Journal of the American Board of Family Medicine最新文献

Background: Leg cramps are common and distressing to patients who report using many treatment options, some of which have potential for significant adverse effects. Such treatments are often underreported to their clinicians, and additional sources for information are sought. Our study investigates patient-reported treatment choices and treatment helpfulness for leg cramp symptom relief, as well as their use of the Internet to identify treatments.

Methods: A newly developed cross-sectional survey was administered in Midwest primary care clinics.

Results: Of 714 survey respondents, 365 reported experiencing leg cramps and are included in our report. The mean age of our participants was 52.2 years (SD = 16.7). The sample was 70.4% female, 90.2% white, and 71.5% rural. Pharmacological treatment options for leg cramps were cited less frequently than nonpharmacological treatments. The most common and helpful pharmacologic interventions were over-the-counter analgesics. Nonpharmacologic treatments included massage, stretching, and walking. Of patients who experienced leg cramps, 30.8% (n = 100) reported looking up treatments on the Internet. The most popular interventions found on the Internet were hydration with either water or electrolyte drinks, potassium, magnesium, and massage of the affected muscle.

Conclusions: Patients with leg cramps use a variety of treatment options. Many nonpharmacological treatment options are at least somewhat beneficial, which thus present less estimated risk with more benefit. Nearly one-third of patients with leg cramps could be at potential risk of medication adverse events, particularly from over-the-counter analgesics. The use of the Internet could be seen as being problematic in nearly the same proportion.

Growing commodification of health care has resulted in a system that is impersonal, fragmented, and inequitable. A potential antidote to this poisonous situation is to understand and treat primary health care as a common good. Common goods are resources supported as essential to the wellbeing of all. They can be actualized through a Collective Impact approach of a developing a common agenda, shared measurement systems, mutually reinforcing activities, continuous communication, and backbone support organizations. Investing in primary health care as a common good, with investments in primary medical care spending, support, and workforce development, complemented by integrated support of public health and social drivers of health, can launch a transitional period that moves US health care toward greater accessibility, effectiveness, equity, and sustainability.

Background: Though cardiac stress tests have long been the standard of care for initial evaluation of cardiac symptoms, our institution, along with others, has noted high rates of incomplete tests.

Objective: To identify sociodemographic factors associated with the completion of cardiac stress tests and to assess the value of completed tests.

Design & participants: We conducted a retrospective chart review evaluating 150 patients with cardiac stress tests orders placed in 1 urban hospital-based primary care practice from 1/1/2018-12/31/2021.

Main measures: Our primary outcome was the completion of the stress test. We examined rates of completion based on sociodemographic factors including age, gender, race, language, and social vulnerability, markers of chronic illness, risk of atherosclerotic cardiovascular disease, and pretest probability of coronary artery disease.

Key results: In a multivariable adjusted model, female gender (OR:0.43 [0.18-1.00]), Black race (OR:0.26 [0.11-0.61]), and dyslipidemia (OR:0.27 [0.090-0.78]) were associated with lower test completion rates. We found no relationship between the likelihood of test completion and pretest probability. In an analysis of tests with low pretest probability, 100% of low-risk stress tests were negative; had any of those tests been positive the highest positive predictive value would have been 25%.

Conclusions: Test completion rates were significantly lower for individuals with female gender, Black race, and a diagnosis of dyslipidemia, highlighting inequities in the completion rates for a potentially lifesaving test. In addition, a substantial number of ordered tests were low risk and low value, highlighting areas of opportunity by advancing the value of cardiovascular care delivered.

Introduction: Health systems are increasingly pursuing efforts to screen for and address social drivers of health (SDOH), the nonmedical factors that contribute to health outcomes and inequities. A large integrated health system (Intermountain Health) launched a program in 2019 to universally screen for and address SDOH.

Methods: Five primary care clinics within Intermountain were purposefully chosen for diversity of setting and practice type (family medicine and pediatric). We conducted 20 semistructured interviews with frontline clinicians and staff from 7/1/2020 to 9/1/2020 to explore attitudes related to feasibility, workflow processes, and facilitators and barriers to successful implementation. We conducted an inductive-deductive analysis to identify key themes and best practices.

Results: Five clinics conducted 16,659 SDOH patient screenings from 12/1/2019 to 11/30/2020 (705 to 7,723 screens per clinic with rates ranging from 7.4% to 52.8% per clinic). Respondent perspectives about the program were mixed. Dominant implementation barriers included staff time constraints, limited availability of social services, and reduced morale. Key facilitators included triage protocols for positive screens independent of the primary care clinician, standardizing previsit digital screening, and instilling a culture of shared ownership through education and team SDOH-focused huddles.

Conclusions: This evaluation of an early systemwide SDOH program implementation called into question the feasibility of universal screening in primary care given staff time constraints and social service availability. Future investigations should explore the impact of targeted screening approaches in diverse clinical settings and quantifying trade offs between SDOH programs and other clinical and organizational priorities.

