported pharmacologic and nonpharmacologic therapies. Although the etiology is thought to be nerve impingement, neurologic and musculoskeletal causes are often not considered in the differential diagnosis. We present a report of a woman with a 2-year history of refractory notalgia paresthetica. Based on spinal imaging showing cervical neuroforaminal stenosis, the patient was prescribed a course of cervical traction. Her symptoms resolved and have not returned after 2 years of followup. We believe this is the first case report of successful treatment of notalgia paresthetica with cervical traction.




The Single Graduate Medical Education (GME) Accreditation System Will Change the Future of the Family Medicine Workforce

2017-11-27T08:01:19-08:00

Background:

Due to the Accreditation Council for Graduate Medical Education (ACGME)/American Osteopathic Association (AOA) single-accreditation model, the specialty of family medicine may see as many as 150 programs and 500 trainees in AOA-accredited programs seek ACGME accreditation. This analysis serves to better understand the composition of physicians completing family medicine residency training and their subsequent certification by the American Board of Family Medicine.

Methods:

We identified residents who completed an ACGME-accredited or dual-accredited family medicine residency program between 2006 and 2016 and cross-tabulated the data by graduation year and by educational background (US Medical Graduate–MD [USMG-MD], USMG-DO, or International Medical Graduate–MD [IMG-MD]) to examine the cohort composition trend over time.

Results:

The number and proportion of osteopaths completing family medicine residency training continues to rise concurrent with a decline in the number and proportion of IMGs. Take Rates for USMG-MDs and USMG-IMGs seem stable; however, the Take Rate for the USMG-DOs has generally been rising since 2011.

Conclusions:

There is a clear change in the composition of graduating trainees entering the family medicine workforce. As the transition to a single accreditation system for graduate medical education progresses, further shifts in the composition of this workforce should be expected.




Strategies for Increasing the Role of Family Medicine in Mexican Health Care Reform

2017-11-27T08:01:19-08:00

There is little or no role for primary care and family medicine in current health reforms in Mexico. However, robust evidence shows that primary care helps prevent morbidity and mortality and increases health equity. Mexico has participated in several international meetings sponsored by the World Organization of National Colleges, Academies and Academic Associations and the North American Primary Care Research Group that are aimed at increased understanding of national health systems and the need to strengthen primary care for improved health outcomes. From 1 of these meetings the Cancún Manifesto emerged, with a strategic plan to increase the stature and impact of the Mexican College of Family Physicians (COLMEXAC) in strengthening primary care in Mexico. We aim to describe this strategic plan and discuss its early implementation, and for this account to serve as a possible formula for other countries. The 5 specific strategies discussed are 1) the need for consensus on the leading role of the Mexican family physician in the national health system; 2) health ecology research; 3) to improve the perception of patients about the benefits of primary care and family medicine; 4) to organize meetings of health providers, users, and other stakeholders; and 5) to promote the professionalization of COLMEXAC as a legal entity.










Author Index to Volume 30, 2017

2017-11-27T08:01:19-08:00




Subject Index to Volume 30, 2017

2017-11-27T08:01:19-08:00




Improving the Health of Patients and Communities: Evolving Practice-based Research (PBR) and Collaborations

2017-09-18T08:22:35-07:00

This issue illustrates how research from practice-based research networks has evolved to span a spectrum from improving patient-level care and practice quality to improving health within local and global communities. Articles address patient-level improvements (a biomarker for cardiovascular disease progression, late-onset anorexia nervosa, complementary health approaches used by patients, and patient preferences related to antibiotics for acute respiratory infections); practice-level improvements (selection of types of fecal immunochemical tests, practice facilitation, practice registry implementation, community-based outreach, and bidirectional texting); and community-level improvements (primary care–public health partnership, influenza surveillance, and establishing family medicine training abroad).




The American Board of Family Medicine: New Tools to Assist Program Directors and Graduates Achieve Success

2017-09-18T08:22:35-07:00

In this commentary we review the improvements in the pass rates for first-time American Board of Family Medicine (ABFM) Certification Examination test takers in the context of new tools and resources for program directors against the backdrop of a changing accreditation system and increased competition for a relatively fixed number of graduate medical education positions in family medicine. While causality cannot be established between the strategic initiatives of the ABFM and higher pass rates, we can all celebrate the new tools and resources provided to residents and program directors, and the improved performance of family medicine graduates on the certification examination.




Performance of Graduating Residents on the American Board of Family Medicine Certification Examination 2009-2016

2017-09-18T08:22:35-07:00

In response to growing concern about the declining performance on the American Board of Family Medicine Certification Examination, several strategies were employed to assist program directors with preparing their residents to take the examination. The effect of these efforts seems to have resulted in significant improvement in performance.




A Randomized Trial of High-Value Change Using Practice Facilitation

2017-09-18T08:22:35-07:00

Purpose:

To understand how focused versus general practice facilitation can impact goal setting, action planning, and team performance in primary care transformation.

Background:

Practice transformation in primary care is a crucial part of health reform, but can fatigue teams, leading to variable results. Practice facilitation may reduce primary care fatigue to help teams reach challenging transformation goals, but may require a more focused approach than previous studies suggest.

Methods:

We performed a 12-month cluster randomized trial, during which 8 primary care clinics received practice facilitation. Four practices in the intervention arm received targeted facilitation to focus quality improvement (QI) goals on high-value elements (HVEs) intended to reduce cost and utilization, whereas 4 control practices received generalized QI facilitation. We investigated the impact of the targeted versus generalized approach on goal selection, action item selection and achievement, HVE attainment, and collaborative practice, using quantitative and qualitative methods.

