Journal of the American Board of Family Medicine最新文献

Introduction: To develop and externally validate a simple risk score for influenza diagnosis based using vaccination history and patient-reported symptoms.

Methods: Adult outpatients in 12 European countries during flu season with a chief complaint of acute cough between 2007 and 2010 were used to derive and internally validate the risk score (Genomics to combat Resistance against Antibiotics in Community acquired LRTI in Europe (GRACE) data), and contemporary US data were used for external validation (EAST-PC data). Patient-reported symptoms were recorded and polymerase chain reaction (PCR) was used to diagnose influenza. The score was derived using logistic regression and assigning points based on the β -coefficients. The score was externally validated in a contemporary US population (EAST-PC data). Accuracy was measured using influenza prevalence in each risk group and the area under the receiver operating characteristic curve (AUC). Calibration was assessed by plotting observed versus expected.

Results: We developed a risk score with 6 items (subjective fever, interfered with usual activity, headache, wheeze, phlegm, and recent flu vaccine) and a range from -5 to 6 points. The AUC was 0.75 for both derivation and internal validation subgroups. The prevalence of influenza was 15.1% in the GRACE data and 14.4% in the EAST-PC data. The percentage with influenza in the low, moderate, and high-risk groups was 6.8%, 21.8%, 35.3 in the external validation population (EAST-PC data). The low-risk group included 61% of participants in the external validation. Calibration was excellent.

Conclusions: We developed and externally validated the FluScoreVax risk score, available as an app. It classifies 61% of patients as low risk, of whom only 7% had influenza.

Background: Patients at risk of atherosclerotic cardiovascular disease (ASCVD) have low statin use. Clinician perceptions of the ASCVD risk estimates that guide statin prescribing may contribute to poor uptake. At the time of the study, the only equations used to predict ASCVD risk (the Pooled Cohort Equations; PCE) provided race-specific estimates, a controversial practice and a potential reason why clinicians may scrutinize these estimates. We sought to examine how clinicians perceived ASCVD estimates, in relation to their perceptions of race and, also, more broadly.

Methods: We conducted an interpretive description study using ten 45-minute semistructured interviews with primary care physicians in North Carolina between March and April 2022. Interviews focused on the PCE ASCVD risk calculator and perspectives of race as it relates to ASCVD. Responses were analyzed using both deductive and inductive approaches to identify primary topics.

Results: 5 men and 5 women participated. Of these, 6 identified as White, 2 as Black, and 2 as Asian. Three main topics emerged. First, participants felt conflicted about the role of race in ASCVD risk. Second, they had several concerns with the calculator that went beyond race, including its emphasis on statin use and lack of social determinants of health. Finally, participants universally valued the PCE ASCVD calculator as a tool to educate patients and inspire statin initiation and behavioral change.

Conclusions: The PCE ASCVD risk calculator was seen as most useful in facilitating discussions regarding behavior and lifestyle changes, suggesting the potential benefit of incorporating variables related to patients' health behaviors in a revised model. The new PREVENT equations provide a helpful first step by removing race and including social determinants. The next step may be to add health behaviors and visual images to facilitate patient counseling and comprehension.

Background: Telemedicine can improve access between physicians and patients and improve outcomes when deployed strategically in patients with chronic diseases. Telemedicine not only showed success in the care of chronic diseases, but its application also expanded exponentially during the COVID-19 pandemic. At our institution, a 12-week telemedicine diabetes "boot camp" was launched for patients with uncontrolled diabetes as an innovative means of providing accessible and high-quality patient care in primary care settings.

Methods: Patients at primary care and endocrinology clinics with diabetes mellitus (DM) and glycohemoglobin (A1C) > 8.0% were voluntarily enrolled from September 2020 to November 2021. Dietitians and diabetes care and education specialists conducted biweekly visits via telemedicine for twelve weeks. Patient demographics, A1C, body mass index (BMI), and blood pressure were measured before and after the intervention.