In July 2023, primary health care experts from more than 20 countries, the World Health Organization (WHO), and most agencies within the US Department of Health and Human Services (HHS) met at the National Academy of Sciences in Washington, DC, to catalyze action toward revitalizing primary care in the United States align efforts to advance primary health care worldwide, and improve health and security for all.¹ This meeting was informed by the NASEM's critical primary care report, which highlighted the need for federal leadership to strengthen primary care services in the United States, especially for underserved populations, and to inform primary care systems around the world. To that end, this meeting was designed to explore the challenges and opportunities of investing in primary health care as a common good and critical for health security and resilience across the globe.² In this issue, you will find {number} special communications from this conference that highlight the need to evolve from primary care to primary health care, the importance of primary care and public health collaboration, and the necessity for ongoing external scientific expertise to inform US federal government coordination efforts.Despite the clear consensus among global stakeholders regarding the importance of Primary Health Care to health equity, behavioral health, health security, and pandemic resilience, a year later the anticipated HHS Action Plan to guide implementation of the NASEM primary care recommendations has yet to be launched. While some agencies are moving ahead with initiatives and programs within their purview, the lack of a Primary Care Action Plan remains a missed opportunity to coalesce politically powerful stakeholders around a united and much-needed vision for a US health system centered on Primary Health Care, particularly in light of our challenges in responding to COVID-19.

Introduction: Unhealthy alcohol use (UAU) is associated with preventable morbidity and mortality and accounted for more than 140,000 deaths per year in the US during 2015 to 2019. The United States Preventive Services Task Force recommends routine screening for UAU in adults aged 18 years and older and pregnant persons, followed by brief counseling for a positive screening (B recommendation). Primary care clinicians can improve UAU outcomes by universally screening and offering brief counseling. This study aimed to increase screening, brief intervention, medication-assisted treatment (MAT), or referral for treatment (SBI/RT + MAT) in primary care practices.

Methods: Cluster-randomized study to investigate 1) the effectiveness of virtual practice facilitation as a method to enhance implementation of SBI/RT + MAT and 2) the potential added benefit of using alcohol use eLearning modules to guide and focus the process and content of virtual practice facilitation.

Results: Sixty-one primary care practices in Colorado enrolled in the study, with 43 primary practices completing the intervention and reporting 9-month data. Results show significant overall improvements in SBI/RT + MAT practice implementation scores from baseline to 9-month follow-up (P < .0001) and no differences between groups. The number of patients screened for UAU and/or Alcohol Use Disorder (AUD), receiving brief intervention, receiving an AUD diagnosis all significantly increased from baseline (P < .0001); and number receiving MAT also significantly increased (P < .0014).

Discussion: Practice facilitation can assist primary care practices in improving SBI/RT + MAT processes and patient outcomes, with the results providing initial evidence for successful use of virtual practice facilitation.

Introduction: Peer coaching has the potential to enhance the effectiveness of clinical performance feedback reports to family physicians, but few peer-coaching quality improvement programs have been implemented and evaluated in primary care. Authors designed, implemented and evaluated a peer-coaching program for family physicians in a large, academic primary-care organization to explore its potential to enhance family physicians' use of clinical performance data for quality improvement.

Methods: Coaches were nominated by their peers and were trained to follow an evidence-informed facilitated feedback model for coaching. Data were collected through surveys, a focus-group with coaches, and individual interviews with coached family physicians ("coachees"). Data were analyzed inductively using reflexive thematic analysis.

Results: Authors trained 10 coaches who coached 25 family physicians over 3 months. Coachees who completed the survey (21/25) indicated a desire for additional coaching sessions in future; most (19/21) reported confidence in making practice change. Interview (n = 11) and focus-group participants (n = 8) findings validated acceptability of the coaching approach that emphasized empathy ahead of change-talk. Coaches helped coachees interpret care-quality measures, deal with negative emotional responses evoked, encouraged a sense of accountability for improvement, and sometimes offered new ways to manage common challenges. Coaching sessions led to a wide range of practice-improvement goals. However, effects on practice change were felt to be limited by the data available and the focus on individual physician factors when broader clinic issues acted as important barriers to improvement.

Conclusions: Peer coaching is a feasible approach to supporting family physicians' use of data for learning and practice improvement. More research is needed to understand the impact on practice outcomes and physician wellness.

Background: Transgender and nonbinary (TGNB) patients face significant health disparities and negative experiences in health care spaces. With our family medicine residency clinic caring for an increasing number of TGNB patients, we sought to better understand the unique experiences and needs of this population.

Methods: We utilized a mixed methods approach, recruiting participants via our online patient portal and inviting them to complete a 36-item online survey and/or participate in one of four 90-minute focus groups exploring their interactions with a variety of care team members, perspectives on our physical clinic space, ideas for improvement, and other areas. We analyzed survey data using descriptive statistics and performed open coding on survey free-text responses and interview transcripts to identify salient themes.

Results: 90 TGNB patients completed the survey, and 20 participated in the focus groups. Participants described a variety of positive interpersonal and noninterpersonal experiences including being gendered correctly, clinicians being knowledgeable and responsive to feedback, and seeing visible markers of LGBTQ+ inclusivity. Negative experiences included misgendering and deadnaming, being asked unnecessary questions, and being outed as TGNB without their consent.

Conclusions: Participants' positive and negative health care experiences, along with their specific recommendations for interpersonal and system-level change, will help guide ongoing efforts to improve the care of TGNB patients at our clinic. Future needs assessments and ongoing conversations with our TGNB patients are needed to further explore this study's emerging themes, with particular attention to the impact of age, race/ethnicity, primary language, and other intersecting identities on TGNB patient experiences.