Journal of the American Board of Family Medicine最新文献

Background: The association between interpersonal continuity of care (CoC) and progression from the prediabetic state to Type 2 Diabetes (T2D) remains unknown.

Aim: To evaluate the association between interpersonal CoC and the progression to T2D among persons with prediabetes.

Design and setting: A retrospective cohort study using electronic health record (EHR) data from 6620 patients at Geisinger, a large rural health care system in Danville, PA.

Methods: Cox regression methods were used to estimate the hazard ratio associated with progression to T2D within 3-years of being diagnosed with prediabetes.

Results: One additional visit with the primary care provider most frequently seen by the patient is associated with 14% decreased risk (HR = 0.86; 95% CI = 0.85, 0.87; P < .001) of transitioning to type 2 diabetes within 3 years of being diagnosed with prediabetes.

Conclusions: This study demonstrates an association between increased interpersonal CoC after a person is diagnosed with prediabetes and a reduced risk of progressing to T2D within 3 years.

At standard doses, direct oral anticoagulants (DOACs) were associated with a reduced risk of systemic embolism and intracranial hemorrhage (ICH) when compared with warfarin, with a greater derived benefit at lower creatinine clearance (CrCl-down to 25 mL/min). Lower doses of DOACs were associated with increased overall mortality without a significant decrease in ICH and incident bleeding when compared with standard dose DOACs and warfarin, across all CrCl down to 25 mL/min.¹.

Objective: To understand how primary care clinics coordinate services for complex patients and whether clinics with an integrated social worker do it differently.

Methods: Cross-sectional survey of the 213 most experienced care coordinators for each of the 317 participating clinics. The survey asks about staffing, communications, care model (nursing vs integrated social worker), resources, support, services, how services are available and delivered, payment approach, and satisfaction. Clinics using the integrated model include the social worker as part of the care team, responsible for assessing and coordinating services for social needs, and communicating directly with both patients and clinicians.

Results: Out of 317 clinics from 42 diverse care systems, 139 had an integrated social worker and 178 did not. Care coordinators in the integrated social worker clinics had somewhat larger patient panels and worked with almost twice as many clinicians. These care coordinators were also less likely to be on site and more likely to communicate with patients and clinicians by telephone rather than in person. Care coordinators in the integrated social worker clinics were 10 to 30% more likely to assess patients' social needs, provide a broader range of services, and to be more engaged in the process of referral for community services.

Conclusion: Clinics with an integrated social worker seem to differ in the frequency and approach to care coordination as well as in how social needs are addressed from those that use a nursing model while providing most medical/nursing services at similar or higher rates.

The minority tax has been defined as a set of disparities that those who are underrepresented in medicine face in addition to clinical care, education, and research responsibilities. These taxes include systemic racism, diversity efforts, clinical and promotion disparities, lack of faculty development, and isolation. Much has been added to the literature to better define and characterize the minority tax and propose suggestions for mitigations. This article builds on the existing literature that defines clinical efforts and diversity efforts disparities by exploring the intersections of these disparities through the experiences of family medicine faculty in the clinical environment. The authors, who are all academic family medicine physicians from minoritized communities, use their lived experiences to share how the diversity efforts disparity impacts patient care. Themes noted include health system wide challenges for patients whose preferred language is not English and the importance of racial and ethnic concordance between patients and the physician workforce.

Purpose: To determine whether the construct of family medicine clinical decision making ability was invariant across modes of administration, the 1-day examination and the longitudinal assessment. We attempted to identify item characteristics associated with differences in difficulty across modes of administration.

Methods: The data were item difficulty calibrations based on examinee responses to the 1-day examination and the longitudinal assessment. A repeated measures design was employed to identify question calibration differences across modes of administration, so that the stability of the question difficulty across modes of administration could be assessed. A qualitative review of the flagged questions was conducted to identify characteristics associated with questions becoming easier or more difficult.

Results: The correlation between the pairs of calibrations was moderately positive r(298) = 0.558, P < .001 suggesting that the questions are functioning somewhat similarly across the different modes of administration; however, the scatterplot demonstrates that many of the questions became easier. Of the 298 repeated measures t test, 37% (110) did not show a significant difference, 43% (128) became easier on the longitudinal assessment, and 20% (60) became more difficult.

Conclusions: This study suggests that changes in item difficulty do occur when extra time and the use of external resources are permitted. Usually the questions get easier, but in some cases the question becomes more difficult. Possible reasons for this are presented, and a method to adjust the item difficulty in a way to maintain a single construct is presented.

Introduction: Colorectal cancer (CRC) is the second leading cause of cancer death in the United States. While patient-reported barriers have been previously described, few studies have analyzed how patients' social needs affect screening rates.