Results:

Intervention clinics selected an average of 7 goals and 29 action items, compared with 8 goals and 40 action items among controls. Eighty-three percent of intervention goals were related to HVEs, compared with 27% of goals among controls. Intervention clinics selected 101 HVE goals and met 68%, while controls selected 41 and met 61%. Analysis of pre-post practice surveys indicated greater improvement among intervention across 4 of 8 domains of collaborative practice.

Conclusion:

Targeted facilitation may be more effective than a generalized approach to support practices in reaching high-value change goals, as well as fostering improvement of team focus on goals, roles and responsibilities.




An Innovative Community-based Model for Improving Preventive Care in Rural Counties

2017-09-18T08:22:35-07:00

Objective:

This quasi-experimental pilot study aimed to implement and evaluate a sustainable, rural community–based patient outreach model for preventive care provided through primary care practices (PCPs) located in a rural county in Oklahoma. A Wellness Coordinator (WC) working with PCPs, the county health department, the county hospital, and a health information exchange (HIE) organization helped county residents receive evidence-based preventive services.

Methods:

The WC used a community wellness registry connected to electronic medical records via HIE and called patients at the county level based on PCP-prioritized and tailored protocols. The registry flagged patient-level preventive care gaps, tracked outreach efforts, and documented the delivery of preventive services throughout the community. Return on investment (ROI) for prioritized preventive services was estimated in participating organizations.

Results:

Six of the 7 PCPs in the county expressed interest in the project. Three of these practices fully implemented the 1-year outreach program starting in mid 2015. The regional HIE supplied periodic data updates for 9138 county residents to help the coordinators address care gaps using the community registry. A total of 5034 outreach calls were made by the WC in the first year and 7776 prioritized recommendations were offered when care gaps were detected. Of the 5034 distinct patients who received a call, 1146 (22%) were up to date on all prioritized services, whereas 3888 (78%) were due for at least 1 of the selected services. Health care organizations in the county significantly improved the delivery of selected preventive services (mean increase, 35% across 10 services; P = .004; range, 3% to 215%) and realized a mean ROI of 80% for these services (range, 32% to 122%). The health system that employed the WC earned an estimated revenue of $52,000 realizing a 40% ROI for the coordinator position.

Conclusions:

Although more research is needed, our pilot study suggests that it may be feasible and cost effective to implement an innovative, county-level patient outreach program for improving preventive care in rural settings.




Coronary Artery Calcium Progression Is Associated with Cardiovascular Events Among Asymptomatic Individuals: From the North Texas Primary Care Practice-based Research Network (NorTex-PBRN)

2017-09-18T08:22:35-07:00

Background:

Although incidental coronary artery calcium (CAC) has been established as a surrogate measure for atherosclerotic plaque burden, little is known about its progression and the associated risks. This study looks at the association of select cardiovascular risk factors with the progression of CAC over a 2-year period and the relationship between CAC progression and experiencing a composite cardiovascular disease (CVD) event.

Methods:

Repeated CAC measurements were obtained for 311 asymptomatic participants aged >44 years, who were recruited from a collaborative network of primary care clinics.

Results:

An average of 24.4 months separated scans and CAC scores increased by a mean of 24.45 Agatston units. A total of 113 participants (30%) demonstrated CAC progression, whereas the rest showed no change or a decrease in CAC over 2 years. In adjusted regression models that controlled for age and sex, the following were associated with 2-year CAC progression: dyslipidemia, systolic blood pressure, fasting glucose, and non–high-density lipoprotein. Moreover, those with progressive CAC measures were >4 times more likely to experience a composite CVD event in 2 years, after controlling for known risk factors.

Conclusions:

Overall, several baseline risk factors remained significant after adjusting for age and sex. CAC progression was independently associated with a composite CVD event.




Primary Care and Public Health Perspectives on Integration at the Local Level: A Multi-State Study

2017-09-18T08:22:35-07:00

Objective:

The Institute of Medicine argues that the integration of primary care (PC) and public health (PH) is of paramount importance. We undertook this qualitative study to better understand how these collaborations function.

Data Sources:

Investigators from PC and PH practice-based research networks in Colorado, Minnesota, Washington, and Wisconsin identified 40 key informants from the PH and PC fields within their respective states.

Study Design:

The key informants participated in standardized, semistructured interviews.

Data Collection:

Coinvestigators from each state conducted telephone interviews. The interviews were recorded, transcribed, and analyzed using NVivo 10.

Principal Findings:

Participants described 2 main types of themes. One, which we have termed "foundational" aspects of partnership, includes leadership, communication, mutual awareness, formal processes, history and values. The other, which we have characterized as "energizing" aspects of partnerships, includes having a shared strategic vision, opportunity, and the shifting culture in PC and PH. While the vast majority of participants described the value of foundational aspects of partnership, those who reported having more active collaborations were more likely to also describe the energizing aspects of partnerships.

Conclusions:

Our findings indicate that interactions between foundational aspects and energizing aspects of partnerships are dynamic. Further exploration of these aspects may help us to understand how best to support the integration of PC and PH.




Bidirectional Text Messaging to Improve Adherence to Recommended Lipid Testing

2017-09-18T08:22:35-07:00

Background:

Synergies between technology and health care in the United States are accelerating, increasing opportunities to leverage these technologies to improve patient care.

