Journal of the American Board of Family Medicine最新文献

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.

Purpose: Inadequate bowel preparation (IBP) for colonoscopies is associated with missed polyps and cancers, prolonged procedure times, lower colonoscopy completion rates, and need for a repeat procedure. The purposes of this study were to assess: 1) whether impaired cognitive status (measured by an abnormal clock drawing test) was associated with IBP, and 2) the association of participant demographic and clinical characteristics with IBP.

Methods: Cross-sectional cohort study conducted in 3 academic centers. Subjects, 50 to 85 years old, completed 5 stool tests on a single sample and a clock drawing before undergoing a screening or surveillance colonoscopy. Clock drawings were validated by the Mendes-Santos method and Watson method. A generalized linear mixed model was conducted to estimate factors associated with IBP, based on Aronchick bowel preparation score.

Results: The 2,016 participants had a mean age of 63 years (SD = 7.95); 1,274 (63%) were female; 119 (6%) had IBP; and 421 (21%) had an abnormal clock drawing. After controlling for age in the multivariable model, the odds of having an IBP versus adequate were 1.44 (95% CI, 0.94-2.22) for those with an abnormal clock drawing score compared with those with a normal score. The only variable significantly associated with IBP was household income, with an odds of 2.48 (95% CI, 1.56-3.95) for household income of <$40,000 compared with income >$80,000.

Conclusions: Lower household income was associated with greater odds of IBP. The association between an abnormal clock drawing score and IBP was not statistically significant.NCT03264898 (clinicaltrials.gov) - Comparative Effectiveness of FITs with Colonoscopy.

Introduction: There are concerns of postacute sequelae of COVID-19, but the impact of long COVID on the US workforce is unclear.

Methods: We analyzed the nationally representative 2022 Medical Expenditure Panel Survey (MEPS). Adult (aged 18 or above) full time workers were classified as those who had never had COVID-19, those who had COVID-19 without long COVID, and those who had long COVID. The number of days of work missed due to illness in 2022 was assessed in unadjusted negative binomial regressions and those adjusted for paid sick leave, age, sex, race and comorbidities.

Results: Among 125,151,402 (weighted) adults, 42.9% never had COVID-19, 49.6% had COVID-19 without long COVID, and 7.5% had long COVID. Patients with long COVID missed more than 8 days of work in a year which was 171% higher than patients without COVID-19% and 62% higher than those who had COVID-19 without long COVID. After adjusting for potential confounding variables, patients who had COVID-19 without long COVID had a greater rate of missing work (IRR 1.75; 95% CI 1.51, 2.04) compared with those who did not have COVID-19. Long COVID patients had an even higher rate of missing work (IRR 2.21; 95% CI 1.79, 2.73) compared with those who did not have COVID-19.

Discussion: An additional outcome for patients with long COVID is an impact on the workforce and significantly more missed workdays.

Background: Comprehensiveness in primary care is defined as the breadth of services provided by a health care clinician team and is an important metric related to patient outcomes and care delivery. We describe a novel measure of comprehensiveness based on ICD-10 codes.

Methods: We compare the distribution of ICD-10 codes from the care of a large population at a regional academic health system to the distribution of codes from the National Ambulatory Medical Care Survey (NAMCS) using linear regression and the mathematical inner product.

Results: The linear regression between the pattern of ICD-10 codes for the selected population and the NAMCS has a slope 1.00, 95% CI 0.57:1.43, P = .0002, R² 0.62. When considering specific specialty areas of practice, primary care is distinct from specialty care based on the inner product between the distribution of care for a given specialty independent of whether a regional or national reference population is used.

Conclusion: The distribution of care based on ICD-10 codes provides a stable and possibly generalizable reference for comprehensive care. The inner product of an ICD-10 care distribution and a reference provides a quantitative estimate of comprehensiveness that distinguishes primary care from specialty care.

Objectives: This study compared the performance of and patient preference for New York City Health and Hospital's (NYC H + H) social needs screener to 2 widely used screeners, a version of the Accountable Health Communities screener and the WellRx screener, that include the same core domains of social needs.

Methods: Two NYC H + H primary care clinics provided data for analysis. A convenience sample completed 1 of the 2 other screeners during May-June 2024, in addition to the NYC H + H screener. Analyses compared rates of needs detected and number of needs identified as well as patient preference.

Results: The H + H screener performed similarly to both alternate screeners in identifying patients with social needs, (κ = 0.7, P < .001 and κ = 0.6, P < .001). The number of positive items identified by each screener was virtually identical. Patients preferred the H + H screener to the alternates, but differences were not statistically significant.

Conclusions: Despite differences in question phrasing and response options, all 3 screeners performed similarly.

Purpose: The purpose of this study is to gain understanding on factors identified by primary care practice members as impacting sustainability of diabetes Shared Medical Appointments (SMAs) after participating in a pragmatic trial that included sustainability planning. SMAs provide diabetes self-management education and support (DSMES) in primary care, though sustainability can be challenging.

Methods: The Invested in Diabetes study was a pragmatic comparative effectiveness trial of 2 approaches to providing SMAs for adults with type 2 diabetes. Qualitative interviews at the study end explored primary care practices' experiences with SMAs and perspectives on sustainability, analyzed using a grounded theory hermeneutic editing approach.

Results: Seventy-nine interviews were conducted in 20 participating practices. One primary finding and 3 themes on factors necessary for sustainment emerged: finding: SMAs were seen as valuable, but sustainment plans were inconsistent; theme 1) Sustainability hinges on practical factors, some not supported in current health care payment models; theme 2) Relevance and efficiency are important: future diabetes SMAs anticipated adaptations or revisions; and theme 3) Improvement in reportable practice quality measures would be an incentive to continue SMAs.

Discussion: Diabetes SMAs were perceived as beneficial, but difficult to sustain. We found that primary care teams want to provide SMAs and that changes in how primary care practices are reimbursed could support implementation and sustainment of DSMES approaches such as SMAs, leading to improved patient outcomes.

Conclusion: There is urgent need for explicit attention to policy change, health care payment innovation, and novel reimbursement models to enhance sustainability of diabetes SMAs.