Annals of Family Medicine最新文献

Purpose: Latino pediatric patients have a higher prevalence of obesity, but less is known about how factors related to nativity are associated with obesity in youth. We examined the prevalence of childhood and adolescent obesity in primary care over time by nativity status for Latino and non-Hispanic White children.

Methods: In this serial cross-sectional analysis, we used electronic health records from a multi-state network of community health centers which included data from clinics in 21 US states for patients aged 9 to 17 years from 2012 through 2020 in at least 1 of 4 nonmutually exclusive cross sections. We estimated the adjusted odds and prevalence of having obesity (ie, body mass index [BMI] at the 95th percentile or greater for age and sex) at all encounters during each cross section by ethnicity and nativity status.

Results: The sample included a total of 147,376 patients. In the 2012-2013 cross section, 38,697 children and adolescents had at least 1 BMI measurement recorded compared with 72,747 in the 2018-2020 cross section. US-born Latino children had higher odds of having obesity than non-Hispanic White children. Foreign-born Latino and non-Hispanic White children had lower prevalence of obesity in each cross section compared with US-born Latino children (with a range from 20.4% [95% CI, 16.9%-23.8%] to 32.7% [95% CI, 31.6%-33.9%]).

Conclusions: Differences in the prevalence of documented childhood and adolescent obesity by nativity status exist in this sample of community health center patients. This demonstrates opportunity for primary care practice to further consider patients' background and culture when providing obesity care and cardiovascular and metabolic disease prevention.

Purpose: Prescribing cascades occur when one medication is used to treat adverse effects of another medication. Older adults with polypharmacy are at higher risk for this phenomenon. We examined the prevalence, magnitude, and effect modification of 9 prescribing cascades (ThinkCascades) among older community-dwelling adults in a national prescription database.

Methods: We used prescription sequence symmetry analysis to examine prescriptions for ThinkCascades medications dispensed in primary care under the General Medical Services scheme in Ireland. Analyses were based on prescriptions dispensed between 2017 and 2020 among 533,464 adults aged 65 years or older. Incident users of both medications in each ThinkCascades dyad were included. We used an observation window of 365 days and examined other windows in sensitivity analyses. Adjusted sequence ratios (aSRs) took into account secular prescribing trends. We also conducted analyses stratified by sex, age, and individual index medication.

Results: Five prescribing cascades had significant positive aSRs, indicating that the patient was more likely to receive the index medication before the marker medication. The largest signal was identified for the calcium channel blocker to diuretic cascade (prevalence, 2.6%; aSR = 1.93; 95% CI, 1.79-2.09). Positive signals were also identified for the α ₁-receptor blocker to vestibular sedative cascade (prevalence, 3.0%; aSR = 1.63; 95% CI, 1.46-1.81); the selective serotonin reuptake inhibitor/selective norepinephrine reuptake inhibitor to sleep medication cascade (prevalence, 2.5%; aSR = 1.54; 95% CI, 1.40-1.69); the antipsychotic to antiparkinsonian cascade (prevalence, 0.4%; aSR = 1.20; 95% CI, 1.00-1.43); and the benzodiazepine to antipsychotic cascade (prevalence, 3.2%; aSR = 1.15; 95% CI, 1.08-1.21).

Conclusions: To our knowledge, this study is the first to describe the prevalence of an expert consensus-based list of prescribing cascades, ThinkCascades, in a national population of older adults, and it identified 5 clinically relevant prescribing cascades. These findings highlight prescribing cascades as an important underresearched area contributing to complex polypharmacy among older people living with multimorbidity.

Purpose: The Enhanced Primary Care Diabetes (EPCD) model is nurse led and leverages interdisciplinary support to improve diabetes quality indicators. The model has been found to be effective overall; however, because narrowing health disparities is a key objective, we aimed to assess differential effectiveness of the model among various racial and ethnic groups.

Methods: This retrospective cohort study compared the time to meeting the D5, a publicly reported quality measure (composite indicator of glycemic and blood pressure control, aspirin use for secondary prevention of cardiovascular disease, statin use, and documented abstinence from tobacco use), after enrollment in the EPCD program by Black, Hispanic/Latine, and Asian patients compared with White patients with diabetes (age 18-75 years) receiving care at 13 primary care practices by multivariable Cox proportional hazards regression. Patients enrolled in the program from January 1, 2020 to December 31, 2020; the study period end date was August 1, 2022.

Results: The EPCD program enrolled 1,749 patients (none of whom met the D5 at entry) and 1,061 (60.7%) met the D5 during the study period. Black patients were less likely to meet the D5 compared with White patients (adjusted hazard ratio 0.68; 95% CI, 0.52-0.90; P = .007); there was no difference among Asian and Hispanic patients compared with White patients. Compared with White patients (median 1.1/year; interquartile range [IQR] 0.4, 2.7), Asian patients had fewer nurse touch points (median 0.8/year; IQR 0, 1.4) during the study period, whereas Black patients had more (median 2.2/year; IQR 0.6, 4.0) and Hispanic patients showed no significant difference.

