Journal of the American Board of Family Medicine最新文献

The notion of medical aid in dying dates back to 1994 and the approval of the Death with Dignity Act by the citizens of Oregon. Therein was incorporated the notion of competent terminally ill patients being permitted to resort to the self administration of lethal physician-prescribed drugs. Several other states followed suit. Medical aid in dying is now broadly applied in the US under strict legal oversight in an ever-growing number of states.

Introduction: Immediate postpartum long-acting reversible contraception (IPP-LARC) after delivery may decrease rapid repeat pregnancy (RRP). RRP is associated with preterm birth, small for gestational age, low birth weight, and infant/maternal mortality. In April 2017, the Ohio legislature passed SB 332, mandating immediate postpartum LARC coverage. Later that year, our hospital made the IPP-LARC Nexplanon (and not intrauterine devices [IUDs]) available to all delivering patients. This study aimed to see if SB 332 is associated with decreased RRP.

Methods: Using electronic health record and state registry data, we examined sociodemographic and perinatal care variables for 726 pregnant adolescents and adults delivering at our hospital during the 12 months before and after IPP-LARC became available. We then determined the association between RRP and these variables.

Results: After LARC became available, 62/368 patients chose Nexplanon. Gravidity (OR: 1.128) and vaginal delivery (OR: 1.682) were negatively associated with RRP while age at delivery was inversely associated (OR: 0.902, p < .001). The adjusted mean probability of RRP was 6% for those who had IPP-LARC placement, compared with 20% for those who did not. LARC availability was positively associated with RRP but not significantly (OR: 1.287, p = .195).

Conclusions: After SB 332's passage, IPP-LARC availability was positively associated with RRP, but the percentage of patients who chose IPP-LARC was low. However, RRP occurred less often among patients who chose IPP-LARC placement. Hospital systems must actively invest in patient education and provider support to ensure interventions to reduce rapid repeat pregnancy are optimally utilized by vulnerable populations.

Objectives: This cross-sectional retrospective survey study modeled on previous research explored the prevalence of period poverty in 1 urban setting to inform future targeted interventions toward improving menstrual equity.

Methods: An 8-item questionnaire was developed by a menstrual health equity work group led by the Allentown Health Bureau, Pennsylvania. Data collection occurred for 1.5 years, using an anonymous online survey tool and convenience sampling. Study participants were recruited with an informational flier (with QR code and web address pointing to the questionnaire) posted in various public locations.

Results: A total of 353 people who menstruate, aged 13 to 54, representing 5 of Allentown's 7 ZIP code regions responded. The majority were impacted by period poverty, either by missing a life event (77.9%) or engaging in an at-risk menstrual hygiene behavior (79.0%). Most (91.5%) had been educated in menstrual health. Doctor's offices (40.3%) and social media (27.8%) were the most frequently cited sources for learning about the survey. ZIP codes were significantly associated with engaging in at-risk behaviors (P < .001), missing a life event (P < .001), no menstrual health education (P = .03), and preference for period underwear (P = .04). Age was significantly associated with preferring pads (P = .007) and tampons (P = .03).

Conclusions: Period poverty was found to impact a substantial number of people in Allentown, Pennsylvania. Interventions will need to be tailored to ZIP code and age-group. Future study should aim for a larger sample size and additional questions, about menstrual education.

Objective: Expanding access to high-quality contraceptive care in primary care is key to achieving reproductive health equity. We assessed the impact of an equity-focused quality improvement learning collaborative (QILC) on contraceptive care at community health centers (CHCs) through innovative performance measurement.

Methods: We developed a 9-month QILC including monthly learning sessions on reproductive health equity and person-centered contraceptive care, supporting resources, peer-learning opportunities, and technical assistance. We assessed QILC impact through 3 performance measures collected prepost QILC: the Person-Centered Contraceptive Counseling (PCCC) measure that assesses contraceptive counseling; the Contraceptive Care Screening electronic clinical quality measure (eCQM) (CCS-SINC); and contraceptive use eCQM (CU-SINC). CHCs collected PCCC surveys from patients prepost QILC, and we extracted electronic health record data to calculate eCQMs. To assess intervention impact, we compared prepost PCCC scores and eCQM percentages.