Methods:

This study was a collaboration between an academic study team, a rural primary care clinic, and a local nonprofit informatics company developing tools to improve patient care through population management. Our team created a text messaging management tool, then developed methods for and tested the feasibility of bidirectional text messaging to remind eligible patients about the need for lipid testing. We measured patient response to the text messages, then interviewed 8 patients to explore their text messaging experience.

Results:

Of the 129 patients the clinic was able to contact by phone, 29.4% had no cell phone or text-messaging capabilities. An additional 20% refused to participate. Two thirds of the 28 patients who participated in the text messaging intervention (67.9%) responded to at least 1 of the up to 3 messages. Seven of 8 interviewed patients had a positive text-messaging experience.

Conclusions:

Bidirectional text messaging is a feasible and largely acceptable form of communication for test reminders that has the potential to reach large numbers of patients in clinical care.




New Method for Real Time Influenza Surveillance in Primary Care: A Wisconsin Research and Education Network (WREN) Supported Study

2017-09-18T08:22:35-07:00

Introduction:

The goal of public health infectious disease surveillance systems is to provide accurate laboratory results in near-real time. When it comes to influenza surveillance, most current systems are encumbered with inherent delays encountered in the real-life chaos of medical practice. To combat this, we implemented and tested near-real-time surveillance using a rapid influenza detection test (RIDT) coupled with immediate, wireless transmission of results to public health entities.

Methods:

A network of 19 primary care clinics across Wisconsin were recruited, including 4 sites already involved in ongoing influenza surveillance and 15 sites that were new to surveillance activities. Each site was provided with a Quidel Sofia Influenza A+B RIDT analyzer attached to a wireless router. Influenza test results, along with patient age, were transmitted immediately to a cloud-based server, automatically compiled, and forwarded to the surveillance team daily. Weekly counts of positive influenza A and B cases were compared with positive polymerase chain reaction (PCR) detections from an independent surveillance system within the state.

Results:

Following Institutional Review Board (IRB) and institutional approvals, we recruited 19 surveillance sites, installed equipment, and trained staff within 4 months. Of the 1119 cases tested between September 15, 2013 and June 28, 2014, 316 were positive for influenza. The system provided early detection of the influenza outbreak in Wisconsin. The influenza peak between January 12 and 25, 2014, as well as the epidemic curve, closely matched that derived from the established PCR laboratory network (r = 0.927; P < .001).

Conclusions:

A network of influenza RIDTs with wireless transmission of results approximated the long-sought-after goal of real-time influenza surveillance. Results from the initial year strongly support this approach to highly accurate and timely influenza surveillance.




Use of Complementary Health Approaches Among Diverse Primary Care Patients with Type 2 Diabetes and Association with Cardiometabolic Outcomes: From the SF Bay Collaborative Research Network (SF Bay CRN)

2017-09-18T08:22:35-07:00

Purpose:

To describe use of complementary health approaches (CHAs) among patients with type 2 diabetes, and independent associations between CHA use and Hemoglobin A1c (A1C) and lower-density lipoprotein (LDL) cholesterol.

Methods:

Participants were enrolled onto the SMARTSteps Program, a diabetes self-management support program conducted between 2009 and 2013 in San Francisco. At the 6-month interview, CHA use in the prior 30 days was estimated using a 12-item validated instrument. Demographic and diabetes-related measures A1C were assessed at baseline and 6-month followup. AIC and LDL values were ascertained from chart review over the study period. Medication adherence was measured using pharmacy claims data at 6 and 12 months.

Results:

Patients (n = 278) completed 6-month interviews: 74% were women and 71.9% were non-English speaking. Any CHA use was reported by 51.4% overall. CHA modalities included vitamins/nutritional supplements (25.9%), spirituality/prayer (21.2%), natural remedies/herbs (24.5%), massage/acupressure (11.5%), and meditation/yoga/tai chi (10.4%). CHA costs per month were $43.86 (SD = 118.08). Nearly one third reported CHA (30.0%) specifically for their type 2 diabetes. In regression models, elevated A1C (>8.0%) was not significantly associated with overall CHA use (odds ratio [OR] = 1.78; 95% confidence interval [CI], 0.7 to 4.52) whereas elevated LDL was (OR = 3.93; 95% CI, 1.57 to 9.81). With medication adherence added in exploratory analysis, these findings were not significant.

Conclusions:

CHA use is common among patients with type 2 diabetes and may be associated with poor cardiometabolic control and medication adherence.




"Finding the Right FIT": Rural Patient Preferences for Fecal Immunochemical Test (FIT) Characteristics

2017-09-18T08:22:35-07:00

Purpose: Colorectal cancer (CRC) is the third leading cause of cancer death in the United States, yet 1 in 3 Americans have never been screened for CRC. Annual screening using fecal immunochemical tests (FITs) is often a preferred modality in populations experiencing CRC screening disparities. Although multiple studies evaluate the clinical effectiveness of FITs, few studies assess patient preferences toward kit characteristics. We conducted this community-led study to assess patient preferences for FIT characteristics and to use study findings in concert with clinical effectiveness data to inform regional FIT selection. Methods: We collaborated with local health system leaders to identify FITs and recruit age eligible (50 to 75 years), English or Spanish speaking community members. Participants completed up to 6 FITs and associated questionnaires and were invited to participate in a follow-up focus group. We used a sequential explanatory mixed-methods design to assess participant preferences and rank FIT kits. First, we used quantitative data from user testing to measure acceptability, ease of completion, and specimen adequacy through a descriptive analysis of 1) fixed response questionnaire items on participant attitudes toward and experiences with FIT kits, and 2) a clinical assessment of adherence to directions regarding collection, packaging, and return of specimens. Second, we analyzed qualitative data from focus groups to refine FIT rankings and gain deeper insight into the pros and cons associated with each tested kit. Findings: Seventy-six FITs were completed by 18 participants (Range, 3 to 6 kits per participant). Over half (56%, n = 10) of the participants were Hispanic and 50% were female (n = 9). Thirteen participants attended 1 of 3 focus groups. Participants preferred FITs that were single sample, used a probe and vial for sample collection, and had simple, large-font instructions with colorful pictures. Participants reported challenges using paper to catch samples, had difficulty labeling tests, and emphasized the importance of having care team members provide verbal instructions on test completion and follow-up support for patients with abnormal results. FIT rankings from most to least preferred were OC-Light, Hemosure iFOB Test, InSure FIT, QuickVue, OneStep+, and Hemoccult ICT. Conclusions: FIT characteristics influenced patient's perceptions of test acceptability and feasibility. Health system leaders, payers, and clinicians should select FITs [...]



