Annals of Family Medicine最新文献

Family physicians are key members of the rural health care workforce, which is inadequate for current needs. From the American Medical Association Physician Masterfile, we identified actively practicing US family physicians during 2017-2023 and their region of practice. We found a year-over-year decrease in family physicians practicing in rural areas, with a net loss of 11% nationwide over the 7 years studied. We observed the greatest percentage loss of rural family physicians in the Northeast and the least percentage loss in the West. Ensuring an adequate rural family physician workforce likely requires a tailored regional approach such as medical school pathway programs from rural communities.

Outpatient follow-up care for traumatic brain injury (TBI) is inconsistent. The Action Collaborative on TBI Care, convened under the auspices of the National Academies of Sciences, Engineering, and Medicine, aimed to standardize management with a clinical practice guideline. The guideline is intended for community-dwelling adults with TBI who are able to care for themselves at hospital discharge or who did not require acute hospital care. Guideline topics were selected and prioritized with input from individuals with lived experience and clinicians. Existing evidence-based clinical practice guidelines (k = 18) were identified from systematic literature reviews. Recommendations for each priority topic were extracted from existing guidelines and synthesized using the ADAPTE process. Strength of evidence ratings were assigned based on the American Academy of Family Physician's adaptation of GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) through consensus voting. A draft guideline underwent external review by 20 health professional and brain injury organizations. The Action Collaborative on TBI Care guideline provides recommendations for 11 priority topics: (1) confirm the diagnosis; (2) determine whether emergency department evaluation is required; (3) request neuroimaging and neuropsychological assessment when indicated; (4) screen for social determinants of health; (5) provide guidance on return to usual activities; (6) educate the patient and family; (7) assess for risk of persistent symptoms; (8) prioritize which symptoms to target first; (9) initiate treatment for posttraumatic headache; (10) screen and initiate treatment for mental health disorders; and (11) decide if and when to refer to specialty care.

Purpose: Educational debt among physicians is growing and contributes to burnout symptoms. Work hours have been associated with burnout symptoms among medical learners and early-career physicians. It is not known if medical debt is directly associated with increasing work hours among early-career family physicians.

Methods: We created a longitudinal cohort of family physicians who were 3 years into their career using data from the American Board of Family Medicine. We assessed whether educational debt at the time of residency graduation was correlated with hours worked and with burnout symptoms at this career stage. Logistic regression analysis was used to determine if educational debt level and hours worked per week were independently associated with burnout symptoms.

Results: Among 4,905 early-career family physicians,17.8% had no educational debt while 16.2% had more than $350,000 of debt. Educational debt was positively correlated with mean hours worked per week (P = .002) and with burnout symptoms (P <.001). Also, mean hours worked per week were positively correlated with burnout symptoms (P <.001). In adjusted logistic regression analysis, family physicians had elevated odds of burnout if they had educational debt of $250,000 to $350,000 (adjusted odds ratio = 1.24; 95% CI, 1.01-1.51) and greater than $350,000 (adjusted odds ratio = 1.47; 95% CI, 1.19-1.82) as compared with no debt. Their odds of burnout symptoms also increased with work hours (adjusted odds ratio = 2.87; CI, 2.40-3.44 for ≥60 hours vs <40 hours weekly).

Conclusions: Among early-career family physicians, those with higher educational debt worked more hours. Both educational debt and work hours were independently associated with symptoms of burnout. Reducing educational debt may help prevent burnout symptoms and their downstream consequences.

We investigated whether ultrasound (US)-guided intrauterine device (IUD) insertion reduces procedure time and pain compared to conventional methods. A quasi-randomized prospective study at a Federally Qualified Teaching Health Center enrolled a total of 50 IUD insertion cases. In the US-guided group (n = 25), IUD insertion was performed under transabdominal US guidance without uterine sounding and bimanual examination. In the conventional group (n = 22), insertion was followed by bimanual examination and uterine sounding. The procedure time was significantly shorter in the US-guided group (P = .033), while pain scores were not different between the groups (P = .161). Transabdominal US guidance during IUD insertion may enhance procedural efficiency and serve as a valuable tool in teaching health centers.

Purpose: Most studies evaluating access to primary care have focused on changes in family physicians (FPs), with less exploration of patient differences over time. We examined both physicians and patients, including changes over time in the age and medical complexity of people seeing FPs.

Methods: We conducted a population-based cohort study using administrative health data, including physician claims and hospital data, examining patients cared for by FPs providing comprehensive primary care from 2004 to 2020 in Alberta, Canada. We assessed changes in FPs and used validated algorithms to examine changes in comorbidity among adults cared for by those physicians.

