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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 that are both clinically effective and incorporate patient preferred test characteristics. Consideration of patient preferences may facilitate FIT return, especially in populations at higher risk for experiencing CRC screening disparities.




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 subspecialty training. Five RHPs proposed to increase GME funding for primary care, 3 for psychiatry, and 1 for subspecialty care.

Conclusions:

Hospital CHNAs and other regional health assessments could be potentially strategic mechanisms to assess community needs as well as GME accountability in light of community needs and to guide GME expansion more strategically. Internal Revenue Service guidance regarding CHNAs could include workforce needs assessment and intervention requirements. Preference for future Medicaid or Medicare GME funding expansion could potentially favor states that use CHNAs or RHPs to identify workforce needs and track outcomes of related interventions.




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.




Research on Clinical Decisions Made Daily in Family Medicine

2017-05-08T15:22:37-07:00

This issue presents research on the types of decisions that are required daily in family medicine. Patients often make these health decisions, and family physicians help patients with these decisions daily. Patients and their family physicians discuss when to quit screening for colon cancer, which treatment to choose for localized prostate cancer, when to test for pertussis when a cough is present, whether to take prescribed medications, how to complete more preventive services, and how to understand the "new genetics", and family physician use of telehealth.










Funding Instability Reduces the Impact of the Federal Teaching Health Center Graduate Medical Education Program

2017-05-08T15:22:37-07:00

The Teaching Health Center Graduate Medical Education (THCGME) program is a decentralized residency training component of the Affordable Care Act, created to combat critical shortages and maldistribution of primary care physicians. The Accreditation Council of Graduate Medical Education and federal data reveal that the THCGME program accounted for 33% of the net increase in family medicine residency positions between 2011 and 2015. However, amid concerns about the program's stability, the contribution of the THCGME program to the net increase fell to 7% after 2015.




Prediction of Primary Care Depression Outcomes at Six Months: Validation of DOC-6 (C)

2017-05-08T15:22:37-07:00

Background:

The goal of this study was to develop and validate an assessment tool for adult primary care patients diagnosed with depression to determine predictive probability of clinical outcomes at 6 months.

Methods:

We retrospectively reviewed 3096 adult patients enrolled in collaborative care management (CCM) for depression. Patients enrolled on or before December 31, 2013, served as the training set (n = 2525), whereas those enrolled after that date served as the preliminary validation set (n = 571).

Results:

Six variables (2 demographic and 4 clinical) were statistically significant in determining clinical outcomes. Using the validation data set, the remission classifier produced the receiver operating characteristics (ROC) curve with a c-statistic or area under the curve (AUC) of 0.62 with predicted probabilities than ranged from 14.5% to 79.1%, with a median of 50.6%. The persistent depressive symptoms (PDS) classifier produced an ROC curve with a c-statistic or AUC of 0.67 and predicted probabilities that ranged from 5.5% to 73.1%, with a median of 23.5%.

Conclusions:

We were able to identify readily available variables and then validated these in the prediction of depression remission and PDS at 6 months. The DOC-6 tool may be used to predict which patients may be at risk for worse outcomes.




Patient Knowledge and Qualities of Treatment Decisions for Localized Prostate Cancer

2017-05-08T15:22:37-07:00

Background:

Controversy surrounds treatment for localized prostate cancer (LPC).

Objectives:

To assess men's localized prostate cancer (LPC) knowledge and its association with decision-making difficulty, satisfaction and regret.

Methods:

Population-based sample of 201 men (104 white, 97 black), ≤ 75 years with newly diagnosed LPC completed a self-administered survey.

Results:

Mean age was 61(±7.6) years; two-thirds had less than a Bachelor's degree. Mean LPC knowledge was low, 5.87 (±2.53, maximum score 11). More than a third of men who received surgery or radiation did not know about serious long-term treatment side effects. Fewer than half of the men correctly answered comparative side effect and survival benefit questions between surgery and radiation. Knowledge gaps were greatest among black men, men with lower education, single men. Tumor aggressiveness (i.e. PSA level, Gleason score) and treatment choice were not associated with knowledge. Knowledge was not associated with decisional satisfaction or regret. However, greater knowledge was associated with greater decision-making difficulty (P = .018).

Conclusions:

Significant LPC knowledge gaps existed across groups, with greater knowledge gaps among black men. The association of decision-making difficulty with knowledge was independent of race. Better patient education is needed, but may not alleviate men's decision-making difficulty due to inherent scientific uncertainty.




When Primary Care Providers (PCPs) Help Patients Choose Prostate Cancer Treatment

2017-05-08T15:22:37-07:00

Background:

The role of primary care providers (PCPs) in decision making around cancer care remains largely unknown. We evaluated how frequently men with localized prostate cancer report receiving help from their PCP about their treatment, and whether those men who do are less likely to receive definitive treatment.

Methods:

We mailed surveys to men newly diagnosed with localized prostate cancer between 2012 and 2014 in the greater Philadelphia region. Participants were asked whether their PCP helped decide how to treat their cancer. The outcome was receipt of definitive treatment (either radical prostatectomy or radiotherapy).

