Journal of the American Board of Family Medicine最新文献

Introduction: The population in need of primary care is rapidly growing and increasingly complex with respect to chronic disease burden. We must develop alternative and more efficient approaches to managing patients if we are to increase access to care without sacrificing continuity; however, there is little guidance for innovation strategies at the practice level.

Methods: The Mayo Clinic Department of Family Medicine engaged in a 2-year multistage planning process to develop plans for the Family Medicine Learning and Experience (FLEX) Lab to identify opportunities for innovation to improve daily practice. The purpose of the FLEX Lab is to drive continuous advancements within the context of our health system with the goal of delivering high-quality care to a greater number of patients while working within the constraints of limited staffing.

Results: Key lessons from the planning stage led to the development of a contextualized, incremental, and continuous approach to design and innovation. In its first phase, the FLEX Lab implemented a set of interventions that were novel to the unit itself, including nurse-led hypertension management, task-shifting rooming responsibilities, incorporating telehealth visits into routine clinician schedules, and ambient documentation to replace clinician-generated visit notes. We present a description of the overall FLEX Lab approach including early-stage findings and future work.

Conclusions: The FLEX Lab is an adaptable and generalizable example of how health systems can strategically implement practice improvements informed by real-time input from clinicians and staff to support continuous and phased evolution.

Background: Primary care practices with greater integration of behavioral health care have better patient-reported outcomes. We sought to identify whether there is a threshold effect in the relationship between the degree of Integrated Behavioral Health (IBH) and patient-reported outcomes.

Methods: Secondary analysis of survey results from Integrating Behavioral Health and Primary Care, a multistate longitudinal randomized, controlled study of 3,929 adults with multiple chronic medical and behavioral conditions. Patient outcomes included Patient-Reported Outcomes Measurement Information System-29 (PROMIS-29) functional status (PROMIS-29), depression (PHQ-9), anxiety (GAD-7), the Duke Activity Status Index, Consultation and Relational Empathy (CARE), patient centeredness, and utilization. IBH was measured by the Practice Integration Profile (PIP) version 1.0. The optimal threshold was identified by examining the relationship of PIP to PROMIS-29. The discriminatory power of the threshold was examined using multilevel linear regression with adjustment for potential confounders.

Results: Fifteen of 44 practices with 1,237 patients were highly integrated (PIP ≥ 65). All outcomes tended to be better in patients from practices with high integration. After adjustment for potential confounders, the relationship remained beneficial for all outcomes, with Pain Intensity (-0.51 [95% CI -0.97, 0.04]), patient centeredness (2.52 [0.88, 4.16]), and CARE (1.62 [0.62, 2.61]) statistically significant.

Conclusions: Patients in high integration practices report better outcomes. A measurable target for IBH, such as a PIP total score ≥ 65, provides a focus for practice leadership and guidance on the time and resources needed to achieve integration associated with positive patient outcomes. The results of this analysis provide further evidence of the broad, beneficial impacts of integrating behavioral health and primary care services.

Introduction: Long COVID (LC) is associated with significantly more days of work missed due to illness. Given this impact on the workforce, we estimated the lost labor costs associated with these additional missed workdays among individuals with LC in the US in 2022.

Methods: 104,889,622 (weighted) adult full-time workers in the 2022 Medical Expenditure Panel Survey were categorized as: never had COVID-19, had COVID-19 without LC, and had LC. The estimated cost of lost labor from days of work missed due to illness/injury in 2022 was calculated as: (hours worked per week ÷ 5) × (hourly wage) × (days of work missed). Differences in mean costs were assessed using one-way ANOVA. The population-level lost labor cost associated with LC was estimated as (mean lost labor cost for LC - mean lost labor cost for never had COVID-19) × (number of full-time workers ≥18 years in the US in 2022 × prevalence of LC in the study population).

Results: The total estimated lost labor cost from days of work missed due to illness/injury for individuals with LC was $15,863,994,281 (SE, $1,748,160,632). The mean lost labor cost for individuals with LC was more than twice that of individuals who never had COVID-19 and significantly higher than those who had COVID-19 without LC. The population-level lost labor cost associated with LC was estimated to be $12,784,168,675.20 (SE, $1,946,074,821.60).

Discussion: These findings highlight the substantial economic impact of LC, totaling more than $12 billion in lost labor costs in 2022, emphasizing the need for targeted prevention and treatment strategies.