Results: Nine CHCs participated in the QILC. Assessing contraceptive care screening, median increase in CCS-SINC was 14.4% (Interquartile range [IQR]: 7.5%-40.4%) between baseline and endline. CHCs realized an increase in CU-SINC (median relative Δ: 4.9%; IQR [3.7%-22.3%). Compared with baseline, at endline, 5 of 9 CHCs improved their PCCC score (Δ 2.1% to 26.2%) and 3 of those surpassed the 80% benchmark for high-quality care. Greater improvement in performance measure scores was noted among CHCs with leadership buy-in and lower staff turnover.

Conclusions: Participation in an equity-focused and measurement-driven QILC led to improvements in person-centered contraceptive care delivery.

This issue includes information gathered from multiple health systems, covers many chronic health conditions and risk factors, and gives estimates of patient panel size. Women's health articles cover period poverty, contraception and prenatal care. Other articles tackle the complex goal of improving care for at-risk patients and those with multiple chronic and behavioral health conditions, plus the potentially sensitive question of screening for potential firearm violence exposure.

Introduction: The Veterans Health Administration (VHA) historically has spent a larger percentage of total medical expenditures on primary care than other US payers, but more recent estimates are unknown. Further, no studies have identified whether geographic differences in primary care spending exist within the VHA's 18 regional Veteran Integrated Service Networks (VISNs). Our objective was to characterize the percent and per-Veteran absolute spending on primary care nationally and by VISN in the VHA in 2022.

Methods: We calculated primary care and total VHA spending in fiscal year 2022 nationally and by VISN. We then calculated the per-Veteran absolute spending and percent of total national expenditures attributed to primary care.

Results: In 2022, VHA spent $848 per-Veteran on primary care (9.2% of total medical expenditures). Across the 18 VISNs, per-Veteran spending ranged from $641 to $1079, with the 25^th and 75^th percentiles ranging from $802 to $881. Primary care percent spending ranged from 7.1% to 11.2%, with the 25^th and 75^th percentile ranging from 8.5% to 9.7%. Only 6 of 18 VISNs were in the same quartile for primary care spending in each metric.

Discussion: Primary care spending in the VHA in 2022 as a percentage of total medical expenditures was stable compared with prior estimates. In addition, our results show discordance in each VISN's spending quartile based on the metric utilized. This finding suggests that each metric may capture a different element of primary care spending.

Family physicians in the National Health Service Corps (NHSC) are more likely than non-NHSC physicians to practice in high-need areas, but retention declines over time. Despite higher retention than non-NHSC physicians, NHSC participants experienced greater declines from 3 to 6 years post-residency (MUA: 85.0% to 60.7%; HPSA: 76.0% 6 to 66.2%; rural: 29.8% to 21.3%), underscoring the need for policies that sustain long-term commitment.

Purpose: Ongoing changes in the operations and constraints of the health care system are likely affecting how patients make decisions about care seeking. Therefore, we analyzed data from a national survey asking people where they would seek care if they had no limits.

Methods: We conducted surveys of patient experiences and perceptions regarding primary care delivery and access during the pandemic, one of which conducted during November 15 to 23, 2021 included a question asking: "If you had no limits (such as insurance coverage, or what you could afford), what would be your first choice for handling most of your health concerns?" A multidisciplinary team analyzed responses using a 3-step process: identified categories using a grounded approach, tallied category frequencies using a template-based coding approach, and involved an auditor to search for confirming/disconfirming data.

Main findings: Among 1,211 respondents with usable answers, the most frequent first preference for handling most health concerns was primary care (49.1%). Other common responses were hospital or health system (11.9%), a convenient/easily accessible source (11.6%), the current source of care (8.3%), a source that would provide quality care (8.2%), or a specialist (8.0%). Less common preferences include urgent care, clinicians with whom the respondent had a relationship, a specific procedure or treatment, self-care, alternative medicine, mental/behavioral health care, holistic/wellness/preventive medicine, or pharmacy.

Conclusion: A majority of respondents among a large national sample of patients preferred primary care for handling most health concerns. Given the known benefits of primary care, systems should support, rather than constrain, that preference.