Results:

A total of 2386 men responded (adjusted response rate, 51.1%). Among these men, 38.2% reported receiving help from their PCP regarding choosing a treatment, and 79.6% received definitive treatment. In adjusted analyses, non-Hispanic black men (odds ratio, 1.76; 95% confidence interval, 1.37–2.27) were more likely than non-Hispanic white men to report receiving help from their PCP. However, men who did receive help were not more likely to forgo definitive treatment overall (P = .58) or in the subgroups of men who may be least likely to benefit from definitive treatment.

Conclusions:

Though a substantial proportion of men reported receiving help from their PCP about prostate cancer treatment, these discussions were not associated with different treatment patterns. Further effort is needed to determine how to optimize the role of PCPs in supporting patients to make preference-sensitive cancer decisions.




Clinical Diagnosis of Bordetella Pertussis Infection: A Systematic Review

2017-05-08T15:22:37-07:00

Background:

Bordetella pertussis (BP) is a common cause of prolonged cough. Our objective was to perform an updated systematic review of the clinical diagnosis of BP without restriction by patient age.

Methods:

We identified prospective cohort studies of patients with cough or suspected pertussis and assessed study quality using QUADAS-2. We performed bivariate meta-analysis to calculate summary estimates of accuracy and created summary receiver operating characteristic curves to explore heterogeneity by vaccination status and age.

Results:

Of 381 studies initially identified, 22 met our inclusion criteria, of which 14 had a low risk of bias. The overall clinical impression was the most accurate predictor of BP (positive likelihood ratio [LR+], 3.3; negative likelihood ratio [LR–], 0.63). The presence of whooping cough (LR+, 2.1) and posttussive vomiting (LR+, 1.7) somewhat increased the likelihood of BP, whereas the absence of paroxysmal cough (LR–, 0.58) and the absence of sputum (LR–, 0.63) decreased it. Whooping cough and posttussive vomiting have lower sensitivity in adults. Clinical criteria defined by the Centers for Disease Control and Prevention were sensitive (0.90) but nonspecific. Typical signs and symptoms of BP may be more sensitive but less specific in vaccinated patients.

Conclusions:

The clinician's overall impression was the most accurate way to determine the likelihood of BP infection when a patient initially presented. Clinical decision rules that combine signs, symptoms, and point-of-care tests have not yet been developed or validated.




Family Physicians Report Considerable Interest in, but Limited Use of, Telehealth Services

2017-05-08T15:22:37-07:00

Purpose:

Little is known about the attitudes toward and adoption of telehealth services among family physicians (FPs), the largest primary care physician group. We conducted a national survey of FPs, randomly sampled from membership organization files, to investigate use of and barriers to using telehealth services.

Methods:

Using bivariate analyses, we examined how telehealth usage affected FPs' identified barriers to using telehealth services. Logistic regressions show the factors associated both with using telehealth services and with barriers to using telehealth services.

Results:

Surveys reached 4980 FPs; 1557 surveys were eligible for analysis (31% response rate). Among FPs, 15% reported using telehealth services during 2014. After controlling for the characteristics of the physicians and their practice, FPs who were based in a rural setting, worked in a practice owned by an integrated health system or other ownership structure, and provided hospital/urgent/emergency care were more likely to use telehealth. Physician and practice characteristics by telehealth use status, sex of the physician, practice location, years in practice, care provided, and practice ownership were associated with the barriers identified.

Conclusions:

Telehealth use was limited among FPs. Many of the barriers to using telehealth services cited by FPs are amenable to policy modification.




Patient Beliefs Have a Greater Impact Than Barriers on Medication Adherence in a Community Health Center

2017-05-08T15:22:37-07:00

Purpose:

Nonadherence to medicines contributes to poor health outcomes, especially for patients with complicated medicine regimens. We examined adherence among patients at a family health center and the impact that barriers to getting medicines and negative beliefs about medicines have on adherence.

Methods:

A survey was administered incorporating the 8-item Morisky Medication Adherence Scale, questions from the Beliefs about Medicine Questionnaire, and questions about patients' external barriers to getting medicines. Low adherence was examined by any external barrier and by higher negative beliefs, adjusting for patient characteristics.

Results:

The convenience sample of 343 participants is demographically representative of the larger population. Among these patients, 54% report low adherence, 51% have at least 1 barrier to adherence, and 52% report more negative than positive beliefs about medicines. When beliefs and barriers are examined together, patients with negative beliefs are 49% less likely to adhere than those with more positive beliefs, whereas barriers show no significant impact on adherence.

Conclusions:

Negative beliefs about medicines are as prevalent in this population as external barriers to accessing medicines, but negative beliefs were more significantly associated with adherence than external barriers. Physicians should identify and address patients' negative beliefs about medicines to improve adherence rates.




Factors Related to Implementation and Reach of a Pragmatic Multisite Trial: The My Own Health Report (MOHR) Study

2017-05-08T15:22:37-07:00

Background:

Contextual factors relevant to translating healthcare improvement interventions to different settings are rarely collected systematically. This study articulates a prospective method for assessing and describing contextual factors related to implementation and patient reach of a pragmatic trial in primary care.

