Journal of the American Board of Family Medicine最新文献

Background: Patient portals provide patients with access to their health information, including medical history and conditions, lab results, and upcoming appointments and ability to message their care team. However, not all patients have access to their portal.

Methods: A cross-sectional survey of 233 adult family medicine patients from 4 community health clinics and a local community organization was conducted. The survey assessed patient demographics, internet usage, device ownership, and engagement with patient portals.

Key results: Nearly half (47%) of patients had never accessed any portal, whether their own, a friend's, or family member's. Among patients without home internet, 66% had never used a portal. 36% of laptop owners, 37% of desktop owners, and 34% of tablet owners had never used a portal. Across different self-identified identities, 46% of White patients, 41% of Black patients, and 53% of Hispanic/Latino patients had never used a portal. Among English speakers, 42% had never used a portal, compared with 59% of Spanish speakers. Roughly one-third (32%) of patients were interested in portal training, with more than half preferring individualized training.

Conclusions: Significant disparities in patient portal access exist in safety net practices. In addition to limited access to digital technology, lack of awareness of portal benefits and lack of clinician discussion and assistance likely contribute to inequities. Many patients desire individual portal training.

Background: Practice-Based Research Networks (PBRNs) facilitate important clinical research by connecting primary care clinicians with research opportunities. The West Virginia Practice-Based Research Network (WVPBRN), supported by the West Virginia Clinical and Translational Science Institute (WVCTSI), developed the Collective Outcomes Research Engagement (CORE) Survey to reduce barriers and support clinician participation in research.

Methods: The CORE Survey is an annual, centralized tool that combines investigator-driven questions into a single survey, aimed at reducing survey fatigue while supporting relevant research. Proposals are reviewed and selected based on relevance to primary care, feasibility, and alignment with WVPBRN priorities. The survey is distributed through the WVPBRN listserv using a snowball sampling approach. Investigators receive their results within 30 days to support analysis, dissemination, and grant development, with analytic support provided by network staff.

Results: From 2018 to 2023, the CORE Survey received 39 proposals, with 21 selected for inclusion. Resulting outputs include 4 peer-reviewed publications, 1 policy change, multiple local and national presentations, and data used in successful grant submissions. Response levels have remained stable, with 68 respondents in 2023.

Conclusion: The CORE Survey has become a sustainable and reproducible part of WVPBRN infrastructure that supports clinician-driven research across West Virginia. While research outputs vary year to year, the process has maintained steady engagement and contributed to a growing pipeline of scholarly activity. This model may benefit other PBRNs seeking to strengthen research participation in rural primary care.

Workforce projections predict a significant lack of primary care providers nationally. Increased family medicine residency programs and positions have been celebrated as the answer to these projections. Since 2012, the number of positions offered annually has increased almost 2-fold from 2,740 to 5,357. While this has the potential to help alleviate this disaster, very few are questioning the unintended consequences of additional family medicine positions. Over this same 14-year period, the number of programs failing to fill in the National Residency Match Program have increased 4.5-fold (64 to 288) with the number of unfilled slots increasing over 5.5-fold (142 to 805). Linear rates of change for unfilled residency programs per every 1,000 residency positions created have increased from 0.4 prior to 2018 to 69.3 between 2018 and 2021 to 271.5 after 2021. Unfilled programs experience multiple negative consequences including reputation damage and increase coverage responsibilities. Further addition of family medicine training position volume is therefore likely harmful to existing programs. Better solutions should be explored to creatively increase student interest in family medicine by emphasizing and leveraging the value of family medicine physicians and primary care.

Introduction: Soft tissue concerns are common, yet most primary care physicians must refer patients to radiology for further imaging, leading to potential delays in diagnosis and management. Point-of-care ultrasound (POCUS) is increasingly available in primary care and has been shown to improve clinical decision making. However, current Family Medicine POCUS curricula focus primarily on cellulitis and abscess, overlooking other common soft tissue pathologies. This study aims to evaluate the frequency of soft tissue pathologies and associated follow-up recommendations on comprehensive radiology ultrasound exams ordered by Family Medicine physicians.

Methods: A retrospective study of radiology-performed comprehensive ultrasound exams ordered by an academic urban Family Medicine practice over the course of the 2019 was performed. Data collected included patient demographics, ultrasound findings, anatomic location, and follow-up recommendations. Diagnoses were categorized, and time from order to completion was calculated.

Results: Soft tissue ultrasounds comprised 10% (n = 168) of all ultrasound studies ordered. The most common diagnosis were lymph nodes, n = 44 (25%), lipomas n = 32 (18%), and no lesion/normal n = 23 (13%). Only 2 studies diagnosed abscess (1%). The median time from order date to completion was 6 days (IQR 2 to 22 days), with 48% waiting over a week. Half (51%) of studies required no further follow up, while 26% required additional imaging or biopsy.

Discussion: These findings highlight the need for expanded Family Medicine POCUS training to include high-yield diagnoses such as lipomas, lymph nodes, and cysts. POCUS could reduce unnecessary referrals, expedite care, and improve diagnostic confidence. Future research should explore primary care-specific POCUS protocols and their impact on patient outcomes.

