Journal of the American Board of Family Medicine最新文献

A new Patient Psychological Safety Scale (PPSS) has potential to address an often-unrecognized problem. Should HbA1c be used to follow diabetes in patients with concurrent sickle cell disease? Are there significant differences resulting from HbA1c point-of-care versus send-off testing? Which treatment for which type of incontinence? Which factors are more predictive of emotional exhaustion for clinicians versus nonclinician staff? Does your office apply fluoride to young children's teeth? Is testosterone deficiency associated with death in older men? How does ChatGPT impact board certification exams? What is the most effective treatment for vasomotor symptoms associated with menopause?

Urinary incontinence management varies depending on the type of incontinence and severity of symptoms. Types of incontinence include stress (SUI), urge or overactive bladder (OAB), mixed, neurogenic, and overflow incontinence. First-line treatment for OAB and SUI is nonpharmacologic management. Behavioral therapy is first-line treatment for urge incontinence. Vaginal mechanical devices (cones, pessaries, and urethral plugs), pelvic floor muscle training, and electroacupuncture are recommended as first-line treatment for women with SUI. Biofeedback and electric muscle stimulation can be adjunctive therapy for SUI. Antimuscarinics and β-3 agonists can be used as adjective therapy for those with OAB who do not improve with behavioral therapy. β-3 agonists have less anticholinergic side effects compared with antimuscarinics for OAB. Adverse medication effects can often lead to discontinuation due to poor tolerability. Third-line therapies are for those who fail conservative and pharmacologic therapies and lack high-grade evidence. Neuromodulation, neurotoxin injections, vaginal laser therapy, and acupuncture are third-line in OAB management. Pharmacologic management with α-1-blockers is recommended as first-line treatment for moderate to severe overflow incontinence from BPH. 5-α reductase inhibitors can be used as an adjunct medication in those with refractory overflow incontinence symptoms and a PSA ≥ 1.5 mg/dL. Clean intermittent catheterization is first-line therapy for neurogenic bladder but can increase risk of catheter-associated urinary tract infection. Clinicians should assess type of incontinence, patient goals, side effect profile, and tolerability to determine an individualized treatment plan for each patient.

This article looks back on the story of the Ambulatory Sentinel Practice Network (ASPN) and its successor, the National Research Network (NRN), through the eyes of its leaders during the first 40 years. Facilitated conversations over 2 years iteratively coalesced key facts and patterns in this collective account of what they had observed. Time-durable patterns observed are distilled for interpretation and application by contemporary practice-based research network (PBRN) leaders as they move forward. Looking back is done via developmental eras. The ASPN was proposed in 1978 as a set of change strategies for primary care research, ASPN gathered momentum through efforts of individuals, institutions, and small grants that mobilized enthusiasm and commitment in the face of headwinds. The network expanded into the research mainstream from 1988, addressing large socially important questions with greater acceptance and volume of PBRN research. The ASPN is now in an era of scaling up and adapting to huge technological, organizational, and business shifts and a growing emphasis on patient and community engagement, safety, and disparities. Archetypal dilemmas and balances that emerged and reemerged across these eras are distilled, along with ways they were addressed at the time. The authors then project their 40-year experience to future vistas they believe the PBRN value proposition can be adapted and extended; what they regard as promising directions future leaders to take.

Introduction: Psychological safety is the perception that it is safe to express oneself without fear of ridicule. Better patient outcomes are associated with health care teams that experience psychological safety. However, the psychological safety of the patient has largely been ignored, even though it may affect patient forthrightness and adherence. We developed an initial Patient Psychological Safety Scale (PPSS) to assess patients' experience of psychological safety.

Methods: Thirteen items modified from team-focused measures of psychological safety comprised the initial version of the PPSS. To explore criterion validity, 8 items pertaining to nondisclosure of important information were used. A convenience sample of 100 patients from 4 primary care settings completed a survey comprised of the PPSS and nondisclosure questions.