Methods:

In a qualitative case-series, contextual factors were assessed from the My Own Health Report (MOHR) study, focused on systematic health risk assessments and goal setting for unhealthy behaviors and behavioral health in nine primary care practices. Practice staff interviews and observations, guided by a context template were conducted prospectively at three time points. Patient reach was calculated as percentage of patients completing MOHR of those who were offered MOHR and themes describing contextual factors were summarized through an iterative, data immersion process.

These included practice members' motivations towards MOHR, practice staff capacity for implementation, practice information system capacity, external resources to support quality improvement, community linkages, and implementation strategy fit with patient populations.

Conclusions:

Systematically assessing contextual factors prospectively throughout implementation of quality improvement initiatives helps translation to other health care settings. Knowledge of contextual factors is essential for scaling up of effective interventions.




Patient-Entered Wellness Data and Tailored Electronic Recommendations Increase Preventive Care

2017-05-08T15:22:37-07:00

Purpose:

We investigated whether a tool using patient-entered wellness data to generate tailored electronic recommendations improved preventive care delivery.

Methods:

We conducted a mixed-methods retrospective study of primary care encounters utilizing an Integrated Wellness Tool with a matched-comparison before-and-after study design. Encounters took place at a single clinic within the Cleveland Clinic Health System. The primary outcome was preventive orders placed. Index patients were matched, based on propensity scores, with comparison patients seen in the same clinic several months earlier.

Results:

Five providers conducted 863 patient encounters using the tool during the study period. During encounters using the tool, providers placed more orders for smoking cessation programs (2.4 vs 0.5%, P < .01), lifestyle medicine (2.4 vs 0%, P < .01) and psychology (2.3 vs 1.0%, P = .04) consults, online nutrition (2.4 vs 1.4%, P = .04) and stress management (5.5 vs 0.9%, P < .01) programs, spirometry (5.9 vs 1.7%, P < .01) and polysomnography (6.3 vs 1.3%, P < .01) tests, and antidepressant (7.2 vs 3.9%, P = .01) and hypnotic (2.2 vs 0.7%, P = .01) medications when compared with matched encounters.

Conclusions:

Patients are willing to enter lifestyle data, and these data influence provider orders.




Delivery of Health Coaching by Medical Assistants in Primary Care

2017-05-08T15:22:37-07:00

Background:

Health coaching is potentially a practical method to assist patients in achieving and maintaining healthy lifestyles. In health coaching, the coach partners with the patient, helping patients discover their own strengths, challenges, and solutions.

Methods:

Two medical assistants were provided with brief training. The 12-week program consisted of telephone coaching with in-person visits at the beginning and end of the program. Coaching targeted improvements in diet, physical activity, and/or sleep habits using a self-care planning form.

Results:

A total of 82 subjects enrolled in the program, 72% completed 8 weeks and 49% completed 12 weeks. Subjects who completed assessments at 12 weeks had significant weight loss despite the fact that weight loss was not a study goal. There also were improvements in diet and physical activity. Subject who completed the study were highly satisfied with the program and felt that health coaching should be available in all family medicine clinics. The main barrier providers voiced was remembering to refer patients. The medical providers indicated high satisfaction with the study and valued having coaching available for their patients.

Conclusions:

Medical assistants can be trained to assist patients with lifestyle changes that are associated with improved health and weight control.




Physician Perceptions of Surveillance Follow-up Colonoscopy in Older Adults

2017-05-08T15:22:37-07:00

Background:

Few data exist regarding when to stop surveillance colonoscopy among older adults with a history of adenomatous colorectal polyps. Our goal was to understand decision making around surveillance colonoscopy among primary care providers (PCPs) and gastroenterologists.

Methods:

We designed a 15-item survey for PCPs and gastroenterologists that evaluated factors important in decision making about surveillance colonoscopy in older adults.

Results:

In October 2015, 88 PCPs and 30 gastroenterologists completed the survey. Life expectancy (40%), gastroenterology recommendation (8%), and patient preference (12%) were the most important factors for PCPs. Findings on prior colonoscopy were most important among gastroenterologists. Regardless of specialty, respondents felt that the existing literature on surveillance colonoscopy in older adults is inadequate.

Conclusions:

More data surrounding the benefits and risk of surveillance colonoscopy are needed to inform when to stop surveillance colonoscopy among older adults with a positive screening history.




Therapeutic Dermoscopy to Facilitate Detection and Extraction of Foreign Bodies

2017-05-08T15:22:37-07:00

Foreign bodies are occasionally seen by family physicians. Plantar foreign bodies in particular pose a special challenge because they involve weight-bearing regions that are difficult to access. If left undetected long enough, these may lead to hospitalization, surgery, or even longstanding complications such as tumors, contractures, infections, and chronic ulcers. Dermoscopy of the cutaneous surface allows early detection of indwelling foreign bodies with a far greater degree of accuracy than with the naked eye. Furthermore, use of a polarized dermatoscope provides ideal illumination and 3-dimensional visualization of the involved site, and facilitates extraction of the penetrating object. This technique could be used for similar injuries involving other body surfaces.




