Annals of Family Medicine最新文献

When my patient accidentally told me he loved as I was leaving his hospital room, it made me think about how we end encounters and how we could do better. Physicians leave patient encounters multiple times a day, yet we receive no teaching or guidance on how to end an encounter. If we hurry away after a challenging encounter, what does that convey to the patient about the impact they have or don't have on us? Since that afternoon with my patient, I've made a habit of pausing outside of rooms before moving on, especially after deeply difficult or uncomfortable conversations. It feels like one small thing I can do to demonstrate that, no matter the awkwardness or challenge, I will not abandon them.

Purpose: Despite availability of effective diabetes medications, 27% of Israeli patients did not reach glycemic control goals in 2019. Financial hardship markedly impacts diabetes management. The American Diabetes Association recommends financial incentive initiatives as part of quality improvement programs. We investigated the impact of a conditional reduction in medication out-of-pocket costs vs standard payment on glycemic control.

Methods: A total of 186 patients with uncontrolled type 2 diabetes were recruited from neighborhoods having low socioeconomic status and randomly assigned to an intervention group or a control group. Patients in the intervention group were offered a discount on drug expenses (up to 600 new Israeli shekels or US $156, distributed through vouchers redeemable at pharmacies) that was conditional on improved glycemic control. Patients in the control group paid for their medications as usual.

Results: At baseline, study participants had a mean glycated hemoglobin (HbA_1c) level of 9.1%. The mean reduction in HbA_1c level at 6 months in per protocol analysis was 1.4% (95% CI, 1.1%-1.7%) in the intervention group and 0.7% (95% CI, 0.3%-1.0%) in the control group (P <.001). Multivariate linear regression analysis also demonstrated a significant difference in HbA_1c reduction between groups (difference = 0.7%; 95% CI, 0.3%-1.2%;P = .001) after controlling for age, sex, baseline HbA_1c level, body mass index, societal sector, income, education, and diabetes duration.

Conclusions: Financial incentives have the potential to enhance diabetes control in populations having low socioeconomic status and could be integrated into health plans as an optional program for patients with chronic disease in disadvantaged areas.

Having just returned to India after completing clinical electives in the United States, I was posted at a densely populated urban clinic. To deal with the large volume of patients, doctors often resorted to treating them symptomatically instead of searching for an underlying diagnosis, therefore minimizing the time spent with each of them. This clinic was where I met a patient presenting with undiagnosed dizziness for one and a half years. Deciding to take the time to perform one additional physical test, I was able to diagnose and help her, and thus experience a newfound joy. I argue that if doctors are a little more attentive to their patients' symptoms, they can capitalize on the benefits of the Indian medical system and impact many additional lives.

Purpose: A failure to retain family physicians already in practice is contributing to the current crisis for patients who are unable to access primary care. In this study we explored the reasons why Ontario family physicians left comprehensive care practice to identify what types of policies are critically needed for retention.

Methods: This qualitative study involved semistructured interviews, conducted in July-August 2024, with family physicians who left comprehensive care practice within the past 8 years. Virtual interviews were audio recorded, transcribed with double coding used for analysis and to identify categories from data. We sought participant validation of findings to enhance credibility and obtain feedback.

Results: Twelve participants were included: 4 family physicians each in early, mid-, and late career stages. Policy areas viewed as critical for retaining family physicians include financial, systemic, administrative burden, and support for family medicine. Participants described their experiences and decisions to leave comprehensive practice with 113 specific priorities identified, which, if addressed, are seen to be able to limit attrition from family medicine.

Conclusion: Patients seeking access to primary care will continue to be thwarted because family physicians' careers are increasingly being shortened with early exits. Retention of practicing family physicians requires immediate attention from government, with the primary challenge related to financial stability of practices in Ontario. Although there are numerous system challenges in health care, addressing those that add burden to family physicians would lessen burnout and provide much needed supports to professionals who do not choose to leave careers lightly.

Purpose: This study compared the budget impact of 4 deimplementation strategies designed to promote guideline-concordant opioid prescribing.

Methods: In this cluster randomized trial of 32 primary care clinics, deimplementation strategies targeted the system, clinic, and prescriber levels. All clinics received system-level educational meetings with audit/feedback reports. At month 3, one-half were randomized to add practice facilitation, a clinic-level strategy. At month 9, one-half were again randomized to add prescriber peer consulting, a prescriber-level strategy, resulting in 4 groups: system, system + clinic, system + prescriber, and system + clinic + prescriber. The primary outcome was change in mean morphine milligram equivalent dosage. Secondary outcomes included adherence to opioid risk mitigation metrics (urine drug testing, treatment agreements, pain/function screening, and mental health screening). We calculated the cost of delivering each implementation strategy and budget impacts associated with changes in health care utilization.

Results: Implementation costs per clinic were as follows: $4,416 (system), $5,610 (system + clinic), $7,164 (system + prescriber), and $8,358 (system + clinic + prescriber). With health care utilization changes incorporated, the system strategy's per-clinic costs increased to $10,908, yielding the greatest budget impact, the system + clinic strategy had the least budget impact at $7,266, and the system + prescriber budget impact was $9,625. The budget impact for system + clinic + prescriber was $8,703.

Conclusions: Higher-intensity deimplementation strategies significantly decreased mean morphine milligram equivalent and increased pain/function screening while decreasing treatment agreements and urine drug screening. The lowest-cost strategy (system) led to more costly downstream health care utilization, resulting in the greatest budget impact. Adding clinic- and prescriber-level strategies might help health systems decrease reliance on opioids for chronic pain, with less budget impact than providing system-level strategies alone.