Annals of Family Medicine最新文献

Purpose: We aimed to evaluate continuity of care (CoC) for patients receiving home-based care and assess its effect on urgent care use and hospital admissions.

Methods: This cohort study used data from a population-based electronic health record system across 3 primary health care (PHC) centers in Barcelona, Spain, involving patients receiving permanent home care. We measured CoC with the usual provider of care for general practitioners (GPs) and nurses over a 1-year period. Associations were analyzed using adjusted logistic-mixed regression models. We used time-dependent receiver operating characteristic curves to identify the optimal CoC threshold and adjusted Cox survival models to examine cumulative incidence.

Results: We studied 1,207 patients (71.5% women) with a mean age of 88.5 years. General practitioners showed a mean CoC of 73.3% and PHC nurses 83.1%. Greater CoC for GPs and PHC nurses was associated with decreased urgent care use and hospital admissions (all odds ratios ≤ 0.45; P ≤ .004). An optimal CoC threshold of ≥75% for GPs was identified (sensitivity = 0.78; 95% CI, 0.74-0.83), with a modest area under the curve of 0.59 (95% CI, 0.55-0.62). Multivariate models showed that this threshold was significantly associated with decreased urgent care use and hospital admissions for both providers (hazard ratios = 0.61-0.69; P < .05).

Conclusions: Greater CoC for GPs and nurses was associated with decreased urgent care and hospital admissions. A threshold of ≥75% of visits with assigned GPs or nurses might optimize health outcomes for these vulnerable patients. Maintaining a high level of relational CoC, particularly for older adults requiring home care services, can lead to more efficient and targeted health care utilization.

Background: Home visits provide essential access to primary care for frail or homebound older adults. In Ontario, Canada, a 2019 policy change removed some financial incentives for physicians to conduct home visits. This was followed by the COVID-19 pandemic and rapid adoption of virtual care, potentially disrupting the provision of home visits.

Methods: We conducted a population-based interrupted time series analysis of Ontario residents aged ≥65 years during the period July 2014 to June 2024. The interruptions were an incentive reform in October 2019 and the onset of COVID-19 in March 2020. The main outcome was the monthly number of primary care home visits per 10,000 older adults, standardized by age and sex. Segmented autoregressive models estimated changes in level and trend at interruption. Secondary analyses examined differences by age, rurality, dementia status, and visit type (palliative vs nonpalliative).

Results: From July 2014 to September 2019, home visits increased by 0.14 (95% CI, 0.05-0.23) visits per 10,000 residents per month. From October 2019 to June 2020, visits decreased by 29.7% (95% CI, 26.0%-33.1%). There was no significant postinterruption trend. Nonpalliative visits decreased more sharply (34.5%) than palliative visits (21.3%).

Conclusions: Home visits decreased sharply after incentive reform and the COVID-19 pandemic, with no evidence of recovery except among palliative visits. These findings suggest a structural shift in primary care delivery. Further research should investigate consequences on health outcomes for older adults and optimal models of primary care for older adults with challenges accessing office-based care.

Purpose: To increase access to fresh produce for Medicaid patients with type 2 diabetes or prediabetes, a local health department partnered with 3 Federally Qualified Health Centers to implement a produce prescription program in Los Angeles County. Program participants received $40 per month for 6 months through an electronic debit card to purchase fresh fruits and vegetables at participating grocery stores. This observational study assessed improvements in participants' nutrition security, defined as the consistent access, availability, and affordability of foods and beverages that promote well-being and prevent disease.

Methods: Program participants completed a questionnaire that included a 2-item household nutrition security screening tool and a 6-item household food security module at the program's beginning (baseline) and end (follow-up). Analyses were based on 1,309 participants who completed the questionnaire at both time points.

Results: After completing the program, the proportion of participants who reported being nutrition secure increased by an absolute 15.5% from baseline (from 23.2% to 38.7%). This improvement in nutrition security was statistically significant after adjusting for sociodemographics, baseline food security status, and fruit and vegetable consumption (adjusted odds ratio = 2.95; 95% CI, 2.11-4.13). Despite the nutrition incentive, most participants (85.6% vs 88.4% at baseline, P = .03) still stated healthy foods were "too expensive"-although more of them reported being able to locate a store that had healthy food options after completing the program.