The "New Genetics" in Clinical Practice: A Brief Primer

2017-05-08T15:22:37-07:00

Major advances in human genetics have led to the identification of 4451 genes to date with disease-carrying mutations, thereby enabling precise diagnoses of all of these monogenic disorders. Limitations to the use of the "new genetics" do exist, however, including the recognition of genetic heterogeneity, many variants of unknown significance, and incidental diagnoses. This article reviews information to help use these advances to aid accurate diagnoses, identify carriers, and determine prenatal diagnoses, providing opportunities to avoid or prevent serious and fatal genetic disorders.




A Primary Care System to Improve Health Care Efficiency: Lessons from Ecuador

2017-05-08T15:22:37-07:00

Ecuador is a country with few resources to spend on health care. Historically, Ecuador has struggled to find a model for health care that is efficient, effective, and available to all people in the country, even those in underserved and rural communities. In 2000, the Ecuador Ministry of Public Health implemented a new system of health care that used primary care as its platform. Since then, Ecuador has been able to increase its health care efficiency, increasing its ranking from 111 of 211 countries worldwide in 2000, to 20 of 211 countries in 2014. This article briefly reviews the new components of the system implemented in Ecuador and examines the tools used to accomplish this. The discussion also compares and contrasts the Ecuador and US systems, and identifies concepts and policies from Ecuador that could improve the US system.




Effect of Continuity of Care on Emergency Department Visits in Elderly Patients with Asthma in Taiwan

2017-05-08T15:22:37-07:00

Background:

Continuity of care (COC) is positively associated with health care outcomes. However, the effect of COC on the reduction of asthma-related emergency department (ED) visits among older asthmatic patients is not clearly understood.

Methods:

We conducted a retrospective cohort study using the Taiwan nationwide health insurance claims database between 2004 and 2013. Patients aged 65 years with asthma during 2005 to 2011 were selected. The COC index (COCI) is used to measure the number of individual physicians a patient sees in the first year and we identified asthma-related ED visit in the subsequent year. Cox model was used to examine the hazard ratio (HR) between COC and an ED visit for asthma.

Results:

Among a total of 3395 subjects, the overall mean COC was 0.73, and 48.5% of subjects had perfect COC (COCI = 1). After controlling for covariables, in the group of patients with low COC, the risk of having an asthma-related ED visit was higher compared with those with perfect COC (Adjusted HR, 2.11; 95% CI, 1.37–3.25).

Conclusions:

Elderly asthmatic patients with lower COC had a significantly higher likelihood of having asthma-related ED visits.




Improving Performance Improvement

2017-05-08T15:22:37-07:00




Improving Family Medicine with Thoughtful Research

2017-03-08T13:54:48-08:00

This issue is about improving primary health care outcomes, from behavioral health to opioid issues to diagnosing hypertension to providing hope for childhood obesity. It includes hints for integrating behavioral health and care managers into family medicine practices. Opiate prescribing practices vary considerably between Japan and the United States, with helpful insights for our opiate abuse epidemic. Suicidality is high among patients taking opiates. Diagnosing hypertension the recommended way is not easily accomplished. Primary care clinicians are important in infertility and prostate cancer treatment, and in support of men who commit interpersonal violence and people with cognitive impairment who wander. The "July effect" seems to persist. Parents' views on obesity in children can be changed—for the better. Family physicians have less burnout than has been previously reported, and many provide palliative care. Doctors think diseases, patients think about how well they feel. Do we find healthy lifestyles in retirement?







Prevalence of Burnout in Board Certified Family Physicians

2017-03-08T13:54:48-08:00

Physician burnout has become a critical issue in a rapidly changing health care environment and is reported to be increasing. However, little is known about the prevalence of this problem among board-certified family physicians. Using an abbreviated burnout survey, we found a lower prevalence of this problem than has been previously reported.




Building a Sustainable Primary Care Workforce: Where Do We Go from Here?

2017-03-08T13:54:48-08:00

The article by Puffer et al in this month's JABFM confirms a high burnout rate (25%) among family physicians renewing their credentials, with a higher rate among young and female doctors. Recent reports confirm high burnout rates among general internists. Thus, mechanisms to monitor and improve worklife in primary care are urgently needed. We describe the Mini Z (for "zero burnout program") measure, designed for these purposes, and suggest interventions that might improve satisfaction and sustainability in primary care, including longer visits, clinician control of work schedules, scribe support for electronic medical record work, team-based care, and an explicit emphasis on work-home balance.




Outcomes of Integrated Behavioral Health with Primary Care

2017-03-08T13:54:48-08:00

Background:

Integrating behavioral health and primary care is beneficial to patients and health systems. However, for integration to be widely adopted, studies demonstrating its benefits in community practices are needed. The objective of this study was to evaluate effect of integrated care, adapted to local contexts, on depression severity and patients' experience of care.

Methods:

This study used a convergent mixed-methods design, merging findings from a quasi-experimental study with patient interviews conducted as part of Advancing Care Together, a community demonstration project that created an innovation incubator for practices implementing evidence-based integration strategies. The study included 475 patients with a 9-item Patient Health Questionnaire (PHQ-9) score ≥10 at baseline, from 5 practices.