Results: A confirmatory factor analysis (CFA) indicated that the 13-item PPSS did not measure 1 factor. A subsequent exploratory factor analysis (EFA) identified 2 factors. A second CFA was conducted on a modified 9-item PPSS representing the 2 factors and retaining items with a factor loading of 0.40 or higher, and the results indicated a good fit. Internal reliability and validity for factors 1 (relationship comfort) (α = 0.95) and 2 (belonging) (α = 0.88) were strong. Although few respondents endorsed nondisclosure, there was a significant association between lower relationship comfort and nondisclosure of disagreement with clinician recommendation (median difference = 5.0, P = .001).

Conclusions: Patients' experience of psychological safety may affect clinical outcomes. The PPSS provides a starting point for further study of this potentially important variable.

Background: Health care workers with responsibilities caring for dependent adults or children outside of work may be particularly vulnerable to burnout. We examined the relationship between gender, caregiving, and burnout among primary care clinicians and staff in the context of the COVID-19 pandemic.

Methods: Longitudinal cohort study using survey data collected in February 2020 and May 2021 from primary care clinicians and staff in a university-based health system. The association between gender, caregiving hours, and perceived workplace support for caregiving responsibilities on the outcome of emotional exhaustion was tested using linear models with fixed effects.

Results: The response rate for the survey was 76% for clinicians and 90% for staff in February 2020% and 70% for clinicians and 85% for staff in March 2021. Respondents included 336 clinicians and staff, with 77% identifying as female. Female clinicians reported greater emotional exhaustion than male clinicians in 2021. Female gender, more caregiving hours, and lower workplace support were associated with higher clinician burnout. In longitudinal analysis for clinicians, hours of caregiving but not work supportiveness was associated with an increase in emotional exhaustion from 2020 to 2021. For staff, supportiveness of the workplace for caregiving responsibilities, but not gender or caregiving hours, was associated with lower exhaustion in 2021 and was protective against increased exhaustion from 2020 to 2021.

Conclusions: Beyond the acute stressors of the COVID-19 pandemic, ensuring the sustainability of a health care workforce that shoulders caregiving responsibility requires policies and operational models that adequately support workers with high caregiving responsibilities and work supports that encourage workers to take full advantage of the accommodations for which they are eligible.

Importance: Hypogonadism is defined by consistently low serum testosterone levels in conjunction with clinical symptoms. Testosterone replacement therapy (TRT) can be used to achieve physiologic levels of testosterone. Testosterone deficiency is associated with increased mortality and poorer health outcomes.

Purpose: To compare rates of mortality, atrial fibrillation (AF), stroke, myocardial infarction (MI), and prostate cancer in hypogonadal men who received TRT versus those who did not.

Methods: The TriNetX database was utilized to access deidentified, retrospective propensity matched EMR data from 57 participating health care organizations between 2005 to 2020. Cohorts included males 40 to 80 years old diagnosed with hypogonadism who were prescribed TRT versus no TRT. Propensity matching was performed to reduce bias and balance confounding factors between the 2 groups. The following 3-year outcomes were analyzed: mortality, AF, stroke, MI, and prostate cancer.

Results: There were 163,456 male patients identified with hypogonadism, and 133,584 were included after propensity matching. There was a lower mortality rate, (3.1% vs 3.6%; RR, 0.886; P < .001), decreased risk of AF (3.6% vs 4.0%; RR 0.900; P < .001), less stroke (1.6% vs 1.8%; RR, 0.898; P < .011), and fewer cases of prostate cancer (1.9% vs 2.9%; RR 0.648; P < .001) for patients on TRT.

Conclusions: Using TRT is associated with moderately lower rates of mortality, atrial fibrillation, stroke, and prostate cancer in hypogonadal men versus no TRT. There is potential for missed cases of stroke, prostate cancer, and cardiovascular disease incidence not captured by the database. As prescriptions of TRT increase, understanding risks and benefits will help guide future practice.

