Annals of Family Medicine最新文献

Purpose: We aimed to address fears and lived experiences of cognitive decline among adults via whole-person conversations that elicit problems and goals that matter most to patients. Currently, 6.7 million Americans have Alzheimer disease or related dementias, with an additional 28 million people reporting subjective cognitive decline-a possible indicator of Alzheimer disease and related dementias. A review of tools for older adults with cognitive impairment showed strong clinical specificity, with insufficient whole-person support for patients. We developed and tested the feasibility and acceptability of a tool to enhance conversations for adults with cognitive impairment at the point of care.

Methods: We conducted a feasibility study to build a conversation tool, guided by principles of shared decision making, called the "About Me" Care Card. Informed by an environmental scan, we created and pilot-tested prototypes at implementation sites. All phases were overseen by a multidisciplinary steering committee.

Results: Fourteen diverse clinicians consisting of 7 clinician types across 7 institutions piloted the card during in-person visits or by telephone. Observations showed that the card (1) allowed time to elicit what matters most to patients, (2) created space for personalized care conversations, (3) opened an examination of social care needs, and (4) moderated emotional relationships between families and individuals.

Conclusion: A community-based codesign process led to a feasible tool for primary care teams to facilitate whole-person conversations with aging adults. The About Me Care Card appeared to broaden conversations compared with routine care. More work is needed to determine scalability and effects on outcomes.

Purpose: We aimed to assess long-term inhaled corticosteroid (ICS) risks in chronic obstructive pulmonary disease (COPD) management.

Methods: We extracted electronic health record data for individuals aged >45 years with COPD from a data repository. The prevalent cohort required a diagnosis of COPD any time during the observation period, and the inception cohort required a diagnosis of COPD made after entry into the database. A composite outcome of any new diagnosis of type 2 diabetes, cataracts, pneumonia, osteoporosis, or nontraumatic fracture; and recurrent event outcomes of repeated pneumonia or nontraumatic fracture were compared for long-term (>24 months) vs short-term (<4 months) ICS exposure.

Results: We assessed outcomes for 318,385 and 209,062 individuals in the prevalent and inception cohorts, respectively. The composite dichotomous outcome was significantly greater for long-term vs short-term ICS use for the prevalent (hazard ratio [HR] = 2.65; 95% CI, 2.62-2.68; P <.001) and inception (HR = 2.60; 95% CI, 2.56-2.64; P <.001) cohorts. For the inception cohort, the absolute risk difference of the composite outcome was 20.26% (29.41% minus 9.15%), with a number needed to harm of 5. Hazard ratios were significantly increased in the prevalent and inception cohorts for recurrent pneumonia (HR = 2.88; 95% CI, 2.62-3.16; P <.001 and HR = 2.85; 95% CI, 2.53-3.22; P <.001, respectively) and recurrent fracture (HR = 1.77; 95% CI, 1.42-2.21; P <.001 and HR = 1.57; 95% CI, 1.20-2.06; P <.001).

Conclusions: Long-term ICS use for COPD is associated with significantly greater rates of the composite outcome of type 2 diabetes, cataracts, pneumonia, osteoporosis, and nontraumatic fracture; recurrent pneumonia; and recurrent fracture.

What would you do if someone approached you to sign a publishing form on your partner's behalf within mere weeks of their death? After my trusted, brilliant coworker died, I grappled daily between grieving her loss and driving productivity on her assigned projects. Because, after all, the world keeps spinning, research progresses, and manuscripts have to be published. In attempting to honor her memory through post-mortem authorship on publications, I was faced with a unique quandary of how to procure a signature on legal publishing forms, which is often requested during the publication process. Little guidance is available for corresponding authors on this issue, so I call on academic publishers to create post-mortem authorship policies that prioritize compassion, dignity, and rationality in the wake of grief.