Urine drug monitoring is widely used in outpatient addiction treatment, particularly for patients receiving medications for opioid use disorder (MOUD). While intended to support recovery and enhance clinical decision-making, the actual benefits of urine drug screening (UDS) remain uncertain. Evidence demonstrating improved patient outcomes is lacking, and the potential harms of routine screening are often underrecognized. These harms include false positives, patient stigma, racial bias, and trauma. UDS may also strain therapeutic relationships, particularly when used without transparency or patient consent. This essay calls for a more thoughtful, evidence-informed approach to drug screening in primary care. Clinicians should weigh the limitations of UDS and prioritize strategies that build trust, respect patient autonomy, and support long-term recovery.

Point-of-care ultrasound (POCUS) has emerged as a powerful tool for bedside diagnosis and management, offering real-time clinical insights and cost savings. Its integration into rural family medicine could reduce reliance on advanced imaging, improve patient satisfaction, and support physician versatility across primary, emergency, and procedural care. Despite these advantages, POCUS adoption remains limited, largely due to ambiguous and inconsistent reimbursement policies. Rural Health Clinic all-inclusive payment models, state Medicaid variability, and Local Coverage Determination gaps undermine financial sustainability. Cost analyses demonstrate meaningful system-level savings, yet physician revenue remains constrained, particularly in Medicare-heavy rural populations. Policy solutions include adjusting rural payment models, establishing national Local Coverage Determinations (LCDs), introducing visit modifiers, and leveraging tele-ultrasound and hybrid training approaches. Complementary pathways, such as limited out-of-pocket patient payments, may provide short-term support but risk inequities. Aligning reimbursement policy with demonstrated clinical and economic benefits is critical to scaling POCUS in rural family medicine and strengthening equitable access to care.

Introduction: Identifying patients with a history of cancer in primary care remains a barrier to implementing optimal survivorship care.

Methods: As part of an intervention to support primary care practices to deliver breast cancer survivorship care, our team developed a process that uses electronic health record (EHR) reporting capabilities to systematically identify patients with breast cancer history. This intervention was fielded in 13 primary care practices in an integrated health system. End-user feedback throughout the intervention informed refinements of the procedure and provided insights into the appropriateness and feasibility of implementing this tool.

Results: Practice members were able to successfully generate reports that included lists of patients with a history of breast cancer at both the practice and clinician level. Feedback from those implementing the intervention led to refinements that included expanding users who could generate and access the reports to include nonphysicians and adding additional search criteria.

Discussion: Implementation of system-wide EHR reports and instruction of clinic champions on procedures to generate analytics of breast cancer survivors can facilitate informatics skill-building and enable primary care teams to engage in breast cancer survivorship care.

Conclusion: This method of creating practice- and clinician-specific cancer survivor patient registries can be applied in other contexts to support the delivery of evidence-based survivorship care.

Background: In 2018, prostate cancer screening with prostate specific antigen (PSA) received a "C" recommendation from the US Preventive Services Task Force for men aged 55 to 69 years. In January 2023, our health system implemented a point-of-care electronic reminder for primary care clinicians to discuss PSA screening for men aged 55 to 69.

Methods: We assessed the impact of reminder implementation on monthly rates of PSA ordering from January 1, 2022 to July 31, 2024 by performing interrupted time series analyses for men aged 55 to 69 years (for whom the reminder was implemented) and men aged 50 to 54, 70 to 74, and ≥75 years.

Results: Before reminder implementation, PSA was ordered in a median of 6.4% of visits for men aged 55 to 69 years versus a median of 10.2% of visits after reminder [adjusted incidence rate ratio (aIRR) 1.57 (95% CI: 1.43-1.73)]. The postreminder period was associated with smaller but significantly increased rates of PSA ordering in men aged 50 to 54 [aIRR 1.44 (1.25-1.65)], 70 to 74 [aIRR 1.26 (1.14-1.39)], and ≥75 years [aIRR 1.11 (1.02-1.11)].

Conclusions: Implementation of an electonic medical record (EMR) reminder to discuss PSA screening was associated with a large increase in PSA ordering among men in the targeted age-group, but also smaller increases in age groups for whom the balance of benefits and harms of PSA screening may be less favorable.

Introduction: Cystic fibrosis transmembrane conductance regulator (CFTR) modulators have revolutionized care for people with cystic fibrosis (pwCF) by improving quality of life and extending life spans. These factors support the need for pwCF to establish care with a Primary Care Provider (PCP). It is currently unclear how many adult pwCF routinely interact with a PCP.

Methods: This IRB approved, retrospective study included patients over 18 years old, seen in the adult Cystic fibrosis (CF) clinic, who were prescribed elexacaftor/tezacaftor/ivacaftor (ETI) between 8/31/2022 and 8/31/2023 at University of Iowa Health Care. The primary outcome of the study was to determine the percentage of pwCF with a PCP designated as a member of their care team in the electronic medical record (EMR). The secondary outcomes determined the percentage of pwCF who completed preventative health screenings for comorbid conditions and received appropriate cancer screenings and immunizations.

Results: Of the 115 included patients, 60% (69/115) had a PCP identified in the EMR. PwCF have uncontrolled blood pressure regardless of whether they have a PCP identified in the EMR (76.5%) or not (78.3%). Rates of influenza (p=0.006) and pneumococcal (p=0.006) vaccinations were significantly lower for pwCF without a PCP.

Discussion: There is a gap in healthcare for pwCF, especially for those who do not routinely interact with a PCP. CF clinicians may not be up to date on primary care management and PCPs may not be comfortable with treating patients with a high acuity chronic condition. PCPs should be better integrated into the CF care team to ensure pwCF are receiving comprehensive care.