Journal of the American Board of Family Medicine最新文献

Introduction: United States Preventive Service Task Force guidelines recommend annual low-dose computed tomography for lung cancer screening (LCS) for people with significant history of cigarette use. While the national prevalence of lung cancer screening remains low, with known racial and ethnic disparities, studies have yet to examine LCS screening disparities by nativity among Latino patients.

Methods: We evaluated the documentation and prevalence of LCS orders in the electronic health record in Latino patients, by place of birth, in a multistate network of community health centers, over a 10-year study period (2013 to 2022), adjusting for patient and clinical demographic factors.

Results: Among patients who reported current or former cigarette use (n = 126,528), the prevalence of a LCS order was 7.3%. Among 62,483 patients with a documented 30+ year pack-history, US-born Latinos had equal odds as non-Latino Whites to have LCS ordered (OR = 0.71, 95% CI = 0.42-1.21), while odds were lower for both foreign-born Latinos (OR = 0.47, 95% CI = 0.29 to 0.75) and Latinos without a place of birth recorded (OR = 0.63, 95% CI = 0.54-0.73).

Conclusion: The prevalence of LCS was low overall in a large sample of Latino and non-Hispanic White patients with cigarette smoking history. Foreign-born Latino and Latino patients without a country of birth noted in the record had significantly lower odds of having LCS ordered; this should be considered in clinical screening workflows. Nativity and pack-year history were not documented in most patients. More complete documentation of nativity and pack-year history is necessary to fully assess LCS need and equity in Latino patients of heterogeneous nativity.

Background: Hybrid models of care (ie, telehealth and in-person care delivery options) have been incorporated into primary care clinics to increase patient access to care. We examine the effects of these approaches on the work experiences and wellness of primary care clinical team members providing team-based care to patients.

Methods: In this qualitative study, we conducted semistructured interviews with clinical team members (primary care clinicians, behavioral health consultants, registered nurse) at 2 primary care practices at 2 time points (late 2021-mid 2022 (n = 14); midlate 2023 (n = 11)). We used an inductive approach to analyze data.

Key results: Benefits of hybrid models of care included increased patient access and personal flexibility; however, it was noted that the fragmented in-clinic schedules that emerged from the hybrid model resulted in reduced in-clinic interactions. This led to less information sharing among team members and a degradation of informal support networks that could adversely impact patient care. To mitigate these challenges, many preferred that most of their clinical shifts occurred in-person, in the clinic, with 1 to 2 sessions per week for in-home (telework) shifts.

Conclusions: In team-based primary care clinics, hybrid care models can impact interactions among clinical team members and shape the day-to-day environment in which clinical teams work. To optimize hybrid care approaches in the primary care setting, organization leaders must consider the impact of hybrid care models on clinic and team culture, and the well-being of clinical team members.

Initiation of pitavastatin in adults aged 40 to 75 living with HIV treated with highly active antiretroviral therapy (HAART) with low-to-moderate 10-year atherosclerotic cardiovascular disease (ASCVD) risk decreases the incidence of major cardiovascular events (MACE).

In patients younger than 21 years of age with a provoked deep venous thrombosis (DVT), anticoagulation for 6 weeks is noninferior to anticoagulation for 3 months.¹.

Purpose: The few studies about primary care based controlled substance safety committees (CSSC) to date have been primarily quantitative, focused on patient outcomes and lacked contextual data around their implementation. The purpose of this study is to qualitatively identify barriers and facilitators to the use of CDCs guidelines around opioid prescribing and the implementation of controlled substance safety committee in a primary care practice.

Methods: Ten semistructured interviews were conducted with primary care clinicians in an academic medical practice. Potential barriers and facilitators to the uptake and use of the CDC opioid guidelines and the practice's CSSC were coded and analyzed against the Capability, Opportunity, and Motivation framework for Behavior change framework (COM-B).

Results: Six key themes were identified around uptake of the CDC guidelines. In general, the CSSC addressed some of the capability barriers around the guidelines but had limited impact on increasing motivation to follow the guidelines. We found the same recommendation in the guidelines could have differing impact on prescribing behavior.

Conclusions: Simply promoting guidelines may be insufficient, especially for those viewing them as rules rather than recommendations. Our findings underscore the fact that guidelines are merely a starting point, not an endpoint of implementation.

Introduction: This study evaluates participation in Wisconsin Medicaid's Prenatal Care Coordination (PNCC) program and its association with children's well-child visit (WCV) receipt.