Results:

Statistically significant reductions in mean PHQ-9 scores were observed in all practices, ranging from 2.72 to 6.46 points. Clinically, 50% of patients had a ≥5-point reduction in PHQ-9 score and 32% had a ≥50% reduction. This finding was corroborated by patient interviews that demonstrated positive experiences with behavioral health clinicians and acquiring new skills to cope with adverse situations at work and home.

Conclusions:

Integrating behavioral health and primary care, when adapted to fit into community practices, reduced depression severity and enhanced patients' experience of care. Integration is a worthwhile investment; clinical leaders, policymakers, and payers should support integration in their communities.




Physician and Staff Acceptance of Care Managers in Primary Care Offices

2017-03-08T13:54:48-08:00

Introduction:

Embedded care managers are increasingly implemented as part of the care team within primary care practices, yet previous studies have indicated variability in acceptance by physicians and staff. This study assesses the acceptability of care managers among staff and physicians within the Michigan Primary Care Transformation (MiPCT) demonstration.

Methods:

Care manager acceptance was measured using a web-based survey distributed to practices participating in the MiPCT demonstration. Results: Both physicians and staff reported high levels of care manager acceptance. Longer length of care manager employment at the practice, higher care manager FTE dedicated to care management, and care manager employed by practice were all significantly associated with care manager acceptance.

Discussion:

The MiPCT demonstration found high care manager acceptance across all care team members. The high level of acceptance may be due to the structures and processes developed by MiPCT to support implementation of care managers and the length of the intervention period.

Conclusion:

The MiPCT demonstration confirms that following three years of implementation, embedded care managers are acceptable to both physicians and staff within primary care practices. Importantly, embeddedness, or the amount of time care managers are located within practices, is associated with increased acceptance.




Prediction of Suicide Ideation and Attempt Among Substance-Using Patients in Primary Care

2017-03-08T13:54:48-08:00

Background:

Suicide is a major public health concern, particularly among people who use illicit substances and/or non-prescribed medications.

Methods:

The present study prospectively assessed the incidence and predictors of suicidal ideation (SI) and suicide attempt (SA) among 868 substance-using patients over 12 months after receiving primary care within seven public primary care clinics.

Results:

Participants reported a high incidence of SI (25.9%) and SA (7.1%) over the year following primary care visits. Suicidality was elevated in patients who were female; lacked a high school diploma; were unemployed; reported depression, anxiety, hallucinations, concentration difficulty, or violent behavior; used nicotine or stimulants; used the emergency department or mental health services in the past 90 days; reported current quality-of-life impairment in mobility or usual activities; or reported recent SI or lifetime SA at baseline. In multiple regression analyses, only past 30-day SI, any lifetime SA, past 90-day violent behavior, and current impairment due to anxiety or depression at baseline uniquely predicted SI or SA beyond other variables.

Conclusions:

Results support the need for screening for suicidality among primary care patients who use illicit substances and identify key subgroups of these patients who are at particularly elevated risk for suicidality.




Improving Patient-Clinician Conversations During Annual Wellness Visits

2017-03-08T13:54:48-08:00

Background:

Health risk assessments (HRAs) have been implemented and studied for decades in various settings, but little is known about the effect of introducing HRAs on the dynamics and content of patient-clinician conversations during Medicare Annual Wellness Visits (AWVs) and whether the effective use of HRAs requires additional training and resources.

Methods:

We used Conversation Analysis techniques to analyze 40 AWVs conducted in an academic family medicine residency practice. After a 3-month baseline period, a low-intensity intervention was implemented to explore improvements in the dynamics and content of conversations. Short exit interviews with patients and clinicians were evaluated by standard content analytic techniques.

Results:

Six overarching themes emerged that described the dynamics of AWV conversations. Patients and clinicians sub-optimally utilized the HRA report and missed many opportunities for promoting behavior change. However, a low-intensity, multi-component intervention significantly decreased the proportion of clinician talk time per visit by 9% (P < .001), while it increased the proportion of patient talk time by 7% (P < .001), robustly increased the number and duration of "change talk" by 639% (P = .0007), increased the number of patient cut-ins by 237% (P = .04) and tended to increase the number and duration of clinician "advice talk" (P = .065). Patients felt more informed, empowered, and motivated by the HRA-enhanced wellness visit. Clinicians found that the process helped them construct a more effective visit agenda and it facilitated the convergence of patient goals with evidence-based recommendations.

Conclusions:

Our study suggests that HRAs introduced without proper framing, education, and additional resources may not allow patients and clinicians to leverage AWVs for effective health planning and improvement. A targeted, low-intensity intervention may help patients and clinicians improve the quality of HRA-guided health conversations during AWVs.




Diagnosing Hypertension in Primary Care Clinics According to Current Guidelines

2017-03-08T13:54:48-08:00

Purpose:

This descriptive study examines hypertension diagnostic practices in Utah primary care clinics relative to the 2015 US Preventive Services Task Force (USPSTF) recommendations for the accurate diagnosis of hypertension. We assessed clinic procedures in place to facilitate accurate in-office and out-of-office blood pressure (BP) measurement.