Vasomotor symptoms (VMS) related to the menopausal transition affect the majority of women and contribute to significant quality of life burden. Incidence, length, severity and report of symptoms vary by race, ethnicity, and coexisting health conditions. The pathophysiology of VMS is not fully understood and is likely multifactorial, involving changes in the hypothalamicpituitary-ovarian axis during the menopausal transition. Treatment approaches include lifestyle modifications, hormonal and non-hormonal therapies, including integrative and complementary medicine approaches. Systemic hormone therapy with estrogen is the most effective treatment. Emerging evidence suggests that treatment with SSRIs, SNRIs, and gabapentin is effective for many women who want to avoid hormone therapy. A shared decision approach to treatment decisions involves consideration of risks with treatment options and discussion of patient priorities.

Background: The 2022 Centers for Disease Control's "Clinical Practice Guidelines for Prescribing Opioids for Pain in United States" called for attention and action toward reducing disparities in untreated and undertreated pain among Black and Latino patients. There is growing evidence for controlled substance safety committees (CSSC) to change prescribing culture, but few have been examined through the lens of health equity. We examined the impact of a primary care CSSC on opioid prescribing, including by patients' race and sex.

Methods: We conducted a retrospective cohort study. Our primary outcome was a change in prescribed morphine milligram equivalents (MME) at baseline (2017) and follow-up (2021). We compared the differences in MME by race and sex. We also examined potential intersectional disparities. We used paired t test to compare changes in mean MME's and logistic regression to determine associations between patient characteristics and MME changes.

Results: Our cohort included 93 patients. The mean opioid dose decreased from nearly 200 MME to 136.1 MME, P < .0001. Thirty percent of patients had their dose reduced to under 90 MME by follow-up. The reduction rates by race or sex alone were not statistically significant. There was evidence of intersectional disparities at baseline. Black women were prescribed 88.5 fewer MME's at baseline compared with their White men counterparts, P = .04.

Discussion: Our findings add to the previously documented success of CSSCs in reducing opioid doses for chronic nonmalignant pain to safer levels. We highlight an opportunity for primary care based CSSCs to lead the efforts to identify and address chronic pain management inequities.

Background: Interest is growing in clinic-based programs that screen for and intervene on patients' social risk factors, including housing, food, and transportation. Though several studies suggest these programs can positively impact health, few examine the mechanisms underlying these effects. This study explores pathways through which identifying and intervening on social risks can impact families' health.

Methods: This qualitative study was embedded in a randomized clinical trial that examined the health impacts of participation in a social services navigation program. We conducted semi-structured interviews with 27 English or Spanish-speaking caregivers of pediatric patients who had participated in the navigation program. Interviews were analyzed using thematic analysis.

Results: Caregivers described 3 pathways through which the navigation program affected overall child and/or caregiver health: 1) increasing families' knowledge of and access to social services; 2) helping families connect with health care services; and 3) providing emotional support that reduced caregiver isolation and anxiety. Participants suggested that navigation programs can influence health even when they do not directly impact resource access.

Discussion: Social care programs may impact health through multiple potential pathways. Program impacts seem to be mediated by the extent to which programs increase knowledge of and access to social and health care services and support positive relationships between families and program personnel.

Background: Social risk data collection is expanding in community health centers (CHCs). We explored clinicians' practices of adjusting medical care based on their awareness of patients' social risk factors-that is, changes they make to care plans to mitigate the potential impacts of social risk factors on their patients' care and health outcomes-in a set of Texas CHCs.

Methods: Convergent mixed methods. Surveys/interviews explored clinician perspectives on adjusting medical care based on patient social risk factors. Survey data were analyzed with descriptive statistics; interviews were analyzed using thematic analysis and inductive coding.

Results: Across 4 CHCs, we conducted 15 clinician interviews and collected 97 surveys. Interviews and surveys overall indicated support for adjustment activities. Two main themes emerged: 1) clinicians reported making frequent adjustments to patient care plans based on their awareness of patients' social contexts, while simultaneously expressing concerns about adjustment; and 2) awareness of patients' social risk factors, and clinician time, training, and experience all influenced clinician adjustments.

Conclusions: Clinicians at participating CHCs described routinely adjusting patient care plans based on their patients' social contexts. These adjustments were being made without specific guidelines or training. Standardization of adjustments may facilitate the contextualization of patient care through shared decision making to improve outcomes.