Annals of Family Medicine最新文献

Purpose: Building timely consensus among diverse stakeholders is important in primary health care research. Consensus can be obtained using the nominal group technique which includes 5 steps: (1) introduction and explanation; (2) silent generation of ideas; (3) sharing ideas; (4) discussion; and (5) voting and ranking. The main challenges in using this technique are a lack of representation of different stakeholder opinions and the amount of time taken to reach consensus. In this paper, we demonstrate how to effectively achieve consensus using an adapted nominal group technique that mitigates the challenges.

Methods: This project aimed to reach consensus on the priority care domains for individuals aged 65 or older, using an adapted nominal group technique with 4 strategies: (1) recruit 4 stakeholders groups (older people, clinicians, managers, decision makers) by using maximum variation and snowballing sampling approaches; (2) use remote tools to ensure high participation; (3) add an individual pre-elicitation activity to increase effectiveness; and (4) adapt discussions to the stakeholders' preferences for meaningful engagement.

Results: In total, 28 diverse stakeholders participated. After the pre-elicitation activity and 1 round of group discussion, we reached consensus on a priority domain called symptoms, functioning, and quality of care. Adaptive group discussions and remote tools were the most effective strategies. All participants strongly agreed that they were able to express their views freely. Some perceived a need for emphasizing the alignment between the research objectives and anticipated practice and policy implications.

Conclusions: This adapted nominal group technique is an effective and enriching method when timely consensus is needed among diverse stakeholders. Health care researchers in various fields can benefit from using this research methodology.

Despite medical advances, diabetes management remains a considerable challenge in the United States, with little to no improvement in patient outcomes and stark disparities in underserved communities. One acute challenge is that, as the US population with diabetes grows steadily-numbering 38.4 million people today-there are too few endocrinologists available to treat the disease and the burdens on primary care professionals, who treat more than 90% of cases currently, are staggering. This disconnect between need and care capacity presents what may be the greatest of many threats to the care of diabetic Americans. To understand what is required to solve this need-to-capacity mismatch, we examine the critical role of primary care professionals and propose national policy approaches to empower and improve the nation's primary care architecture for the nearly 12% of Americans who have diabetes. Policy recommendations encompass the integration of the chronic care model and the patient-centered medical home approach, expansion of workforce development initiatives, and payment reform to incentivize team-based care with the aim of ensuring equitable access to essential diabetes management tools. We urge policy makers to prioritize primary care workforce development, enhance reimbursement models, and implement strategies to mitigate disparities in diabetes care. Evidence reviewed here highlights the critical need for a comprehensive, multidimensional approach to diabetes management in primary care, emphasizing the importance of decisive action by policy makers to equip primary care professionals with the necessary resources and support to effectively address the nation's diabetes epidemic.

Purpose: Primary care access is a key health system metric, but little research has compared models to provide primary care access when one's regular physician is not available. We compared health system use after a visit with a patient's own family physician group (ie, within-group physician who was not the patient's primary physician) vs a visit with a walk-in clinic physician who was not part of the patient's family physician group.

Methods: We conducted a population-based, retrospective cohort study using administrative data from Ontario, Canada, including all individuals formally enrolled with a family physician, from April 1, 2019 to March 31, 2020. We compared those visiting within-group physicians to those visiting walk-in clinic physicians using propensity score matching to account for differences in patient characteristics. The primary outcome was any emergency department visit within 7 days of the initial visit.

Results: Matched patients who visited a within-group physician (N = 506,033) were 10% less likely to visit an emergency department in the 7 days after the initial visit compared to patients who saw a walk-in clinic physician (N = 506,033; 20,117 [4.0%] vs 22,320 [4.4%]; risk difference [RD] 0.4%; 95% CI 0.4-0.5; relative risk [RR] 0.90; 95% CI, 0.89-0.92). Restricting to visits occurring on weekends, the observed association was stronger (7,964 [3.7%] vs 10,055 [4.7%]; RD 1.0%; 95% CI 0.9-1.1; RR 0.79; 95% CI, 0.77-0.82). Those accessing after-hours within-group physician visits were more likely to have ≥1 additional virtual or in-person within-group physician visit within 7 days (virtual RR 1.86, in-person RR 1.87).

Conclusions: Compared to visiting a walk-in clinic physician, seeing a within-group physician after hours might decrease downstream emergency department visits. This finding could be explained by better continuity of care and can inform primary care service models and the policies that support them.

Purpose: The Dobbs v Jackson Women's Health Organization (Dobbs) Supreme Court decision revoked the constitutional right to abortion. Now, restrictive state abortion laws may contribute to the shortage and strain already felt in primary care practice, especially related to the provision of reproductive health care. The purpose of this study is to evaluate perceived impacts of state abortion legislation on family medicine clinicians' practice and medical education regarding reproductive health care.