Methods:

An online questionnaire was administered to 321 primary care clinics. We compared current clinic BP measurement practices with the USPTF recommendations and assessed the level of adherence to the recommendations by level of clinic integration with a hospital.

Results:

Of the 321 primary care clinics that received the assessment, 123 (38.3%) completed the questionnaire. Clinics varied significantly in their ability to provide accurate in-office measurement, ranging from 57.5% to 93.5% of clinics complying with USPSTF recommendations. Only 25.2% of clinics reported having access to ambulatory monitoring and 36.6% had instructional materials for accurate home BP monitoring. Clinics integrated with a hospital were more likely to report adherence to recommendations than solo or independent clinics (36.4% vs 10.5%; P < .01).

Conclusion:

This assessment shows that many primary care clinics are not well prepared to implement the USPSTF guidelines for accurate diagnosis of hypertension. Most office practices will benefit from support to develop their capacities.




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

2017-03-08T13:54:48-08:00

Introduction:

Brief tools are needed to help physicians and parents reach consensus on body mass index (BMI) categories for children and to discuss health-improving behaviors. This study tested the FitwitsTM intervention with interactive flashcards and before and- after surveys to improve parents' perceptions of children's BMI status.

Methods:

We enrolled 140 parents and their 9- to 12-year-old children presenting for well child care, regardless of BMI status, scheduled with 53 Fitwits-trained physicians. The Fitwits tool guided a conversation with all parent-child dyads regarding understanding BMI, nutrition, activity, and portion sizes. A survey addressed BMI category perceptions before and after the intervention, requested 2 goal selections, and included open-ended comment areas.

Results:

Fifty-three percent of children were overweight or obese. The primary outcome variable was the rate of correct parental identification of their child's weight status (underweight, healthy, overweight, or obese). The survey before the intervention resulted in 50.0% correct BMI category designations. This changed to 60.6% correct perceptions after the intervention, with movement between correct overweight (34.5% to 51.7%) and obese (4.4% to 24.4%) categories. Secondary outcome variables included specific behavior change goals and the qualitative responses of parents, children, and physicians to the intervention. Parent-child dyads predominantly commented favorably and chose (75.8%) goals corresponding to Fitwits card suggestions.

Conclusions:

An improvement was observed in parental ability to identify the correct BMI category after the intervention during a preadolescent well child visit. Parent underrecognition of overweight/obese children was also observed. Most parent comments were appreciative of the physician interaction, Fitwits flashcards, and health improvement exchange.




The "July Effect": A Look at July Medical Admissions in Teaching Hospitals

2017-03-08T13:54:48-08:00

Purpose:

We examined the effect of admission for myocardial infarction, heart failure, or pneumonia during the first academic quarter compared with all other quarters in teaching versus nonteaching hospitals on length of stay, cost, and mortality.

Methods:

Using data 2011 Nationwide Inpatient Sample, multivariable modeling with an interaction term was used to test teaching hospital effect by academic quarter. Logistic regression was used for mortality and log-transformed linear models for cost and length of stay.

Results:

Charlson Index scores were similar in teaching and nonteaching hospitals. Patients admitted to teaching hospitals for myocardial infarction in the first quarter had a higher risk-adjusted mortality (1.217; confidence interval, 1.147–1.290) than those admitted to a nonteaching hospital during the same quarter (0.849; confidence interval, 0.815–0.885). Mean cost heart failure admissions averaged $584 more, and the mean length of stay was longer (0.10; P = .0127), during the first academic quarter. These effects were not present for quarters 2 through 4.

Conclusions:

This study suggests small increases in mortality among patients admitted with myocardial infarction in the first academic quarter compared with all other quarters in teaching versus nonteaching hospitals. Increased cost and longer stay were seen for those admitted with heart failure.




Congruence of Patient Self-Rating of Health with Family Physician Ratings

2017-03-08T13:54:48-08:00

Background:

A single self-rated health (SRH) question is associated with health outcomes, but agreement between SRH and physician-rated patient health (PRPH) has been poorly studied. We studied patient and physician reasoning for health ratings and the role played by patient lifestyle and objective health measures in the congruence between SRH and PRPH.

Methods:

Surveys of established family medicine patients and their physicians, and medical record review at 4 offices. Patients and physicians rated patient health on a 5-point scale and gave reasons for the rating and suggestions for improving health. Patients' and physicians' reasons for ratings and improvement suggestions were coded into taxonomies developed from the data. Bivariate relationships between the variables and the difference between SRH and PRPH were examined and all single predictors of the difference were entered into a multivariable regression model.

Results:

Surveys were completed by 506 patients and 33 physicians. SRH and PRPH ratings matched exactly for 38% of the patient-physician dyads. Variables associated with SRH being lower than PRPH were higher patient body mass index (P = .01), seeing the physician previously (P = .04), older age, (P < .001), and a higher comorbidity score (P = .001). Only 25.7% of the dyad reasons for health status rating and 24.1% of needed improvements matched, and these matches were unrelated to SRH/PRPH agreement. Physicians focused on disease in their reasoning for most patients, whereas patients with excellent or very good SRH focused on feeling well.