Patient Willingness to Have Tests to Guide Antibiotic Use for Respiratory Tract Infections: From the WWAMI Region Practice and Research Network (WPRN)

2017-09-18T08:22:35-07:00

Introduction:

The majority of consultations for acute respiratory tract infections (RTIs) lead to prescriptions for antibiotics, which have limited clinical benefit. We explored patients' willingness to have blood tests as part of the diagnostic work-up for RTIs, and patient knowledge about antibiotics.

Methods:

Patients at 6 family medicine clinics were surveyed. Regression modeling was used to determine independent predictors of willingness to have venous and point-of-care (POC) blood tests, and knowledge of the value of antibiotics for RTIs.

Results:

Data were collected from 737 respondents (response rate 83.8%), of whom 65.7% were women, 60.1% were white, and 25.1% were current smokers; patients' mean age was 46.9 years. Sex (female), race (white), and a preference to avoid antibiotics were independent predictors of greater level of antibiotic knowledge. A total of 63.1% were willing to have a venous draw and 79% a POC blood test, to help guide antibiotic decision-making. Non-American Indian/Alaskan Native race, current smoking, and greater knowledge of antibiotics were independent predictors of willingness to have a POC test.

Conclusion:

A large majority of patients seemed willing to have POC tests to facilitate antibiotic prescribing decisions for RTIs. Poor knowledge about antibiotics suggests better education regarding antibiotic use might influence patient attitudes towards use of antibiotics for RTIs.




What Makes for Successful Registry Implementation: A Qualitative Comparative Analysis

2017-09-18T08:22:35-07:00

Purpose:

Registry implementation is an important component of successfully achieving patient-centered medical home designation and an important part of population-based health. The purpose of this study was to examine what factors are evident in the successful implementation of a registry in a selection of Colorado practices involved in quality-improvement activities.

Methods:

In-depth, small-group interviews occurred at 13 practices. The data were recorded, transcribed, and qualitatively analyzed to identify key themes regarding elements of successful registry implementation. Key elements were described as conditions, then calibrated and analyzed using qualitative comparative analysis (QCA).

Results:

The QCA revealed several formulas to successful registry implementation. Key conditions included the importance of Resources and Leadership along with either a Quality Improvement Mindset or a Key Person driving efforts (or both). Health System membership affected the specific formula.

Discussion:

This study is innovative in that it examines which factors and in what combination are necessary for successful implementation of a registry. The findings have implications for primary care quality-improvement efforts.




Geriatric Anorexia Nervosa

2017-09-18T08:22:35-07:00

Eating disorders are not commonly diagnosed in individuals aged >50 years, yet they are associated with significant psychiatric comorbidities and overall morbidity. Anorexia nervosa is the most common eating disorder among this age group, and women are affected most often. We present the fatal case of a 66-year old woman with severe malnutrition and newly diagnosed anorexia nervosa. Inpatient refeeding was unsuccessful, and she succumbed to multisystem organ failure. The timely recognition of eating disorders among older people is important for family physicians who care for patients across the life spectrum.




Family Medicine in Ethiopia: Lessons from a Global Collaboration

2017-09-18T08:22:35-07:00

Background:

Building the capacity of local health systems to provide high-quality, self-sustaining medical education and health care is the central purpose for many global health partnerships (GHPs). Since 2001, our global partner consortium collaborated to establish Family Medicine in Ethiopia; the first Ethiopian family physicians graduated in February 2016.

Methods:

The authors, representing the primary Ethiopian, Canadian, and American partners in the GHP, identified obstacles, accomplishments, opportunities, errors, and observations from the years preceding residency launch and the first 3 years of the residency.

Results:

Common themes were identified through personal reflection and presented as lessons to guide future GHPs.

LESSON 1:

Promote Family Medicine as a distinct specialty.

LESSON 2:

Avoid gaps, conflict, and redundancy in partner priorities and activities.

LESSON 3:

Building relationships takes time and shared experiences.

LESSON 4:

Communicate frequently to create opportunities for success.

LESSON 5:

Engage local leaders to build sustainable, long-lasting programs from the beginning of the partnership.

Conclusions:

GHPs can benefit individual participants, their organizations, and their communities served. Engaging with numerous partners may also result in challenges—conflicting expectations, misinterpretations, and duplication or gaps in efforts. The lessons discussed in this article may be used to inform GHP planning and interactions to maximize benefits and minimize mishaps.
