Results: There were notable changes in FPs over time including more physicians who were women (46.7% in 2020 vs 39% in 2004; P < .001) and trained in low/middle-income countries (17.2% vs 6.3%; P < .001). Patient age and number of comorbidities increased over time. The proportion aged 61-80 years increased from 16.1% in 2004 to 22.1% in 2020 (P < .001). Those with ≥5 comorbid conditions increased from 2.8% to 5.2% (P < .001). There were changes in physician practice over time including decreases in average days worked each year (167 in 2004, 156 in 2020; P = .007) and number of adult patients seen each day (23 vs 20; P < .001).

Conclusions: From 2004 to 2020, there were substantial changes in the characteristics and practices of FPs. In addition, there were notable trends in the characteristics of their patients, including an increasing proportion of older adults, often with more complex comorbidities.

Purpose: A mixed-methods study was conducted to determine if adding pharmacy technicians to primary care teams relieved clinicians and nurses of prescribing tasks and improved perceptions of administrative burden and quality of care.

Methods: A retrospective mixed-methods study using a survey and analysis of electronic health record data was conducted 1 year after deployment of 5 primary care pharmacy technicians in a safety-net group of 11 primary care clinics. Measures included administrative data on pharmacy technician work, survey measures of clinician and nurse ratings of change in administrative burden and impact on patient care, and qualitative responses. Respondants to the survey included 46 physicians, 13 nurse practitioners or physician assistants, and 25 registered nurses (response rate 32%).

Results: In 1 year, the 5 pharmacy technicians addressed 43,782 medication items (65% refills, 18% medication problem, 17% prior authorizations). Mean ratings among clinicians and nurses for medication access work on a pain point scale of 1 to 10 decreased from 8.3 to 3.6 (P <.001) pre- and post-deployment of pharmacy technicians. Clinicians and nurses agreed that the pharmacy technicians had a highly beneficial impact on work experience (59%), quality of care (54%), and patient access to medications (63%). Qualitative analysis of open-ended question responses identified 5 main themes: dealing with prior authorizations, communicating with pharmacies, timely medication access for patients, expertise of pharmacy technicians, and reduced task burden and greater efficiency.

Conclusions: Pharmacy technicians are an underrecognized asset for team-based primary care, bringing expertise in efficiently managing medication access processes that benefits clinician and nurse work experience, quality of care, and patient access to medications.

Purpose: To determine if combining Medicare annual wellness visits (AWVs) and problem-based visits with continuity clinicians could improve patient and clinician engagement and increase the percentage of AWVs completed and capture of quality measures.

Methods: A family medicine department utilized the quality improvement process to increase their percentage of AWVs by increasing the number of combined (ie, AWV and problem-based) visits through clinician education and targeted scheduling. De-identified data with the number of AWVs, eligible members, and clinicians were obtained from institutional data. Significant findings for trends, shifts, and data outside the normal limits were identified through Taylor's change point analysis. Differences in tests ordered pre- and post-implementation were analyzed with Wilcoxon rank sum analysis.

Results: Monthly AWV rates increased from 8.4% to 50.8% over 9 months. No-show rates were lower (11.9%) for combined visits than for AWV-only visits (19.6%; P = .008). Patients had lower no-show rates for AWV with their continuity clinicians (12.5%) compared to appointments with other clinicians (25.4%; P <.001). Compared to the 9 months preceding the study period, quality metrics increased for multiple screenings: breast cancer (P <.001), cervical cancer (P = .009), colorectal cancer (P <.001), depression (P <.001), falls (P = .039), function (P = .003), hepatitis C (P <.001), HIV (P = .006), lung cancer (P = .002), pain (P = .006), and osteoporosis (P <.001),. Hemoglobin A_1c and urine microalbumin testing, and pneumococcal vaccine administration also increased (P <.001). Influenza vaccinations did not significantly increase (P = .913).

Conclusion: Combined visits with continuity clinicians led to significant AWV completion rates and decreased no-show rates leading to improved quality measures.

Purpose: Federal initiatives have encouraged collection of sexual orientation, gender identity, and differences of sex development data in national health surveys. Researchers use these data sets to identify health disparities faced by marginalized populations and shape primary care practices. We summarized the current state of sexual orientation, gender identity, and differences of sex development measures in federal health surveys to inform primary care researchers, outline gaps in data, and discussed their research implications.

Methods: We examined 10 large federal population-based health surveys and, using content analysis, summarized the composition and continuity of their sexual orientation, gender identity, and differences of sex development measures.

Results: Federal health surveys have longstanding measures of sexual orientation, with 4 having more than 10 years of data. Several surveys introduced gender identity questions over the last 2 years. Only 1 survey measured differences of sex development.

Conclusions: Federal surveys have robust sexual orientation measures, but more surveys including gender identity and differences of sex development (DSD)s are needed. The presence of sexual orientation and gender identity measures in these surveys could help identify primary care disparities among sexual and gender minority populations. Research using sexual orientation data benefits from standardization and continuity that has not yet been achieved for gender identity measures across these surveys. New federal restrictions may hamper further collection of sexual orientation and gender identity data. The absence of differences of sex development data places this population at risk of having their needs go unaddressed in primary care settings.