Methods: This cross-sectional study includes 3,443 Kaiser Permanente (KP) patients ages 50 to 75 years who completed the 2020 KP National Social Needs Survey. Five social needs categories were assessed: "Financial Strain," "Housing Instability," "Transportation Issues," "Social Isolation," and "Food Insecurity." Being up to date on CRC screening was determined from patients' electronic health records, defined as meeting Health care Effectiveness Data and Information (HEDIS) criteria for screening. We used multivariable analyses to explore associations between social needs and completion of colorectal cancer screening in 2020, adjusting for demographic factors.

Results: Among the survey respondents, 2,805 (81.5%) were up to date on their colorectal cancer screening. Patients were less likely to be screened if they had severe financial strain (OR 2.1, 95% CI 1.3-3.4), severe social isolation (OR 1.9, 95% CI 1.2 to 3.2), and severe food insecurity (OR 2.5, 95% CI 1.2-5.3). There was a nonsignificant increase in odds of not being up to date with screening for severe transportation issues (OR 3, 95% CI 0.93-10) and severe housing instability (OR 1.7, 95% CI 0.93-3).

Conclusion: Even within a fully insured population with high screening rates, respondents with financial strain, social isolation, and food insecurity had lower odds of being up to date with CRC screening. Future efforts should assess how addressing patients' social needs could lead to increased CRC screening rates.

Income is an important social determinant of health, yet it is rarely discussed among patients and clinicians. Discussing income could open the door to addressing issues like high deductibles, prescription costs, copays, housing expenses, and medical debt. We identify ways to overcome obstacles to talking about this taboo subject.

Background: There is great interest in intensive primary care interventions to address high utilization among medically and socially complex patients. How patients experience these interventions has received less attention.

Objective: To better understand patients' experience of intensive primary care, we interviewed patients receiving care from the Streamlined Unified Meaningfully Managed Interdisciplinary Team (SUMMIT), an ambulatory intensive care intervention at an urban federally qualified health center.

Methods: We interviewed 25 participants enrolled in the SUMMIT randomized controlled trial and conducted a Reflective Thematic Analysis using a hybrid inductive-deductive approach.

Results: Patients reported high levels of medical and social needs that outstripped prior levels of care and resources. They perceived multiple benefits of SUMMIT through the following themes: 1) Team-based care with improved access to services. Patients appreciated their medical and social needs being met, through higher-level, multidisciplinary care. 2) Caring relationships. Patients described the SUMMIT team as being like family and felt that team members had a genuine sense of duty and obligation toward them. 3) Overcoming stigma. Patients felt valued and treated with dignity. 4) Evolving self-efficacy. Over time, patients experienced increasing success, including engagement in care and improved health behaviors.

Conclusion: Patients perceived the SUMMIT team as better meeting their health-related needs, compared with traditional primary care. They spoke of the team as family and felt humanized and supported in overcoming barriers to engagement, which led to increased self-efficacy. Evaluations assessing the effectiveness of intensive primary care should measure potential patient-centered benefits beyond short-term utilization and cost reduction.

Background: Integrated behavioral health (IBH) is a promising approach which embeds behavioral health services into primary care. Yet, IBH has had limited implementation. Our objective was to identify strategies to successfully implement the "Cherokee" IBH model by examining a 2013 to 2019 IBH demonstration project in New Jersey that included Federally Qualified Health Centers (FQHCs) and Community Health Centers (CHCs).

Methods: We conducted qualitative semistructured interviews of 18 primary care and behavioral health clinicians from 10 FQHCs/CHCs in 2022. Interview guide questions drew on the Proctor Implementation Outcomes Framework to capture strategies to optimize acceptability, appropriateness, feasibility, fidelity, penetration, and sustainability of IBH implementations. A template approach was used to code data and identify themes.

Results: All participating FQHCs/CHCs were still offering IBH services 3 years after the demonstration project, suggesting that strategies were successful in implementing and sustaining IBH. Strategies these FQHCs/CHCs employed included: (1) select champions with experience leading organizational change; (2) provide training that emphasizes how brief behavioral health interventions differ from traditional therapy; (3) develop on-going IBH training procedures for new staff; (4) create physical spaces for behavioral health consultants; (5) establish scheduling systems; and (6) identify local IBH billing codes, policies, and procedures.

Discussion: Change management approaches can help in the implementation of IBH; however, additional strategies unique to IBH may be needed to address the attitudinal, organizational, and financial challenges inherent to IBH.

Conclusion: Future implementations should apply multi-faceted approaches that address persistent and seemingly intractable barriers that have inhibited IBH integration.