Quality measurement often focuses solely on clinical processes and outcomes, with relative neglect of patient experience. The use of novel measurement approaches, including patient-reported outcome performance measures and electronic clinical quality measures, provide the opportunity for more nuanced and patient-centered measurement in primary care settings. In this commentary, we described the development of such measures to evaluate contraceptive care quality. Primary care is a crucial setting for delivery of contraceptive care, facilitating access in the context of longitudinal care relationships. When providing this care, it is especially critical to have attention to quality grounded in principles of person-centeredness and equity given the personal nature of reproductive health care alongside the history of reproductive oppression. The described measures provide actionable tools that can be leveraged by family medicine leaders and health systems to support quality, person-centered, and equitable contraceptive care.

Purpose: Electronic health records and patient portals allow patients to communicate with physicians and other members of the health care team. However, few studies have investigated the impact of these tools on chronic disease management. This study examines how patient portal activity can influence the management of type 2 diabetes (T2DM) and hypertension.

Methods: This is a retrospective cohort study from 2018 to 2022 of primary care encounters of large metropolitan health system patients 18 years old and older with a diagnosis of hypertension or T2DM. The primary exposure was total log-ins into the patient portal MyChart (Epic Systems Corporation, Verona, WI). Primary endpoints for hypertension were blood pressure (BP) < 140/90 mmHg, and T2DM was glycohemoglobin (HbA1c) ≤ 8% and tight control (HbA1c ≤ 7%). Multivariate logistic regression models were adjusted for age, ethnicity/race, sex, median household income, Charlson Comorbidity Index, training site status, and baseline disease control.

Results: Regression results showed increased MyChart frequency increased the likelihood of having controlled T2DM (OR 1.77, P < .001). Having baseline BP < 140/90 mmHg or HbA1c control increased the likelihood of outcome control in all models. BP was less likely to be controlled at outcome in African Americans (OR 0.90, P < .001) and more likely to be controlled in males (OR 1.12, P < .001).

Conclusions: Increased patient portal usage is associated with greater likelihood of T2DM and hypertension control. Future studies should examine specific patient portal features, their usage and impact on health outcomes.

Introduction: Black women in the United States face numerous barriers accessing high quality prenatal care. We sought to understand the experience of Black women getting prenatal care in a free faith-based medical clinic and to explore their experiences with staff and clinicians at the clinic.

Methods: From August 2022-January 2023, we conducted qualitative interviews with 14 Black women. Interviews were recorded, transcribed, and coded by 2 researchers. After coding, researchers identified emerging themes through standard qualitative methods. The study was IRB reviewed and approved.

Results: Patients identified meaningful relationships with clinic staff; the impact of a faith-based institution; the complicated relationships with clinicians; and the value of wrap-around services as key aspects of care.

Conclusions: This study highlighted the importance of interpersonal relationships and building trust. Findings support prior research showing Black women's' preference for race- and gender-concordant prenatal care and this being an important contributor to trust.

Background: This proof-of-concept study tested the feasibility and acceptability of INTEGRATE-D, an implementation support intervention for primary care clinics to improve the psychosocial care of patients with type 2 diabetes.

Methods: Cluster randomized controlled pragmatic trial, with a parallel, convergent mixed methods design. Two Intervention Clinics (ICs) were offered tailored training on American Diabetes Association (ADA)-recommended psychosocial care and facilitation to identify and support clinical change. Two Control Clinics (CCs) received no intervention.

Primary outcomes: intervention acceptability, appropriateness and feasibility.

Secondary outcomes: process-of-care metrics (eg, depression screening, diabetes management) and clinical outcomes measures (PHQ-9 and A1C). Qualitative data were collected to assess implementation and experience with the intervention.

Results: ICs were offered training and received 15-months of facilitation. To accommodate COVID-19-related safety restrictions, the intervention was changed to be delivered virtually (eg, remote facilitation and training sessions). Despite an adapted delivery and COVID-19 and staffing stressors, clinics exposed to INTEGRATE-D found it to be acceptable, well-aligned with clinics' needs, and feasible. Qualitative data suggest COVID-19 stressors tempered feasibility. The effect of INTEGRATE-D on process and clinical outcome measures were mixed. Several factors, including differences in ICs and CCs not addressed in randomization and delivery of a less intensive intervention due to the pandemic, may help explain these results.

Conclusions: Given the growing number of people with type 2 diabetes and the importance of psychosocial care for these patients, INTEGRATE-D warrants further pilot-testing with a larger sample of clinics and patients, and under conditions where in-person facilitation and expanded training is possible.