In This Issue: Opiates, Tobacco, Social Determinants of Health, Social Accountability for Non-Profit Hospitals, More on PCMH, and Clinical Topics

2017-07-18T14:54:40-07:00

This issue contains several articles about the factors contributing to the complex and deadly interplay between social determinants of health, pain, mental illness, and addictive substances such as opioids and tobacco. One article clearly is a call to action: more than half of opioid prescriptions in the United States are given to patients with mental health problems. Two articles report work on the next steps for social determinants of health in health care settings. Social accountability based on community health needs assessments required of community hospitals should lead to the creation of more family medicine residency positions. Patient-centered medical home (PCMH) recognition can be costly. A new typology for PCMHs is proposed. Other topics include group advance care planning visits, the interaction of dental and primary care, free clinics, a fix for a squeaking wrist, adherence to latent tuberculosis treatment, and more.







Intention Versus Reality: Family Medicine Residency Graduates' Intention to Practice Obstetrics

2017-07-18T14:54:40-07:00

Although 21% of new family medicine graduates in 2016 reported an intention to include obstetric delivery in their scope of practice, only 7% of family physicians currently do so. The reasons for this stark difference must be identified in order to address potential barriers leading to family medicine graduates ultimately not including obstetric delivery despite intent.




Prescription Opioid Use among Adults with Mental Health Disorders in the United States

2017-07-18T14:54:40-07:00

Background:

The extent to which adults with mental health disorders in the United States receive opioids has not been adequately reported.

Methods:

We performed a cross-sectional study of a nationally representative sample of the noninstitutionalized U.S. adult population from the Medical Expenditure Panel Survey. We examined the relationship between mental health (mood and anxiety) disorders and prescription opioid use (defined as receiving at least 2 prescriptions in a calendar year).

Results:

We estimate that among the 38.6 million Americans with mental health disorders, 18.7% (7.2 million of 38.6 million) use prescription opioids. Adults with mental health conditions receive 51.4% (60 million of 115 million prescriptions) of the total opioid prescriptions distributed in the United States each year. Compared with adults without mental health disorders, adults with mental health disorders were significantly more likely to use opioids (18.7% vs 5.0%; P < .001). In adjusted analyses, having a mental health disorder was associated with prescription opioid use overall (odds ratio, 2.08; 95% confidence interval, 1.83–2.35).

Conclusions:

The 16% of Americans who have mental health disorders receive over half of all opioids prescribed in the United States. Improving pain management among this population is critical to reduce national dependency on opioids.




Screening for Social Determinants of Health in Michigan Health Centers

2017-07-18T14:54:40-07:00

Objective:

Through an academic-community partnership with a statewide consortium of health centers (HCs) in Michigan, we characterize the current scope of screening for social determinants of health (SDH).

Methods:

We requested copies of forms used to screen for SDH at the 39 HC organizations in Michigan. Using content analysis, we examined variation in screening domains and processes. We present descriptive analyses of HC characteristics and patient demographics.

Results:

We received screening documentation from 23 of the 39 HCs (59%), representing 167 delivery sites. We found broad empiric consensus regarding a core set of 13 SDH screening domains that align with nationally recommended screening guidelines. Two additional domains, Culture and Functional Status, were screened for by <40% of HCs. While patient self-report is the most frequent mode of SDH screening (41%), many HCs use staff members to administer the screening documents.

Conclusions:

HCs across a large and diverse state are screening for SDH and largely agree on core SDH screening domains. Using existing empiric data from frontline providers can inform potential best practices in SDH screening.




Developing Electronic Health Record (EHR) Strategies Related to Health Center Patients' Social Determinants of Health

2017-07-18T14:54:40-07:00

Background:

"Social determinants of heath" (SDHs) are nonclinical factors that profoundly affect health. Helping community health centers (CHCs) document patients' SDH data in electronic health records (EHRs) could yield substantial health benefits, but little has been reported about CHCs' development of EHR-based tools for SDH data collection and presentation.

Methods:

We worked with 27 diverse CHC stakeholders to develop strategies for optimizing SDH data collection and presentation in their EHR, and approaches for integrating SDH data collection and the use of those data (eg, through referrals to community resources) into CHC workflows.

Results:

We iteratively developed a set of EHR-based SDH data collection, summary, and referral tools for CHCs. We describe considerations that arose while developing the tools and present some preliminary lessons learned.

Conclusion:

Standardizing SDH data collection and presentation in EHRs could lead to improved patient and population health outcomes in CHCs and other care settings. We know of no previous reports of processes used to develop similar tools. This article provides an example of 1 such process. Lessons from our process may be useful to health care organizations interested in using EHRs to collect and act on SDH data. Research is needed to empirically test the generalizability of these lessons.




Family Physicians' Perceptions of Electronic Cigarettes in Tobacco Use Counseling

2017-07-18T14:54:40-07:00

Background:

Recent support has been shown for physicians to recommend e-cigarettes to patients who are trying to quit smoking. Supporters of this recommendation argue that e-cigarettes are not combustible products and are less harmful and more effective cessation products than regular cigarettes, with less inherent risk. Those who oppose this idea argue that little reliable evidence suggests that e-cigarettes are better cigarette cessation devices than currently available nicotine replacement therapies, and that they pose as much risk as cigarettes. This study was conducted to explore family physicians' perceptions of recommending e-cigarettes as smoking cessation aids to patients who smoke cigarettes.

Methods:

The study used a mixed-methods approach whereby a 12-item survey was sent to 154 family physicians throughout the state of Kansas. Data were collected from 117, a 76% response rate. A multidisciplinary team used an immersion-crystallization approach to analyze the content of respondents' qualitative data; contingency table analysis was used to evaluate the quantitative data.

