Journal of the American Board of Family Medicine最新文献

This issue addresses evidence-based medicine, strengthening supports and resources for primary care, and clinical questions across the broad scope of primary care. Several articles address implementing evidence-based recommendations in primary care. How can you safely delabel low risk penicillin allergies in primary care? Which colorectal stool-DNA-FIT tests were preferred by patients and least difficult to use? Another group of articles address strengthening support and resources for clinicians, including the impact of a group-coaching intervention for burnout and a peer coaching approach to improve use of clinical performance data. Several articles address sexual and reproductive health. Does doxycycline postexposure prophylaxis (PEP) prevent bacterial sexual transmitted infections? What are the best methods to reduce pain and/or anxiety during IUD procedures? Is Mirena still effective at 8 years? Several articles address the care of transgender and gender-diverse patients, including the impact of testosterone on Papanicolaou test results. A variety of other articles provide recommendations related to common clinical concerns in primary care, including a novel, simplified approach to diagnosing and managing causes of shoulder pain.

Background: Certain health-related risk factors require legal interventions. Medical-legal partnerships (MLPs) are collaborations between clinics and lawyers that address these health-harming legal needs (HHLNs) and have been shown to improve health and reduce utilization.

Objective: The objective of this study is to explore the impact, barriers, and facilitators of MLP implementation in primary care clinics.

Methods: A qualitative design using a semistructured interview assessed the perceived impact, barriers, and facilitators of an MLP, among clinicians, clinic and MLP staff, and clinic patients. Open AI software (otter.ai) was used to transcribe interviews, and NVivo was used to code the data. Braun & Clarke's framework was used to identify themes and subthemes.

Results: Sixteen (n = 16) participants were included in this study. Most respondents were women (81%) and white (56%). Four respondents were clinic staff, and 4 were MLP staff while 8 were clinic patients. Several primary themes emerged including: Patients experienced legal issues that were pernicious, pervasive, and complex; through trusting relationships, the MLP was able to improve health and resolve legal issues, for some; mistrust, communication gaps, and inconsistent staffing limited the impact of the MLP; and, the MLP identified coordination and communication strategies to enhance trust and amplify its impact.

Conclusion: HHLNs can have a significant, negative impact on the physical and mental health of patients. Respondents perceived that MLPs improved health and resolved these needs, for some. Despite perceived successes, integration between the clinical and legal organizations was elusive.

Background: Nested within a growing body of evidence of a gender pay gap in medicine are more alarming recent findings from family medicine: a gender pay gap of 16% can be detected at a very early career stage. This article explores qualitative evidence of women's experiences negotiating for their first job out of residency to ascertain women's engagement with and approach to the negotiation process.

Methods: We recruited family physicians who graduated residency in 2019 and responded to the American Board of Family Medicine 2022 graduate survey. We developed a semistructured interview guide following a modified life history approach to uncover women's experiences through the transitory stages from residency to workforce. A qualitative researcher used Zoom to interview 19 geographically and racially diverse early career women physicians. Interviews were transcribed verbatim and analyzed using NVivo software following an Inductive Content Analysis approach.

Results: Three main themes emerged from the data. First, salary was found to be nonnegotiable, exemplified by participants' inability to change initial salary offers. Second, the role of peer support throughout residency and early career was crucial to uncovering and rectifying salary inequity. Third, a pay expectation gap was identified among women from minority and low-income households.

Conclusion: To rectify the gender pay gap in medicine, a systems-level approach is required. This can be achieved through various levels of interventions: societally expanding the use of and removing the stigma around parental leave, recognizing the importance of contributions not currently valued by productivity-based payment models, examining assumptions about leadership; and institutionally moving away from fee-for-service systems, encouraging flexible schedules, increasing salary transparency, and improving advancement transparency.

Background: Screening rates for Human Immunodeficiency Virus (HIV) remain low despite guidelines by both the CDC and USPSTF recommending that all adolescents and adults be screened at least once. The aim of this quality improvement study was to increase HIV screening among eligible patients.

Methods: This quality improvement study assessed the impact of interventions to increase HIV screening in an outpatient population at a large urban safety-net hospital. Outcomes were compared from the preintervention (December 2020 to November 2021) to postintervention years (December 2021 to November 2022). Stepwise electronic alerts to prompt HIV screening paired with provider financial incentives were implemented. The proportion of eligible individuals screened for HIV were compared after intervention implementation.

Results: Average monthly HIV screening increased from 506 ± 97 to 2484 ± 663 between the pre- and postintervention periods, correlating to a 5.1-fold increase in screening (7.8% to 39.8%, P < .01). Increases were seen across all ages, and those aged 55 to 64 and 65+ had the highest relative increase in screening at 7.5 and 9.3-fold, respectively (P < .01). Screening rates increased for Hispanics (7.9% preintervention vs 43.6% postintervention, P < .01). In the pre- and postintervention periods, 41 patients with new HIV diagnoses were identified (13 preintervention and 28 postintervention) and 85.4% were linked to care within 30 days.

