Journal of the American Board of Family Medicine最新文献

Underinvestment in primary care and erosion of the primary care physician workforce are resulting in patients across the US experiencing growing difficulty in obtaining access to primary care. Compounding this access problem, we find that the average patient panel size among US family physicians may have decreased by 25% over the past decade (2013 to 2022). Reversing the decline in access to primary care in the face of decreasing panel sizes requires both better supporting family physicians to manage larger panels, such as by expanding primary care teams, and substantially increasing the supply of family physicians.

Purpose: Clinical trials generally have not assessed efficacy of long-term opioid therapy (LTOT) beyond 6 months because of methodological barriers and ethical concerns. We aimed to measure the effectiveness of LTOT for up to 12 months.

Methods: We conducted a retrospective cohort study among adults with chronic low back pain (CLBP) from April 2016 through August 2022. Participants reporting LTOT (>90 days) were matched to opioid nonusers with propensity scores. Primary outcomes involved low back pain intensity, back-related disability, and pain impact measured with a numerical rating scale, the Roland-Morris Disability Questionnaire, and the Patient-Reported Outcomes Measurement Information System, respectively. Secondary outcomes involved minimally important changes in primary outcomes.

Results: The mean age of 402 matched participants was 55.4 years (S.D., 11.9 years), and 297 (73.9%) were female. There were 119 (59.2%) LTOT users who took opioids continuously for 12 months. The mean daily morphine milligram equivalent dosage at baseline was 36.7 (95% CI, 32.8 to 40.7). There were no differences between LTOT and control groups in mean pain intensity (6.06, 95% CI, 5.80-6.32 vs 5.92, 95% CI, 5.68-6.17), back-related disability (15.32, 95% CI, 14.55-16.09 vs 14.81, 95% CI, 13.99-15.62), or pain impact (32.51, 95% CI, 31.33-33.70 vs 31.22, 95% CI, 30.00 to 32.43). Correspondingly, LTOT users did not report greater likelihood of minimally important changes in any outcome.

Conclusions: Using LTOT for up to 12 months is not more effective in improving CLBP outcomes than treatment without opioids. Clinicians should consider tapering opioid dosage among LTOT users in accordance with clinical practice guidelines.

In pregnant patients at term undergoing induction of labor, early time-based artificial rupture of membranes (AROM) within 1 hour of Foley bulb expulsion results in a shorter duration of labor by nearly 9 hours with no significant difference in cesarean delivery rates or maternal or neonatal adverse outcomes.¹.

Introduction: Given the high sedative prescription rate, the sedative-associated morbidity, and mortality nationally (especially among veterans), we aimed to test the hypothesis that veteran status in the presence of chronic pain would be associated with greater sedative use when compared with nonveteran status.

Methods: The study participants were recruited by Community Health Workers (CHWs) through the ongoing community engagement program (HealthStreet) at the University of Florida. CHWs collected information on sociodemographic factors, health status, and past 30-day drug use patterns.

Results: The study sample comprised 4,732 male participants, of which 21% were veterans, 58% were Blacks and 8.4% had used prescription sedatives in the past 30 days. Veterans (vs nonveterans) were twice as likely to have used prescription sedatives in the past 30 days in the presence of chronic pain.

Conclusions: Veterans with chronic pain are a high-risk population for current prescription sedative use.

Background: Many adolescents do not receive basic preventive care such as influenza vaccinations. The Affordable Care Act (ACA) temporarily increased Medicaid reimbursements for primary care services, including vaccine administration, in 2013 to 2014. The objective of this study is to assess the impact of reimbursement increases on influenza vaccination rates among adolescents with Medicaid.

Methods: This repeated cross-sectional study used a difference-in-difference approach to compare changes in annual influenza vaccination rates for 20,884 adolescents 13 to 17 years old covered by Medicaid with adequate provider-reported data in 18 states with larger extended (>$5, 2013 to 2019) versus larger temporary (2013 to 2014 only) versus smaller reimbursement changes. We used linear probability models with individual-level random effects, adjusting for state and individual characteristics and annual time trends to assess the impact of a Medicaid vaccine administration reimbursement increase on annual influenza vaccination.

Results: Mean Medicaid reimbursements for vaccine administration doubled from 2011 to 2013 to 2014 (eg, from $11 to $22 for CPT 90460). States with smaller reimbursement changes had higher mean reimbursements and higher adjusted vaccination rates at baseline (2011) compared with states with larger temporary and extended reimbursement changes. The reimbursement change was not associated with increases in influenza vaccination rates.

Discussion: Influenza vaccination rates were low among adolescents with Medicaid throughout the study period, particularly in states with lower Medicaid reimbursement levels before the ACA.

Conclusion: That reimbursement increases were not associated with higher vaccination rates suggests additional efforts are needed to improve influenza vaccination rates in this population.

Background: Climate change poses a threat to the health of people worldwide. Little is known about the awareness of primary care clinicians toward climate change and if they are open and prepared to address climate change issues with their patients. As pharmaceuticals are the main source of carbon emissions in primary care, avoiding the prescription of particular climate-harmful medications is a meaningful contribution to the reduction of greenhouse gases.

Methods: This is a cross-sectional questionnaire survey among primary care clinicians in West Michigan conducted in November 2022.

Results: One hundred three primary care clinicians responded (response rate 22.5%). Nearly 1/3 (29.1%) were classified as climate change unaware clinicians who perceived that global warming is not happening, or expressed that it is happening but not caused by human activities or is affecting the weather. In a theoretical scenario on a prescription of a new drug, clinicians tended to prescribe the less harmful drug without discussing options with patients. Although 75.5% of clinicians agreed that climate change aspects have its place in shared decision-making, 76.6% of clinicians expressed a lack of knowledge to advise patients in this regard. In addition, 60.3% of clinicians feared that raising climate change issues in consultations may adversely affect the relationship with the patient.

Discussion: Although many primary care clinicians are open to addressing climate change in their working environment and with their patients, they lack knowledge and confidence to do so. In contrast, the majority of the US population is willing to do more to mitigate climate change. Although curricula on climate change topics are increasingly implemented in student education, programs to educate mid- and late-career clinicians are lacking.

Purpose: In efforts to improve patient care, collaborative approaches to care have been highlighted. The teamlet model is one such approach, in which a primary care clinician works consistently with the same clinical staff member. The purpose of this study is to identify the characteristics of high-performing primary care teamlets, defined as teamlets with low rates of ambulatory care sensitive emergency department (ACSED) visits and ambulatory care sensitive hospital admissions (ACSAs).

Methods: Twenty-six individual qualitative interviews were performed with physicians and their teamlet staff member across 13 teamlets. Potentially important characteristics related to high-performing primary care teamlets were identified, calibrated, and analyzed using qualitative comparative analysis (QCA).

Results: Key characteristics identified by the QCA that were often present in teamlets with low rates of ACSED visits and, to a lesser extent, ACSAs were staff proactiveness in anticipating physician needs and physician-reported trust in their staff member.

Conclusion: This study suggests that physician trust in their staff and proactiveness of staff in anticipating physician needs are important in promoting high-performing teamlets in primary care. Additional studies are indicated to further explore the relationship between these characteristics and high-performing teamlets, and to identify other characteristics that may be important.