Conclusions: This "food as medicine" intervention demonstrated short-term improvements in nutrition security among Medicaid patients with diabetes or prediabetes, suggesting it successfully fulfilled a basic social and disease management need of this population.

Primary care is a worldwide undertaking across nations and languages. CRISP-Consensus Reporting Items for Studies in Primary Care-is a research-reporting guideline developed by and for primary care. Originally created in English, CRISP can build global research capacity and support the reporting, dissemination, and application of primary care research findings. No widely accepted procedure exists for translating research-reporting guidelines, so we developed an explicit guide to translating documents into various languages. We synthesized available guidance with the aim of creating a practical, low-cost workflow for use by international teams of primary care colleagues. The resulting CRISP Translation Guide specifies the documents, team membership and expertise, and process for translation. It outlines a 5-step procedure: (1) translate from source into target language, (2) read in the target language to confirm practical function in context, (3) back-translate into source language, (4) confirm fidelity with the original authors of the source document, and (5) identify and resolve any concerns with the team. All team members are content experts. The translators for steps 1 and 3 are bilingual. The reader in step 2 is a target document user. Each step is a dialog. Translation teams are formally recognized but usually not considered authors. Translated documents include original citations and copyright notices. Using this guide, teams have translated the CRISP Checklist and related documents into Chinese, German, Portuguese (Brazilian), Spanish, and Turkish. Other languages are pending. The CRISP Translation Guide can facilitate the translation of research-reporting guidelines and related documents to support the worldwide dissemination and application of primary care research results. The guide can be applied to other documents as well.

Communication and clinical documentation are core competencies of medical education. With the adoption of open notes, patients have direct access to what clinicians document in their electronic health records. This has transformed clinical documentation from an administrative record-keeping and billing tool into a form of communication with patients. Students should be taught that notes are an extension of the visit that can impact the patient-physician relationship. In the context of relationship-centered care, where the focus lies on the quality of interactions among patients, clinicians, and the broader care team, the language and tone of documentation take on new significance. Clinical notes that are inclusive, respectful, and reflective of the patient's lived experience can help affirm their role as active participants in their care and strengthen the therapeutic alliance. Conversely, depersonalized, biased, or judgmental language may undermine these relationships and negatively affect outcomes. As educators and clinicians, we must train health professional students not only to document with clinical accuracy but also to write in ways that reflect empathy, reduce bias, and promote shared understanding. Patient-centered documentation is a practical and powerful tool for advancing relationship-centered care and improving the experience of both patients and clinicians.

Introduction: Since the COVID-19 pandemic, there has been rapid uptake of portal messaging by patients to address acute and chronic health conditions. Demand for in-person appointments has remained high. It is not known how US patients value trade-offs between rapid portal care, a shorter wait for a visit with any available physician, or a longer wait to see their primary care physician. We used a discrete-choice experiment to elicit patient preferences for different types of care delivery and clinician type, varying time to appointment.

Methods: In 2023 our academic family medicine department queried adult patients about 6 theoretical health concerns and asked them to choose among 4 modes of care with different time frames. The modes of care were: (1) portal messaging with their primary care physician; (2) video visit with a different physician; (3) video visit with their primary care physician; or (4) in-person visit with their primary care physician. We weighted results by gender, race, and age and calculated patient preferences overall and by demographic subcategories.

Results: We received 2,268 usable surveys out of 2,411 (50.4%) responses from 4,780 surveys sent. For all 6 health concerns, patients opted for a 3-day portal message response from their primary care physician over a longer wait for video or in-person visits with their primary care physician or with another physician.

Conclusions: Primary care patients expressed a robust preference for rapid-response portal messaging to address health needs. This raises important concerns about how to support patient desires for this mode care while restructuring primary care infrastructure to ensure financial support for continued safe and sustainable primary care.

During a month-long family medicine rotation in Mineral Wells, Texas, a town known for its mineral water and close-knit community, I gained firsthand experience with the unique challenges and rewards of rural practice. Working alongside my preceptor, I cared for multigenerational families, managed conditions without immediate access to specialists, and navigated the blurred lines between professional and personal roles in a small town. Through encounters ranging from newborn care to chronic disease management, I developed a deeper sense of clinical responsibility, professional identity, and community engagement. This reflection offers a specific account of how immersion in rural medicine reshaped my understanding of what it means to be both a physician and a member of the community.