Methods: Ten questions were added to the 2022 Council of Academic Family Medicine Educational Research Alliance general membership survey to evaluate impact on relevant themes in reproductive health care and training after the Dobbs decision. Responses were categorized by severity of restriction of state abortion policies.

Results: Of 1,196 respondents, 49.7% reported employment in states with very restrictive or restrictive abortion policies. The 991 respondents with clinical responsibilities reported significant (P <.05) changes in their counseling practices, clinical decision making, worry of legal risks, and trust in patients' self-reported reproductive medical history, compared with peers in protective states. Perceived patient trust toward clinicians remained unchanged. Almost one-half of clinical respondents reported an absence of reproductive health care guidance or recommendations. Restrictive abortion policies significantly (P <.05) reduced the desirability and confidence in resident training programs.

Conclusions: Reported changes to clinical activities and training, coming early after the Dobbs decision, affect our current and future workforce and therefore, our patients. Future studies are needed to document continued impact of state restrictions and inform policy to support family medicine clinicians in reproductive health practice and education.

A 70-year-old man with complex multimorbidity and intellectual disability was my patient for the last 5 years of his life. He taught me important lessons about the challenges of practicing medicine as a primary care physician. He embodied all the complexities of multimorbidity, the ways in which clinical decision making can be fraught with uncertainties and tradeoffs. He raised difficult ethical questions for his care team, questions about how to respect the dignity of patients who lack decisional capacity and who do not have surrogate decision makers. The gaps in his care revealed shortcomings of the US health care system, but his care in his final years also showed some of the bright spots in coordinated, team-based care. Most importantly, caring for this patient taught me about the rewards of the human connections that primary care physicians establish with their patients.

Purpose: The purpose of this study was to evaluate the effectiveness of collaborative trauma-informed care (CTIC) for treating depression in primary care in Chile.

Methods: From August 2021 through June 2023, 16 primary care teams in the Maule Region of Chile, were randomly assigned to either the CTIC or usual treatment (UT) group. At baseline, 3 months, and 6 months, 115 patients in the CTIC group, and 99 in the UT group, were blindly evaluated. The primary outcome was reduction in depressive symptoms. Secondary outcomes included improvement in anxiety symptoms, interpersonal and social functioning, emotional regulation, and adherence. Intention-to-treat data analysis, using analysis of covariance was conducted.

Results: There were 214 patients recruited; 85% were women, and 61% had 4 or more adverse childhood experiences. At 6 months, depressive symptoms declined significantly in the CTIC arm relative to UT (adjusted mean difference [AMD]= -3.09, 95% CI, -4.94 to -1.23; d = -0.46, 95% CI,-0.73 to -0.18; P = .001). Anxiety symptoms exhibited a trend toward improvement in the CTIC vs UT group (AMD = -1.50, 95% CI, -3.03 to 0.31; P = .055). No significant differences were observed in other secondary outcomes, except for adherence, which was significantly higher in the CTIC vs UT groups (AMD = 2.59, 95% CI, 1.80-4.99; P = .035).

Conclusions: The CTIC approach demonstrated superior outcomes in treating depression and improving adherence compared with UT. Moreover, the observed trends in anxiety improvement warrant further exploration in future research with a larger sample size. It is necessary to assess the effectiveness of this approach in treating more complex, difficult-to-treat forms of depression.

As the population ages, the prevalence of cognitive impairment due to neurodegenerative diseases such as Alzheimer disease (AD) is expected to double in the United States to nearly 14 million over the next 40 years. AD and related dementias (ADRD) are a leading cause of morbidity and mortality and among the costliest to society. Although emerging biomedical interventions for ADRD focus on early stages and are currently limited to AD, care management can benefit patients with ADRD across the disease course. Moreover, some causes of cognitive impairment are modifiable, and optimal overall management may slow or prevent additional decline. Nevertheless, a sizable proportion of cases of cognitive impairment among older adults remain undiagnosed. Primary care practitioners are often the first health care professionals to encounter cognitive concerns or to be able to observe changes in function resulting from cognitive impairment; hence, they have much to contribute to population health solutions for detecting cognitive impairment among older adults. In this report, we present key points and gaps in knowledge about methods for detecting cognitive impairment in primary care clinics. These were developed via an interdisciplinary Geriatrics Summit hosted by the National Academy of Neuropsychology in 2022, attended by representatives of national organizations engaged in work to improve care of older adults. We propose a novel workflow to facilitate detecting cognitive impairment during routine primary care, focusing on opportunities provided by the annual wellness visit, a preventive visit available to Medicare beneficiaries, along with additional recommendations and opportunities for clinical practice and research.