This study assessed public perceptions of US primary care spending. An online survey was conducted using SurveyMonkey Audience (Symphony Technology Group), achieving a sample of 1,135 adult respondents reflective of the demographic distribution of the US adult population. Respondents' mean estimate of the percentage of US health care spending funding primary care was 51.8% (SD 24.8, interquartile range [IQR] 40). Respondents' mean estimate of the percentage of health care needs addressed by primary care was 58.7% (SD 22.2, IQR 28.5) These results reveal a tremendous disparity between current levels of primary care spending (4.7%) and public perceptions of primary care expenditure and value.

Purpose: Much of the literature on team-based primary care has focused on physician productivity, workload, and burnout. Less is known about how team-based care influences patient satisfaction and perceptions of the trade-off between continuity and access. This study assessed the preferences of family medicine patients for seeing their primary care physician (PCP) vs other team clinicians based on visit type and wait time.

Methods: Our cross-sectional online survey asked patients about their primary care clinics, PCP, portal use, self-reported health, and demographics. For multivariate analysis, we used weighted logistic regression analysis with survey data to calculate maximum likelihood estimates and converted these to odds ratios. We controlled for age and self-reported health as continuous variables and for demographics as categorical variables.

Results: We surveyed 4,795 adult patients and received responses from 2,516 (52.5%). More than one-half of patients preferred to see only their PCP for an annual checkup (52.6%), follow-up of a chronic condition (54.6%), or follow-up for a mental health condition (56.8%). Similarly, the majority of patients preferred to wait 3 to 4 weeks to see their PCP for issues possibly requiring a sensitive examination (68.2%), a new mental health concern (58.9%), or a new concern about a chronic condition (61.1%).

Conclusions: Our findings show that patients value having a PCP and maintaining continuity with their PCP. They also provide insight on when patients would prefer to wait to see their own PCP vs being seen more quickly by another clinician. As health care delivery and scheduling continue to evolve, these findings provide guidance for leaders in primary care.

Purpose: Although studies have shown that more temporally regular (TR) primary care visits are associated with improved patient outcomes, none have examined what clinic staff can do to encourage greater TR visits. This study aims to increase understanding of factors related to health care staff dynamics that contribute to more TR primary care visits for adults with chronic health conditions.

Methods: We conducted semistructured interviews with 15 primary care physicians, 12 nurses, 15 administrative staff, and 4 pharmacists at 12 clinics; one-half characterized as high-TR clinics where patients had regular follow-ups, and the other as low-TR clinics. Interviews were audiotaped, transcribed, and coded using Atlas qualitative data analysis software (Lumivero, LLC).

Results: Themes emerged regarding best ways to promote regular follow-up of patients with chronic conditions. These strategies included having a system to encourage follow-up (beginning with administrative staff reaching out to patients and ending with recruiting the help of patients' family members), routine staff meetings, adaptive workflow, dealing with bureaucracy on patients' behalf, informal channels of communication with patients, and consulting social workers. Clinics with more regular follow-up emphasized teamwork, a peaceful approach toward challenging patients, and flat as opposed to hierarchical organizational structures for personal relationships among staff.

Conclusions: Teamwork between staff members in primary care settings can contribute to more proactive care delivery, with greater potential to prevent long-term complications. The findings suggest that a high-functioning multidisciplinary care team that focuses on creating the right sorts of interactions and teamwork among members of the staff can contribute to engaging patients more effectively.

Physician self-disclosure is frequently employed intentionally to establish rapport, cultivate trust and reciprocity, convey empathy, offer hope and reassurance, or strengthen the credibility of clinical recommendations. Self-disclosure of mental health issues is very personal and is considered to be outside the scope of the patient-physician relationship. This narrative tells my story as a primary care physician trying to help a patient having anxiety and depression. As part of our ongoing motivational discussions, I shared my personal history of mental health issues. Does self-disclosure enhance client-patient rapport and treatment success, or does it hinder such processes?In this case, my self-disclosure successfully overcame impasses in the patient's treatment. Relevant self-revelation accelerated therapy and encouraged my patient to comply with his medication treatment.