Journal of the American Board of Family Medicine最新文献

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.

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.

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.

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: 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.

Consider prescribing doxycycline as prophylaxis for bacterial sexually transmitted infections (STIs) in certain clinical scenarios. New data suggests that a one-time dose of 200 mg doxycycline taken within 72 hours of an unprotected sexual encounter may reduce transmission of syphilis, gonorrhea and chlamydia by a combined two thirds in a high-risk population.

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.

Counsel patients that their Mirena IUD retains contraceptive effectiveness for extended use up to 8 years.¹ The cumulative failure rate for years 6 through 8 was 0.68%, similar to reported rates for the first 5 years of use.

Use the new eGFR_cr-cys equation (estimated glomerular filtration rate equation that incorporates both serum creatinine and serum cystatin C levels) to estimate the GFR for both Black and non-Black individuals because the equation has improved accuracy, minimizes differences in eGFR between race groups, and more accurately reflects chronic kidney disease (CKD) prognosis while eliminating the use of race in GFR estimating equations.