Conclusions: Stepwise interventions targeted at primary care clinicians are an effective way to increase HIV screening rates, particularly in older demographics. Earlier HIV diagnosis coupled with linkage to care is an important strategy in ending the HIV epidemic.

Objective: In this study, we sought to comprehensively evaluate GPT-4 (Generative Pre-trained Transformer)'s performance on the 2022 American Board of Family Medicine's (ABFM) In-Training Examination (ITE), compared with its predecessor, GPT-3.5, and the national family residents' performance on the same examination.

Methods: We utilized both quantitative and qualitative analyses. First, a quantitative analysis was employed to evaluate the model's performance metrics using zero-shot prompt (where only examination questions were provided without any additional information). After this, qualitative analysis was executed to understand the nature of the model's responses, the depth of its medical knowledge, and its ability to comprehend contextual or new information through chain-of-thoughts prompts (interactive conversation) with the model.

Results: This study demonstrated that GPT-4 made significant improvement in accuracy compared with GPT-3.5 over a 4-month interval between their respective release dates. The correct percentage with zero-shot prompt increased from 56% to 84%, which translates to a scaled score growth from 280 to 690, a 410-point increase. Most notably, further chain-of-thought investigation revealed GPT-4's ability to integrate new information and make self-correction when needed.

Conclusions: In this study, GPT-4 has demonstrated notably high accuracy, as well as rapid reading and learning capabilities. These results are consistent with previous research indicating GPT-4's significant potential to assist in clinical decision making. Furthermore, the study highlights the essential role of physicians' critical thinking and lifelong learning skills, particularly evident through the analysis of GPT-4's incorrect responses. This emphasizes the indispensable human element in effectively implementing and using AI technologies in medical settings.

Background: The COVID-19 pandemic social distancing requirements encouraged patients to avoid public spaces including in-office health care visits. Ambulatory-care-sensitive conditions (ACSCs) represent conditions that can be managed with quality primary care and when access is limited, these conditions can lead to avoidable emergency department (ED) visits.

Methods: Using national data on ED visits from 2019 to 2021 in the National Hospital Ambulatory Care Survey, we examined the impact of COVID-19 pandemic on ACSC ED visits among older adults (aged ≥65).

Results: The proportion of ED visits among older adults that were for ACSCs increased between 2019 (17.4%) and 2021 (18.5%). The trend in both rural (26.4%-28.6%) and urban areas (15.4%-16.8%) shows a significant jump from 2019 to 2021 (P < .001).

Conclusions: This rise in ACSC ED use is consistent with a delay in normal primary care during the pandemic.

Objectives: To determine rates of fluoride varnish (FV) application at a tertiary care center between 2018 and 2021 and factors associated with receipt of FV application in the medical setting.

Design: A retrospective chart review and case-control study, matching children who had received FV application and those who had not during a well-child examination, were conducted.

Measures: Current Procedural and Dental Terminology and International Classification of Diseases codes from an electronic medical record were used to determine the rates of FV application.

Analytic strategy: Bivariate and multivariable analyses were conducted to determine factors associated with FV application.

Results: The rate of fluoride applications was low but increased significantly from 0.1% in 2018 to 1.6% in 2020 (P < .0001). Among White, Black, and Hispanic subjects, 39.5%, 65.2%, and 68.9%, respectively, received FV application during well-child exams. Advanced registered nurse practitioners (ARNPs) and physician assistants (PAs) provided 0.05% of FV applications. Multivariable results for 788 patients identified "Black, Hispanic, or other" race and ethnicity or Medicaid insurance type as factors positively associated with receipt of medical FV.

Discussion: This study showed an increase in FV application rates, which may be attributed to a quality improvement project and provider advocates. The prevalence was low and analyses show race and ethnicity and insurance factors associated with the receipt of FV application.

Conclusion: The associated factors suggest medical clinicians may evaluate race and ethnicity or insurance type to determine FV recipients. The results showed ARNPs and PAs may be underutilized clinicians for this preventive treatment.

Latinos represent almost 20% of the US population and face significant health and health care inequities. When compared with socioeconomically similar comparators, they demonstrate better all-cause mortality, a long-observed epidemiologic phenomenon known as the "Latino paradox." In May 2023, we convened the inaugural Latino Primary Care Summit, focused on the theme, "Immigrant Paradox: Primary Care Roles, Implications and Future," with the goal of helping to define a research agenda and recommendations for Latino primary care equity within the context of the Latino paradox. The Summit consisted of 8 expert presentations, including breakout discussion groups and report-outs to the entire Summit group. Six themes were identified from presentation content, and recommendations were drawn from these to better inform a primary care research agenda for Latino health equity. The 6 themes were organized into the following categories: 1) Latino Paradox Considerations, Limitations, and Implications (proper standardization and contextualization). 2) Data Issues (accurate and ethical categorization). 3) Bridging Clinic and Community (understanding partnership development and maintenance). 4) Primary Care Challenges (specific issues related to day-to-day delivery of primary care to Latino patients). 5) Social Needs (implementation and evaluation of social needs screening to Latino patients. 6) Workforce/Academics, Representation Inequities, and Innovation (research training, workforce diversity, and innovation approaches).