Results:

The results showed that family physicians have negative perceptions of e-cigarettes and do not recommend them for smoking cessation. Family physicians are concerned about the effectiveness of e-cigarettes and the uncertainty regarding safety.

Conclusions:

The results suggest that most family physicians do not recommend e-cigarettes for smoking cessation, citing lack of evidence on effectiveness and uncertainty regarding short- and long-term safety.




Costs of Transforming Established Primary Care Practices to Patient-Centered Medical Homes (PCMHs)

2017-07-18T14:54:40-07:00

Background:

The patient-centered medical home (PCMH) shows promise for improving care and reducing costs. We sought to reduce the uncertainty regarding the time and cost of PCMH transformation by quantifying the direct costs of transforming 57 practices in a medical group to National Committee for Quality Assurance (NCQA)-recognized Level III PCMHs.

Methods:

We conducted structured interviews with corporate leaders, and with physicians, practice administrators, and office managers from a representative sample of practices regarding time spent on PCMH transformation and NCQA application, and related purchases. We then developed and sent a survey to all primary care practices (practice-level response rate: initial recognition—44.6%, renewal—35.7%). Direct costs were estimated as time spent multiplied by average hourly wage for the relevant job category, plus observed expenditures.

Results:

We estimated HealthTexas' corporate costs for initial NCQA recognition (2010–2012) at $1,508,503; for renewal (2014–2016), $346,617; the Care Coordination resource costs an additional ongoing $390,790/year. A hypothetical 5-physician HealthTexas practice spent another estimated 239.5 hours ($10,669) obtaining, and 110.5 hours ($4,957) renewing, recognition.

Conclusion:

Centralized PCMH support reduces the burden on practices; however, overall time and cost remains substantial, and should be weighed against the mixed evidence regarding PCMH's impact on quality and costs of care.




The Patient-Centered Medical Home (PCMH) Framing Typology for Understanding the Structure, Function, and Outcomes of PCMHs

2017-07-18T14:54:40-07:00

Introduction:

Patient-centered medical homes (PCHMs) aspire to transform today's challenged primary care services. However, it is unclear which PCMH characteristics produce specific outcomes of interest for care delivery. This study tested a novel typology of PCMH practice transformation, the PCMH framing typology, and evaluated measurable outcomes by each type.

Methods:

Using the Patient-Centered Primary Care Collaborative 2012 to 2013 Annual Review, this secondary analysis of the published PCMH literature extracted data from publications of 59 PCMHs. Each of the 59 sites was categorized as 1 of 4 PCMH types: add-on, renovated, hybrid, or integrated. Six outcome measures (cost reductions, decreased emergency department/hospital utilization, improved quality, improved access, increased preventive services, and improved patient satisfaction) were independently coded for each site. Practices were combined based on type, and mean outcomes scores for each measure were displayed on radar graphs for comparison.

Results:

While each type showed a characteristic pattern of success, only the integrated type improved in all 6 outcomes. No type achieved high success in all measures.

Discussion:

There seem to be 4 types of PCMH, each of which shows a distinctive outcomes profile. Within the PCMH framing typology, direction is emerging for how best to transform primary care to achieve the greatest success.




A Group Visit Initiative Improves Advance Care Planning Documentation among Older Adults in Primary Care

2017-07-18T14:54:40-07:00

Introduction:

Group visits for advance care planning (ACP) may help patients document preferences for decision makers and future care. We assessed the impact of a primary care-based ACP group visit (ACP-GV) intervention on older adults' ACP documentation and why patients participated.

Methods:

Older adults (>65 years) in primary care participated in a 2-session ACP-GV intervention that promotes group dynamics, peer-based learning, and goal setting. Charts were reviewed at baseline, 3 months, and 12 months for documentation of decision makers and ACP forms. We described patients' reasons for participating through analysis of transcripts.

Results:

118 patients (mean age 76 years; 62% female and 82% white) participated in 16 ACP-GV cohorts. From baseline to 3-month follow-up, documentation of decision maker preferences increased from 39% to 81%, and was 89% at 12-month follow-up. Patients with completed ACP forms increased from 20% to 57% at 3 months, and was 67% at 12 months. Reasons for participating included recognizing the importance of ACP, curiosity, participation recommended by primary care provider, desire to talk with family/friends, and desire to complete advance directives.

Conclusions:

This ACP-GV intervention increased ACP documentation among patients with diverse reasons for participating. This is a patient-centered approach to ACP in primary care.




Primary Care Physician Roles in Health Centers with Oral Health Care Units

2017-07-18T14:54:40-07:00

Introduction:

Integrating oral health care and primary care is a priority for improving population health. Primary care physicians (PCP) are filling expanded roles within oral health care to secure strong overall health for their patients.

Methods:

This comparative case study examines the roles of PCPs at 5 federally qualified health centers that have integrated oral health care and primary care. Administrative data were obtained directly from the Health Resources and Services Administration. Key informant interviews were performed with administrators and clinical care team members at each of the health centers. Data were reviewed by 2 experts in oral health to identify emerging roles for physicians.

Results:

PPCPs' roles in health centers' integration models vary, but 3 distinct roles emerged: (1) the physician as a champion, (2) the physician as a collaborator, and (3) the physician as a member of an interprofessional team. In addition, providing physicians with the necessary training to identify oral health issues was critical to preparing physicians to take on expanded roles in integrated health care delivery models.

Conclusions:

Regardless of the roles that they play, family physicians can contribute a great deal to the success of integration models.