Conclusions:

Patients' and physicians' beliefs about patient health frequently lack agreement, confirming the need for shared decision making with patients.




Association between Continuity of Care and Health-Related Quality of Life

2017-03-08T13:54:48-08:00

Background:

Patient-reported outcomes (PROs) are considered potential quality metrics for patients with multiple chronic medical conditions (MCC). Although continuity of care (COC) is an essential MCC care process, the association between common PROs and COC is unknown.

Methods:

We assessed baseline and two-year follow-up self-reported health status, physical, and emotional well-being, and COC in seniors with MCC. Using mixed effects models with repeated measures adjusting for age, gender, and morbidity, we assessed each outcome as a function of COC.

Results:

Of 2,078 seniors, 961 completed the initial survey and 806 completed follow-up. On a 0–100 scale, mean (sd) baseline self-reported health status, physical well-being, and emotional well-being were 48.7 (22.0), 36.4 (11.4), and 54.8 (9.0). On a 0 to 1 scale, mean baseline and 2-year COC were 0.24 (sd 0.22) and 0.22 (0.18). Follow-up self-reported health status, physical well-being, and emotional well-being were 48.8 (23.1), 36.5 (11.5), and 55.3 (8.8). In adjusted primary and secondary analyses using all available data, there were no associations between any outcomes and COC.

Conclusion:

Given the measurement burden of quality assessment, negative associations between potential quality metrics and care processes are informative. Systematic assessment of PROs can inform patient-centered MCC care. However, PRO scores should be used with caution as quality measures.




Retirement and Healthy Lifestyle: A National Health and Nutrition Examination Survey (NHANES) Data Report

2017-03-08T13:54:48-08:00

Background:

The objective of this study was to compare the rates of healthy lifestyle adherence among retired late-middle-aged adults with rates among those who are still working.

Methods:

A national cross-sectional study using data from the National Health and Nutrition Examination survey (NHANES). The main outcome was the proportion of retires versus nonretirees who were adherent to ideal or intermediate goals of the American Heart Association's Life's Simple 7, cardiovascular factors including physical activity, healthy diet, healthy weight, smoking status, total cholesterol, glucose, and blood pressure.

Results:

Retirees were more likely than nonretirees to have poorly controlled blood pressure (23.9% vs 15.1%; P = .05). However, there were no differences in healthy weight, smoking rates, healthy diet, or glucose or cholesterol control (P > .05). In controlled logistic regression analyses, retirees were more likely to be physically active than nonretirees (odds ratio, 1.85; 95% confidence interval, 1.11–3.09), but were not more likely to be following any other Life's Simple 7 factors.

Conclusions:

Retired adults were more likely to be physically active but were not more likely to be adhering to most of the Life's Simple 7 lifestyle and cardiovascular risk factors. More public health attention to encouraging healthy lifestyles during the transition into retirement may be warranted.




How Men with Prostate Cancer Choose Specialists: A Qualitative Study

2017-03-08T13:54:48-08:00

Objective:

The specific specialist that a patient sees can have a large influence on the type of care they receive.

Methods:

We administered semistructured interviews with 47 men diagnosed with prostate adenocarcinoma between 2012 and 2014. Telephone interviews were recorded, transcribed, and analyzed using a systematic thematic approach.

Results:

Three profiles of patients emerged for choosing specialists: active (21.3%), partially active (53.2%), and passive (25.5%). Active patients conducted substantial research when choosing a diagnosing urologist and a treating specialist: they searched online, consulted other men with prostate cancer, and/or visited multiple specialists for opinions. Partially active patients took only 1 additional step to find a treating specialist on their own after receiving a referral from their diagnosing urologist. Passive patients relied exclusively on referrals from their primary care physicians (PCPs) and diagnosing urologists.

Conclusion:

The majority of patients relied on their PCPs for referrals to diagnosing urologists and on their diagnosing urologists to choose the treating specialist. Given these findings and the significance of specialist choice in determining treatment, it is important that PCPs recognize their indirect but potentially important effect on treatment choice when making referrals for prostate cancer. PCPs should consider counseling patients about seeking second opinions from providers with different treatment perspectives and participating in treatment decisions.




Fertility Treatment, Use of in Vitro Fertilization, and Time to Live Birth Based on Initial Provider Type

2017-03-08T13:54:48-08:00

Purpose:

To explore the relationship between the type of clinician (generalist vs subspecialist) initially seen by infertile women, the treatment received, and the time to pregnancy.

Methods:

We analyzed mixed-mode questionnaire data from 867 women with primary infertility enrolled into a retrospective cohort through population- and fertility clinic–based sampling. We compared women presenting first to generalist providers with women presenting first to fertility subspecialists, with the main outcomes of receiving in vitro fertilization (IVF), time to pregnancy, and live birth.