Results: A total of 134 patients were included, and 94 patients (70.2%) completed 6 visits for the full 12-week program. The mean A1C reduction was -2.09% ± 2.4%, and the A1C change was uniform across age groups, gender, ethnicity, BMI, and referral clinic type. A greater A1C reduction in patients who completed all 6 visits was noted although not statistically significant. We found a negative correlation between the initial A1C and the change of A1C. No significant BMI or mean arterial pressure change was observed.

Conclusion: This single arm study demonstrated an improvement in A1C for all patients with a history of poorly controlled diabetes, regardless of patient characteristics. Higher initial A1C was associated with a greater A1C reduction.

Purpose: This study aimed to evaluate the impact of 6 exercise therapies on the quality of life of stroke patients.

Methods: A systematic search was conducted on PubMed, the Web of Science, PsycINFO, and the Cochrane Library to retrieve peer-reviewed articles written in English. The inclusion criteria consisted of (1) experimental or quasi-experimental studies, (2) utilization of different exercise therapies as experimental interventions, (3) inclusion of stroke patients as the target population, and (4) assessment of quality of life as an outcome measure.

Results: The analysis included 25 studies involving 1243 subjects aged 18 years or older. The network meta-analysis revealed that among the 6 exercise therapies examined, Virtual Reality Training (82.3%) had the most significant impact on improving the quality of life in stroke patients. This was followed by Resistance Training (77.3%), Mind-Body Training (61%), Underwater Exercise (52%), Aerobic Exercise Training (44.1%), and High-Intensity Interval Training (19.2%).

Conclusions: Virtual reality training was found to be highly effective in improving the quality of life in stroke patients. In addition, when combined with other exercise therapies, it enhanced physical function and overall quality of life.

Background: Health care professionals are in a unique position to enact health-related social change. Medicine is subject to regulation at the organizational, local, state, and national levels. Federal laws apply to physicians throughout the US; as such, federal policy affects physician practice intentions similarly. However, there is little research on state-level engagement in the political process and none on the participation by family medicine physicians.

Methods: This article examines the nature of physician civic engagement at the state level. Data were gathered and analyzed as part of the 2023 Council of Academic Family Medicine's (CAFM) Educational Research Alliance (CERA) survey of Family Medicine educators and practicing physicians. We used nonparametric statistics (Kruskal-Wallis tests) to analyze ordinal variables. Categorical variables were analyzed using χ² tests. We used multivariable ordinal logistic regression to assess the joint effects of participant characteristics on study outcomes and to adjust for potential confounding.

Results: The policy question section of the survey received 709 responses, a response rate of 21%. Our results show a lack of civic engagement, including less than a third voting in state elections and only 4% making financial contributions to political campaigns. Seventeen percent of respondents reported considering relocating due to state health policies. For all questions, we observed variations by geographical region and gender.

Conclusions: Our findings provide a timely analysis of family medicine physician participation in the political process, the effect of specific health policies, and how these policies are comparatively received among family medicine physicians in the United States.

Background: Overdoses and deaths from synthetic opioids grew sharply in the past decade. Most people with opioid use disorder (OUD) do not receive recommended evidence-based treatment: nationally, 72% to 87% of people who need OUD treatment do not receive medication for opioid use disorder (MOUD). Little is known about practice teams' experiences with home, office, and telehealth induction for MOUD, particularly in primary care.

Methods: We conducted semistructured interviews with primary care clinicians and staff from February through September 2023 to understand experiences providing MOUD via home, office, and telehealth induction. Interviews were part of a PCORI-funded trial, Home versus Office versus telehealth for Medication Enhanced Recovery (HOMER). We used template and editing coding styles to categorize text according to deductive codes derived from research questions and inductive codes derived from multiple readings of transcripts. We used immersion-crystallization to iteratively review coded text and identify interview themes.

