FP essentials最新文献

Long-acting reversible contraceptives (LARCs) include progestin and copper intrauterine devices (IUDs) and progestin subdermal implants. LARCs may be the preferred for individuals who want a method that is highly effective and can last for several years, or for whom estrogen is contraindicated. LARCs should be offered using a shared decision-making approach, keeping in mind that historically these methods have been used coercively to control the reproductive choices of marginalized or disabled people. To ensure safe prescribing and reduce barriers to receiving LARCs, family physicians should be familiar with two evidence-based national contraceptive guidelines: the U.S. Medical Eligibility Criteria for Contraceptive Use (U.S. MEC) and the U.S. Selected Practice Recommendations for Contraceptive Use (U.S. SPR). Information about insertion, removal, potential complications, and expected adverse effects should be included when counseling patients about LARC options. Both types of LARC IUDs can safely be used for emergency contraception if inserted within 5 days of unprotected intercourse. Several oral emergency contraception drug options also are available.

Unintended pregnancy is seen commonly in the family medicine setting. It is defined as a pregnancy that is mistimed (occurring sooner than wanted) or unwanted (not desired at that time or any time in the future). Approximately 45% of all US pregnancies are unintended. Childbirth resulting from an undesired pregnancy has been associated with adverse maternal and child health outcomes. Clinicians should be prepared to manage unplanned pregnancies, including dating pregnancies and discussing pregnancy options. Pregnancy options counseling entails discussing the options to parent, make an adoption plan, or undergo an abortion. Because of the complexity around pregnancy intentions, a framework that places patients at the center of their reproductive decisions and engages them in collaborative decision-making during options counseling is paramount. Patients commonly seek abortion, which is considered essential health care. Because of the current legal climate surrounding abortion in many states, patients may opt to use abortion drugs without licensed clinician oversight, called self-managed medication abortion, which has been shown to be safe and effective. No states require clinicians to report known or suspected self-managed medication abortion.

More than 65% of US women ages 15 to 49 years use contraception every year, many of whom seek care with family medicine. Family physicians are well equipped to provide comprehensive contraceptive counseling to patients in the primary care setting. When discussing options and providing education to patients, clinicians should consider patient preferences, patient autonomy, and adverse effect concerns, and should use a patient-centered approach that upholds the principles of reproductive justice. Nonhormonal methods of contraception include barrier methods and spermicides, fertility awareness-based methods, and (in postpartum individuals) lactational amenorrhea. With barrier methods, spermicides, and fertility awareness-based methods, 13 to 29 out of 100 women may become pregnant. Permanent forms of contraception include female and male sterilization procedures, which are some of the most effective (more than 99% effective) and most commonly used methods in the United States.

Short-acting reversible contraceptives (SARCs) are prescribed routinely by primary care clinicians. SARCs are among the most commonly prescribed contraceptive methods and include combined hormonal oral contraceptive pills, the combined hormonal transdermal patch, the combined hormonal vaginal ring, progestin-only pills, and the 3-month depot medroxyprogesterone acetate injection. To ensure safe prescribing and reduce barriers to receiving SARC methods, family physicians should be familiar with two evidence-based national contraceptive guidelines, the U.S. Medical Eligibility Criteria for Contraceptive Use (U.S. MEC) and the U.S. Selected Practice Recommendations for Contraceptive Use (U.S. SPR). SARCs have benefits in addition to pregnancy prevention; as such, these methods may be chosen for reasons other than contraception.

Electronic health record (EHR) systems have transformed the medical industry. Despite their known benefits, their implementation has resulted in new digital administrative tasks and responsibilities for physicians. This increase in administrative burden has been shown to contribute to physician burnout. Most sources of EHR-related burnout can be categorized into three groups: poor usability, excessive time spent in the EHR, and inefficient workflows. Evidence-based interventions for EHR-related burnout focus on training and education, which improve efficiency in EHR use and may reduce burnout. Optimization of the EHR interface, including personalization and use of targeted workflows, can help address physician frustrations and improve productivity. In the United States, the federal government regulates EHR system development and sets usability requirements. These requirements are critical because visualization and operational design of the user interface have been shown to directly affect patient care and safety. Negative effects of EHR implementation generally are related to increased administrative burden. Positive effects include greater clinician productivity and administrative cost savings. EHR adoption has consistently been associated with positive financial and clinical outcomes. Federal laws continue to be implemented to improve EHR usability, interoperability, and standards for data access and security.

Telemedicine is defined as the provision of clinical services via telephone or video and is a type of telehealth. Telehealth is defined as the use of electronic information and telecommunications technologies for the delivery of health care, health education, and health information. During the COVID-19 pandemic, telemedicine availability and use of telehealth care significantly increased. The integral role of telemedicine during this time prompted the unprecedented integration of telehealth as a quasi-standard of care. Recent studies have shown telemedicine can achieve comparable or superior quality performance compared with in-office visits for a range of clinical areas in large primary care populations. Implementation of telemedicine at the practice level depends on use of strong clinical workflows across the medical team. Effective telemedicine visits rely on adaptation to a digital environment and patient cooperation for virtual physical examinations. There are subtle differences in coding for billing telemedicine visits (mainly for audio-only visits), and many add-on codes for preventive care are eligible for telehealth. Concerns exist about the ethical implications of virtual care, especially regarding privacy and access. The future success of telehealth will depend on a balance of patient autonomy and health outcomes in the context of health equity.

Remote patient monitoring (RPM) provides real-time clinical patient data to the medical team. The foundational element of RPM is communication, including data processing and integration in the electronic health record and communication of data between patients and clinicians. Patient portals are integral to this communication and their use can result in improved health outcomes and patient safety. Patient portals promote engagement of patients in their care, increase access to the medical team, and integrate RPM system data. RPM systems can monitor a spectrum of parameters related to chronic conditions, from vital signs (eg, heart and respiration rates, blood pressure, blood oxygen and glucose levels) to advanced cardiovascular measures. Some RPM systems are capable of automated monitoring. Health care insurance coverage of RPM systems varies widely, which has health equity implications, particularly for high-risk patients with endocrine and cardiovascular conditions. Additional challenges to widespread adoption of RPM include its contribution to administrative burden for physicians, patient data privacy issues, and variable effectiveness of RPM systems in the management of different chronic conditions.

The association between electronic health record (EHR) documentation and physician burnout is well-known. A combination of insufficient time to complete tasks, clinical documentation burden, and electronic inbox overload comprises the definition of documentation-related burnout. Burnout mitigation strategies related to clinical documentation include use of targeted EHR training for documentation, use of medical scribes, and institutional documentation redesign. Mitigation strategies related to electronic inbox overload include assigning designated administrative time for inbox management, tailoring of message content to decrease length, and a team-based approach to clinical workflows. Best practices for improving the efficiency of clinical documentation in the EHR include use of automation tools (eg, macros, templates), physician note optimization, and use of team-based documentation. Clinical documentation aids such as medical scribes, speech recognition software, and artificial intelligence (AI)-based software are popular and often considered a necessary resource in health care. For most practices, decisions regarding which aid to use will likely be determined by cost. Speech recognition software is the lowest cost option. AI-based software and medical scribes are more costly.