Study design: Data came from linked Wisconsin birth records (2011 to 2015) and Medicaid claims and enrollment data (2010 to 2019). The sample comprised 113,347 children with Medicaid-paid births and continuous Medicaid enrollment ranging from 12 to 48 months post-birth. A sibling subsample comprised of 35,373 children. PNCC receipt in pregnancy was measured dichotomously (none; any) and categorically (none; assessment/care plan only; service uptake). Any WCV receipt and recommended WCV receipt (which varied by age) were measured during each year from age 0 up to 4 years old. Conventional logistic regressions and sibling fixed effects (FE) regressions estimated associations between PNCC receipt and WCV receipt.

Results: Demographic-adjusted sibling FE regressions-which best control for unobserved confounding-indicated that any PNCC was positively associated with children receiving any WCVs at age 0 to <1 year-old (OR 1.48; 95% CI 1.05-2.08) and at age 1 to <2 years old (OR 1.24; 95% CI 1.03-1.50). In addition, adjusted sibling FE regressions found that PNCC service uptake was associated with children receiving the recommended number of WCVs at age 0 to <1 year-old (OR 1.35; 95% CI 1.18-1.55).

Conclusions: PNCC may improve children's WCV attendance in the first 2 years of life. Findings underscore the potential for obstetric care coordination programs to enhance the continuity of preventive care for participating families.

Even though 20% of Americans live in rural communities, few research studies intentionally include or engage rural communities. The National Institutes of Health recently launched the CARE for Health™ Initiative that is initially focusing on engaging rural communities and primary care practices in research. In this commentary, we describe activities designed to improve rural clinical and community engagement in research led by two practice-based research networks (the Oregon Rural Practice Research Network and the WWAMI [Washington, Wyoming, Alaska, Montana and Idaho] region Practice and Research Network) funded through this initiative.

Introduction: Physician workforce shortages are expected to reach 48,000 primary care physicians by 2034 with burnout, discrimination (gender, race, and others), and harassment as contributors. Physicians experience discrimination and harassment on a daily basis and continue to work with patients who routinely discriminate against them, which can be directly related to burnout.

Methods: The American Academy of Family Physicians (AAFP) created the Leading Physician Well-Being Certificate Program to combat these issues. Surveys were sent to cohorts at multiple time points - beginning, middle, and end. Multiple evaluation instruments were included in these surveys, but for this analysis, we focused on the Everyday Discrimination Scale (EDS). For Cohort 1 (n = 88, 2021), they received the EDS midway through their cohort. For Cohort 2 (n = 62, 2022), they received the EDS at each time point, but received a Privilege Assessment midway through their cohort due to their answers on the EDS.

Results: Cohort 1 consistently rated the questions with higher levels of discrimination than Cohort 2 scholars. In general, Asian women from Cohort 1 experienced the most discrimination of all the groups (7 statements). For the Privilege Assessment, Asian and other women of color were more likely to indicate less privilege than other groups.

Discussion: Physicians taking the AAFP Leading Physician Well-Being Certificate Program reported have experienced discrimination and harassment. Certain physician groups experience higher levels of discrimination and harassment, and concurrent lower levels of privilege. While unfortunate, discrimination and harassment will continue to play a large role in physicians' lives.

Background: There are no studies on the clinical significance of asymptomatic hypoglycemia detected incidentally during routine testing.

Methods: Baseline fasting serum glucose was determined in 1333 individuals without diabetes (43.3% males, median age 50 years, range 18 to 91 years) to investigate the prevalence of hypoglycemia (fasting serum glucose <70 mg/dL) and the associated demographic, lifestyle, and metabolic factors. Individuals with baseline hypoglycemia were followed (median follow-up, 8.7 years) and assessed for hypoglycemia symptoms. Seven-day continuous glucose monitoring was performed in a subsample of 489 individuals.

Results: Baseline hypoglycemia was observed in 20 individuals (weighted prevalence, 1.58%, 95% confidence interval 0.87%-2.28%). Hypoglycemia was mild and asymptomatic in all cases (median, 67 mg/dL, range 63 to 69 mg/dL). The characteristics of those with hypoglycemia were similar to those with fasting serum glucose 70 to 80 mg/dL. Hypoglycemia was associated with female sex, younger age, and a more favorable metabolic profile (lower body mass index, glycohemoglobin and insulin resistance) than individuals with fasting serum glucose >80 mg/dL. Individuals with baseline hypoglycemia showed no distinct hypoglycemia features in continuous glucose monitoring (n = 9). During follow-up (n = 19), hypoglycemia in routine determinations, always mild, recurred in 42.1% of individuals, although the mean of successive glucose concentrations was higher than baseline in all cases. None of the individuals had symptoms that could constitute Whipple's triad (low serum glucose, symptoms of hypoglycemia, and symptomatic improvement after correction of hypoglycemia) during the follow-up period.

Conclusions: Detection of asymptomatic, mild hypoglycemia in routine blood tests is not indicative of disease and does not require further investigation.