Accrued Cost Savings of a Free Clinic Using Quality-Adjusted Life Years Saved and Return on Investment

2017-07-18T14:54:40-07:00

Introduction:

Savings garnered through the provision of preventive services is a form of profit for health systems. Free clinics have been using this logic to demonstrate their cost-savings. The Community-Based Chronic Disease Management (CCDM) clinic treats hypertension using nurse-led teams, clinical protocols, and community-based settings.

Methods:

We calculated CCDM's cost-effectiveness from 2007 to 2013 using 2 metrics: Quality-adjusted life years (QALYs) saved and return on investment (ROI). QALYs were calculated using the Clinical Preventive Burden (CPB) score for hypertension care. ROI was calculated by tallying the savings from prevented heart attacks, strokes, and emergency department visits against the total operating costs.

Results:

Using conservative assumptions for cost estimates, hypertension care resulted in a value of QALYs saved of $711,000 to $2,133,000 and an ROI ratio range of 0.35 to 1.20. Our study shows that when using conservative assumptions to calculate cost-savings, our free clinic did not save money. Cost-savings did occur, but the amount was modest, was less than that of cost-inputs, and was not likely captured by any single health entity.

Conclusion:

Although free clinics remain a vital health care access point for many Americans, it has yet to be demonstrated that they generate a net savings.




Improving Efficiency While Improving Patient Care in a Student-Run Free Clinic

2017-07-18T14:54:40-07:00

Introduction:

Student-run free clinics (SRFCs) have the capacity to decrease health care inequity in underserved populations. These facilities can benefit from improved patient experience and outcomes. We implemented a series of quality improvement interventions with the objectives to decrease patient wait times and to increase the variety of services provided.

Methods:

A needs assessment was performed. Problems related to time management, communication between staff and providers, clinic resources, and methods for assessing clinic performance were identified as targets to reduce wait times and improve the variety of services provided. Seventeen interventions were designed and implemented over a 2-month period.

Results:

The interventions resulted in improved efficiency for clinic operations and reduced patient wait times. The number of specialty providers, patient visits for specialty care, lifestyle education visits for disease prevention and treatment, free medications, and free laboratory investigations increased to achieve the goal of improving the availability and the variety of services provided.

Conclusions:

We demonstrated that it is feasible to implement successful quality improvement interventions in SRFCs to decrease patient wait times and to increase the variety of services provided. We believe that the changes we implemented can serve as a model for other SRFCs to improve their performance.




Factors That Influence Treatment Completion for Latent Tuberculosis Infection

2017-07-18T14:54:40-07:00

Introduction:

The aim of this study is to describe factors associated with noncompletion of latent tuberculosis infection (LTBI) therapy.

Methods:

We conducted a retrospective cohort study of adults who initiated LTBI treatment with isoniazid, rifampin, or isoniazid-rifapentine at 5 clinics. Demographic, treatment, and monitoring characteristics were abstracted. We estimated descriptive statistics and compared differences between completers and noncompleters using t tests and 2 tests.

Results:

The rate of completion across LTBI regimens was 66% (n = 393). A greater proportion of noncompleters were unmarried, used tobacco and/or alcohol, and had more medical problems than completers (all P < .05). A larger proportion of noncompleters received charity care compared with completers (P < .001). The most common reason for treatment discontinuation was loss to follow-up; the majority of these participants were treated with the longest isoniazid-only regimen.

Conclusions:

Patients at risk of progression to active tuberculosis with factors associated with noncompletion may benefit from interventions that enhance adherence to LTBI therapy. These interventions could include enhanced outreach, incentive programs, or home visits.




Physician Factors Associated with Polypharmacy and Potentially Inappropriate Medication Use

2017-07-18T14:54:40-07:00

Background:

Despite accumulating evidence about the harm of polypharmacy in family medicine, few studies have investigated factors related to polypharmacy. The objective of this study was to explore factors related to physicians' prescribing behavior.

Methods:

We conducted a survey of physicians at 5 family medicine residency practices and a linked health record review of their patients ≥65 years old. The determinants of physicians' mean number of prescriptions and potentially inappropriate medications (PIMs) were examined using a generalized linear model.

Results:

A total of 61 physicians (38 residents, 23 fellows/faculty) completed the survey, and 2103 visits by 932 patients seen by these physicians were analyzed. The mean numbers of prescriptions and PIMs per visit per physician were 9.50 and 0.46, respectively. After controlling for patient race and age, low prescribers were more likely to consider the number of medications (P = .007) and benefit/risk information for deprescribing (P = .017) when making prescribing decisions. Use of the Beers List was marginally significant in lower PIM prescribing (P = .05). Physicians' sex, duration of experience, and perceived confidence were not associated with prescribing patterns.

Conclusions:

Conscious consideration concerning the number of medications and benefit/risk information, as well as using the Beers List, were associated with less polypharmacy and fewer PIMs.