Results: Thirty-eight clinicians and staff from 21 US primary care practices participated in interviews. Home induction is increasingly common and preferred by patients and practice teams, social determinants of health affect induction and maintenance in treatment, clinicians and staff use honest communication to build trusting relationships with patients, practices identified patients as MOUD candidates through word-of-mouth and referrals, and an evolving OUD landscape are causing practices to adapt their care.

Conclusion: Primary care practices are committed to offering MOUD. Findings offer insights about the challenges facing primary care practices in their efforts to deliver MOUD to address a rapidly evolving opioid epidemic.

Background: Care coordination helps patients with complex needs, but heterogeneity in its implementation is not understood. Latent class analysis (LCA) was used to describe types of care coordination in primary care using data from The Minnesota Care Coordination Effectiveness Study (MNCARES), a large representative observational study of Minnesota clinics. We also explore whether program types are associated with clinic, community, or patient characteristics.

Methods: Primary care clinics with care coordination participating in MNCARES were included in this exploratory analysis. Care coordinators responded to survey items about their programs' approaches to addressing social and complex medical needs, communication, care coordination volume, and support and resources available for care coordination. LCA was used to identify and describe distinct types of care coordination using 42 survey items. Bivariate analysis compared types to clinic, community, and patient characteristics.

Results: Four types of care coordination emerged across 316 clinics: type 1 a well-supported social/medical approach, type 2 a high volume social/medical approach, type 3 a well-resourced complex medical needs approach, and type 4 an onsite low volume approach. Type 1 clinics were more likely to have medical and community service access and serve younger patients and those born outside the US. Type 4 clinics were more likely urban with less community service access and served older adults.

Conclusion: This novel LCA approach successfully identified 4 distinct types of care coordination used by participating clinics. These results will help researchers to learn which approaches to care coordination are most effective in which contexts and help clinics decide how to operationalize care coordination.

This JABFM issue covers key clinical topics, leveraging large language models, and the 4Cs of primary care. A validated "FluScoreVax risk score" can guide flu diagnoses. Do you know what symptoms are most predictive of flu? Other articles cover a breadth of clinical topics. For example, how should you evaluate asymptomatic fasting hypoglycemia? Does virtual reality exercise training improve quality of life in stroke patients? Does pitavastatin reduce risk of cardiovascular events in adults with HIV? One featured manuscript provides insights for home, office, and telehealth induction for MOUD in primary care practices. This issue also addresses large language models in physician learning and diagnostic excellence. Several articles cut across the 4Cs of primary care, including primary care comprehensiveness, first contact access, coordination, and continuity. For example, One manuscript reviews balancing access, well-being, and collaboration in care delivery models with team-based care. Finally, this issue addresses the gender wage gap among early-career family physicians.

Purpose: Continuity of care between patients and physicians is a defining element of primary care and a pillar of the Patient Centered Medical Home (PCMH) program. We aimed to investigate the level of short- and long-term continuity within a network of Federally Qualified Health Centers (FQHCs) and the relationship of continuity to PCMH recognition.

Methods: This multi-method study utilized Electronic Health Record data to investigate patient continuity, and survey data to investigate PCMH history. The study population included patients with at least 2 visits between 2008 and 2023 to one of 18 FQHCs. Continuity was measured by calculating the number of primary care providers (PCPs) seen by the patient and the usual provider of care index (UPC Index [the number of visits with the most frequent PCP/total visits]).

Results: Our population consisted of 1,323,547 patients and 19,768,516 encounters. The mean (SD) number of PCPs per patient over one year was 2.01 (1.1). For patients who had visits spanning at least 5 years, the mean was 7.2 (4.7). The mean one-year UPC was .72 (.25) and 5+ year UPC was .47 (.21). No meaningful association was found between continuity measures and PCMH recognition.

Conclusions: These findings show, on average, high numbers of PCPs and poor continuity with a single "usual provider of care" for each patient's care over time at FQHCs. Leveraging performance measures, such as PCMH recognition, to incentivize continuity may be inadequate. Different approaches should be considered to preserve the long-term continuity at the heart of primary care.