Results:

The first contact for most (84%) women with infertility was a generalist provider. Only 8% of women sought care first from a fertility subspecialist, and these women were older and had been trying longer to conceive. Women who presented first to a generalist provider were less likely to receive IVF (adjusted odds ratio, 0.48; 95% confidence interval, 0.28–0.82), were equally likely to achieve pregnancy, and had similar times to pregnancy (adjusted hazard ratio, 1.11; 95% confidence interval, 0.80–1.53) compared with women who presented first to a subspecialist.

Conclusions:

Generalist providers are frequently the first point of care for women with difficulty conceiving and are uniquely positioned to promote the balanced management of infertility.




Physicians' Experiences with Male Patients Who Perpetrate Intimate Partner Violence

2017-03-08T13:54:48-08:00

Introduction:

Despite the prevalence of intimate partner violence (IPV), there is a paucity of research exploring the role that physicians might play in intervening with IPV perpetrators.

Methods:

A qualitative study explored interactions between family medicine physicians and male perpetrators of IPV. Fifteen physicians were purposefully sampled from 1 hospital system. The physicians were individually interviewed using a semistructured interview guide, and interview transcripts were analyzed using techniques from grounded theory.

Results:

Three main themes relating to physicians' experiences were identified: (1) how physicians learned of or identified IPV perpetration by men (usually disclosure by the victim, but perpetrators also disclosed it); (2) how physicians assessed for comorbidities or responded to IPV perpetration by men; and (3) facilitators of and barriers to physician identification of and response to IPV perpetration by men. Facilitators identified include having a trusting relationship with the perpetrator and support services, whereas barriers consisted of strong negative emotions and a lack of training.

Conclusions:

Family medicine physicians in this sample reported feeling underprepared to serve patients whom they know are perpetrators of IPV, particularly if they are also providing care to the victim. Additional research is needed to develop interventions and effective trainings.




Comparison of Opioid Prescribing Patterns in the United States and Japan: Primary Care Physicians' Attitudes and Perceptions

2017-03-08T13:54:48-08:00

Introduction:

Far fewer opioids are prescribed in Japan than in the United States.

Methods:

We conducted an online physician survey assessing attitudes and perceptions that might influence prescribing. A Japanese version was distributed to members of the Japan Primary Care Association and an English version to members of the American Academy of Family Physicians practicing in Oregon.

Results:

We received 461 Japanese responses and 198 from the United States, though overall response rates were low (Japan: 10.1%, United States: 18.5%). Japanese respondents reported far less opioid prescribing than US respondents, especially for acute pain (acute pain: 49.4% vs 97.0%; chronic pain: 63.7% vs 90.9%; P < .001 for both). Almost half of respondents from both countries indicated that patient expectations and satisfaction were important factors that influence prescribing. US respondents were significantly more likely to identify medical indication and legal expectation as reasons to prescribe opioids for acute pain. Most US respondents (95.4%) thought opioids were used too often, versus 6.6% of Japanese respondents.

Conclusions:

Lower opioid use was reported in Japan, especially for acute pain, which may help minimize long-term use. Patient expectations and satisfaction seem to influence opioid prescribing in both countries. The United States could learn from Japanese regulatory and cultural perspectives.




Provision of Palliative Care Services by Family Physicians Is Common

2017-03-08T13:54:48-08:00

Objective:

Provision of palliative care services by primary care physicians is increasingly important with an aging population, but it is unknown whether US primary care physicians see themselves as palliative practitioners.

Methods:

This study used cross-sectional analysis of data from the 2013 American Board of Family Medicine Maintenance of Certification Demographic Survey.

Results:

Of 10,894 family physicians, 33.1% (n = 3609) report providing palliative care. Those providing palliative care are significantly more likely to provide non–clinic-based services such as care in nursing homes, home visits, and hospice. Controlling for other characteristics, physicians reporting palliative care provision are significantly (P < .05) more likely to be older, white, male, rural, and practicing in a patient-centered medical home.

Conclusion:

One third of family physicians recertifying in 2013 reported providing palliative care, with physician and practice characteristics driving reporting palliative care provision.




Ethical Considerations in Electronic Monitoring of the Cognitively Impaired

2017-03-08T13:54:48-08:00

Cognitive impairment afflicts an estimated 16 million people in the United States. Wandering is a concerning behavior associated with cognitive impairment, as it may threaten patient safety. The risks posed by wandering place severe burdens on both professional and informal caregivers, as well as law enforcement institutions throughout the United States. As such, location trackers that could reduce this burden have become increasingly prevalent. As with many assistive technologies, the substantial promise of location trackers is counterbalanced by potential pitfalls with respect to loss of privacy and autonomy. This article reviews the ethical issues raised by electronic monitoring of cognitively impaired persons, with the goal of transcending a narrow focus on decisional capacity in favor of a patient-centered framework that is applicable and adjustable at different stages of cognitive decline. Balancing the ethical principles of beneficence and respect in treating cognitively impaired persons goes beyond the necessary step of evaluating decision-making capacity to include partnering with families, caretakers, and cognitively impaired individuals who wander in a collaborative coalition of care. An approach emphasizing the individual needs of patients and caretakers is best suited to finding solutions that implement tracking technologies in ways that both protect and empower the cognitively impaired.
















A Message from the President

2017-03-08T13:54:48-08:00