Increased Public Accountability for Hospital Nonprofit Status: Potential Impacts on Residency Positions

2017-07-18T14:54:40-07:00

Background: The Institute of Medicine recently called for greater graduate medical education (GME) accountability for meeting the workforce needs of the nation. The Affordable Care Act expanded community health needs assessment (CHNA) requirements for nonprofit and tax-exempt hospitals to include community assessment, intervention, and evaluation every 3 years but did not specify details about workforce. Texas receives relatively little federal GME funding but has used Medicaid waivers to support GME expansion. The objective of this article was to examine Texas CHNAs and regional health partnership (RHP) plans to determine to what extent they identify community workforce need or include targeted GME changes or expansion since the enactment of the Affordable Care Act and the revised Internal Revenue Service requirements for CHNAs. Methods: Texas hospitals (n = 61) received federal GME dollars during the study period. Most of these hospitals completed a CHNA; nearly all hospitals receiving federal GME dollars but not mandated to complete a CHNA participated in similar state-based RHP plans. The 20 RHPs included assessments and intervention proposals under a 1115 Medicaid waiver. Every CHNA and RHP was reviewed for any mention of GME-related needs or interventions. The latest available CHNAs and RHPs were reviewed in 2015. All CHNA and RHP plans were dated 2011 to 2015. Results: Of the 38 hospital CHNAs, 26 identified a workforce need in primary care, 34 in mental health, and 17 in subspecialty care. A total of 36 CHNAs included implementation plans, of which 3 planned to address the primary care workforce need through an increase in GME funding, 1 planned to do so for psychiatry training, and 1 for subspecialty training. Of the 20 RHPs, 18 identified workforce needs in primary care, 20 in mental health, and 15 in subspecial[...]



A Listening Tour: Conversations about Obamacare across America's Heartland

2017-07-18T14:54:40-07:00

During my sabbatical, I rode my bike 3300 miles from Washington, DC, to Seattle, WA, in order to engage in dialog with people along the northern tier of America's heartland. Through informal and candid conversations with >100 people, I gained insights into attitudes and opinions about the Patient Protection and Affordable Care Act (Obamacare). The comments were overwhelmingly negative. In this reflective essay, I share some of the conversations I had and the insights I gained from this remarkable journey across our beautiful country.




Intersection Syndrome: The Subtle Squeak of an Overused Wrist

2017-07-18T14:54:40-07:00

Patient histories that include wrist pain can be pivotal in the distinction between intersection syndrome (IS) and the more common de Quervain's tenosynovitis (DQT). Presented here is a 26-year-old pregnant woman with a history of rowing who developed left radial/dorsal wrist pain and a rubbing/squeaking sensation. Nine months of conservative DQT therapy and a landmark-guided corticosteroid injection failed to relieve her symptoms. An in-clinic ultrasound showed tenosynovitis at the intersection of the first and second compartments, confirming a diagnosis of IS. She found immediate relief with ultrasound-guided saline hydrodissection, the injection of saline into the intercompartmental space to reduce adhesions. Both DQT and IS are overuse injuries caused by repetitive wrist extension, as occurs in rowing, and either condition can worsen after pregnancy. Distinguishing the subtleties between DQT and IS can be challenging. Close attention to the patient's description of the pain can guide treatment, potentially expediting recovery. In addition, saline hydrodissection can be both a diagnostic tool and a potentially therapeutic alternative to steroid injections for such tendinopathies.




A Case of Shingles Following Auricular Acupuncture

2017-07-18T14:54:40-07:00

This is a case report of an occurrence of shingles (herpes zoster [HZ]) following auricular acupuncture. The patient developed acute reactivation HZ in the V1 distribution of the right trigeminal nerve involving the forehead, scalp, and medial upper eyelid 13 days after being treated with auricular acupuncture for chronic low-back pain. The lesions were initially painless, but they clustered and became painful within 2 days. The patient was treated with oral valacyclovir 1000 mg, 3 times daily for 7 days, and ibuprofen as needed. The lesions resolved without sequelae.




Angioedema Spotlight: A Closer Examination of Sacubitril/Valsartan Safety Results

2017-07-18T14:54:40-07:00

Incorporation of neprilysin inhibition into heart failure pharmacotherapy regimens has recently been recommended by U.S. guidelines, based on results from the PARADIGM-HF trial comparing sacubitril/valsartan to enalapril. While most of the discussion has focused on efficacy, a closer examination of the safety results, particularly the incidence of angioedema during the run-in and double-blind periods, is also warranted. Although no major safety concerns were identified, an angioedema risk comparable to enalapril was found, primarily in the black population. Therefore, despite combination with an angiotensin receptor blocker, which historically has a lower incidence of angioedema, the addition of neprilysin inhibition yields an angioedema risk profile comparable to angiotensin converting enzyme (ACE) inhibitors. Clinicians should recognize this safety risk when prescribing sacubitril/valsartan and remain vigilant in counseling patients regarding the signs and symptoms of angioedema. As recommended by the guidelines, avoiding sacubitril/valsartan use concurrently or within 36 hours of the last dose of an ACE inhibitor or in patients with a history of angioedema is also crucial to minimize angioedema risk and prevent patient harm.










Correction to "FitwitsTM Leads to Improved Parental Recognition of Childhood Obesity and Plans to Encourage Change"

2017-07-18T14:54:40-07:00

In the above-mentioned article,1 the electronic version differs from the print version due to a numeric error in Table 4. While the nearby text above the table does use the correct number (23) [proportionate hand-based portion sizes (n = 23)]; Table 4 reads "3" rather than "23" in the third row, first column under Eat healthier portion sizes. The electronic version on the Journal of the American Board of Family Medicine website has been corrected. We apologize for the error, and we regret any confusion or inconvenience it may have caused.




Correction to "Implementation of Technology-based Patient Engagement Strategies within Practice-Based Research Networks"

2017-07-18T14:54:40-07:00

In the above-mentioned article,1 the electronic version differs from the print version due to the placement of the figures. While the figure headings for Figure 1 and 2 are correct, the figures themselves were flipped during the processing of the article. The electronic version on the Journal of the American Board of Family Medicine website has been corrected. We apologize for the error, and we regret any confusion or inconvenience it may have caused.