Introduction: Social determinants of health (SDOH) significantly impact health outcomes, yet their integration into clinical decision making is inconsistent. We examined how family physicians document SDOH in electronic health records (EHRs) and identified factors influencing this practice.

Methods: We performed a cross-sectional analysis of 2,089 family physicians completing the 2022 American Board of Family Medicine Continuous Certification Questionnaire. The outcome was physicians' self-reported SDOH documentation by checking a box within the EHR, writing it in a note, or entering it as a diagnosis. Physician, practice, and community characteristics associated with SDOH documentation were assessed, using logistic regression.

Results: We found that 61% of family physicians documented SDOH in notes, with fewer using checkboxes (46%) or diagnosis codes (35%). Across models, factors persistently positively associated with documenting SDOH included participating in value-based programs, having more resources for social needs, collaborating with neighborhood organizations, and working in a more disadvantaged area (higher Social Deprivation Index [SDI] score). For example, family physicians who worked in areas with the third quartile of SDI (OR = 1.366, 95% CI = 1.037 - 1.799) and the fourth quartile of SDI (OR = 1.364, 95% CI = 1.032 - 1.804) were more likely to enter SDOH as a diagnosis, compared with those in the least disadvantaged areas.

Discussion: Socioeconomic aspects of the communities and a practice-level capacity to address SDOH were the biggest predictors of documenting SDOH, rather than the physicians' own characteristics. These findings affirm the necessity of financial incentives and well-resourced care teams to successfully achieve integrated SDOH in primary care practice.

Introduction: The COVID-19 pandemic has reduced the number of elective in-person visits to primary care practices. This study examined how the pandemic may have affected cervical cancer (CC) screening rates in primary care settings across the United States.

Methods: We conducted a retrospective cross-sectional study using data from the PRIME Registry of the American Board of Family Medicine from March 15, 2017, to March 14, 2022. We included 2,207,355 women aged 21 to 65 years who had visited a clinician (n = 1,052) from any of 472 primary care practices. We compared CC screening rates among eligible women during in-person visits over the 3 prepandemic years with those during the 2 years of the pandemic.

Results: Screening rates (per 100 eligible patients with in-person visits) decreased from 1.85 to 1.12 in the first quarter of the first year and remained lower throughout both years of the pandemic compared with prepandemic year, had not returned to prepandemic levels by the end of the second year. Hispanic or Latino (odds ratio [OR] = 1.96) and Black or African American (OR = 1.37) women were more likely to be screened, whereas those receiving care from male clinicians (OR = 0.34) were less likely to be screened.

Conclusions: CC screening rates remained below prepandemic levels throughout the 2 years of the pandemic. Policy makers and health care professionals should strategize approaches to enhance CC screening rates, including the exploration of alternative methods, such as home-based CC screening. New screening approaches are needed to ensure preparedness for future health crises.

Background: Research is needed to measure the effects of shared decision-making (SDM) on discontinuation of opioid therapy for chronic pain.

Design: Target trial emulation.

Setting: National pain research registry from September 2016 to January 2024.

Participants: A total of 328 patients currently using opioid therapy for chronic low back pain at baseline, including 164 patients each in greater and lesser SDM groups matched on propensity scores.

Measurements: SDM was measured with the Communication Behavior Questionnaire. Primary outcomes involving discontinuation of opioid therapy and opioid prescribing frequency and secondary outcomes of pain, function, and health-related quality of life were measured over 12 months.

Results: The mean (SD) age of patients was 56.1 (SD, 11.1) years and 239 (72.9%) were female. During 1178 quarterly encounters, greater SDM was associated with less frequent discontinuation of opioid therapy 3 months postbaseline (RR, 0.56; 95% CI, 0.37-0.86; P = .006) and more frequent opioid prescribing 3 to 12 months postbaseline (RR, 1.24; 95% CI, 1.11-1.38: P < .001). Although greater SDM was associated with worse physical function, and opioid therapy was associated with greater back-related disability and worse physical function, these results were not clinically important. SDM x opioid therapy interaction effects were not observed, indicating that more frequent use of opioid therapy with SDM did not yield better outcomes.

Conclusions: SDM was associated with less frequent short-term discontinuation of opioid therapy and more frequent long-term opioid prescribing that was not associated with better outcomes. Thus, SDM is necessary but insufficient to improve opioid prescribing for patients with chronic pain.