Conclusions: Time to meeting the D5 was longer for Black patients compared with White patients in the EPCD model, despite greater engagement with the care team. Further research is needed to identify factors driving these disparities.

Purpose: People experiencing homelessness have lower rates of cancer screening than housed people, contributing to later stages at cancer diagnosis and poor outcomes. We examined whether gaining housing increased rates of cancer screening in a cohort of homeless veterans.

Methods: We conducted a retrospective cohort study examining all veterans experiencing homelessness who were eligible for, but not up to date on, colorectal and breast cancer screening from 2011 to 2021. Our exposure was gaining housing in the 24 months after the index clinic visit, conceptualized as a time-varying covariate. Our primary outcome was undergoing breast or colorectal screening in the 24 months after that visit. We performed bivariate analysis and Cox proportional hazards analysis, clustering on the facility level and adjusting for clinical and demographic covariates.

Results: Our cohort included 117,619 homeless veterans who were eligible for but not up to date on colorectal cancer screening at their index visit, of whom 57,705 (49.0%) gained housing over 24 months. The cohort included 6,517 homeless veterans who were eligible for but not up to date on breast cancer screening, of whom 3,101 (47.5%) gained housing over 24 months. Compared with peers who remained homeless, veterans who gained housing were more than twice as likely to undergo colorectal cancer screening (adjusted hazard ratio, 2.3; 95% CI, 2.2-2.3; P <.001) and breast cancer screening (adjusted hazard ratio, 2.4; 95% CI, 2.2-2.7; P <.001).

Conclusions: Veterans experiencing homelessness who gain housing have higher rates of cancer screening. This finding supports promotion of housing to improve health outcomes for homeless individuals.

Purpose: Secure messaging has increased in primary care, but we lack information on who uses it at a high level. Characterizing this population is important to inform policy about patients most likely to be affected by secure messaging reimbursement and coverage decisions; to contextualize the secure messaging work burden for primary care; and to understand how secure messaging complements use of other primary care access points. Our objectives were to describe characteristics of high users, assess their overall primary care and emergency department use, and determine the proportion of total Veterans Health Administration primary care messages exchanged by this group.

Methods: We conducted a 1-year retrospective cross-sectional analysis and multivariate logistic regression analysis of all veterans assigned to primary care on October 1, 2022 who exchanged at least 1 secure message with primary care by September 30, 2023. We calculated descriptive statistics and assessed whether certain veteran characteristics were associated with high user status (use in the 95th or higher percentile of all messages exchanged annually).

Results: Patients were more likely to be high users if they were older (adjusted odds ratio [aOR] for age ≥75 years = 2.49); had highest frailty (fourth quartile aOR = 2.65) or high physical comorbidity (Gagne score of 2 aOR = 1.17 and score of 3 aOR = 1.14); lived with schizophrenia or bipolar disorder (aOR = 1.23); or had posttraumatic stress disorder, anxiety, or depression (aOR = 1.16) (P < .05 for each). Patients were less likely to be high users if they identified as Black (aOR = 0.74), Hispanic (aOR = 0.80), or Asian/Pacific Islander/Native Hawaiian (aOR = 0.85), or were male (aOR = 0.78) (P < .05 for each). High users exchanged 30.5% of all messages. Few high users of secure messaging were also high users of other primary care encounters (only 14.0% were high users of in-person visits, 11.3% of video visits, and 11.8% of telephone visits) or the emergency department (8.0% of visits).

Conclusions: A small percentage of veterans exchange a disproportionate share of total secure messages. Most high users of secure messaging do not use other primary care or emergency department services at the same high frequency as secure messaging. High users commonly have high physical comorbidity, are frail, and live with mental health conditions, and racial disparities exist.

Purpose: Strengthening primary care's integration function is a systematic approach to promote integrated care. Understanding the factors influencing the process of integrating care for every patient is crucial for effective intervention planning. The objective of this study was to generate an analytic framework and evidence map of the barriers and facilitators perceived by family physicians (FPs) in clinical integration, a process to coordinate health care services across time, place, discipline, diseases, and patient demographics.

Methods: Using the Joanna Briggs Institute umbrella review methodology, we searched the MEDLINE, Embase, and CINAHL databases, identifying 90 reviews (2010-2022) on primary care FPs and clinical integration. We adopted a best-fit framework approach to group the factors into a customized clinical integration framework, reflecting how a health care system functions. Two evidence maps were created to visualize the reviews' distribution. We validated the framework with another 21 reviews (2022-2024).

Results: The analytic framework consisted of 9 themes and 21 subthemes based on 2,891 factors derived from external and internal sources within primary care practices. Several subthemes were common across themes related to individuals (FPs, physicians other than family physicians and allied health providers, patients) and operating units (systems, organizations, practices), highlighting shared elements. The professional theme was the most significant, appearing in 86% of the reviews and including subthemes related to diseases, clinical guidelines, and teamwork. In contrast, themes related to systems, organizations, and practices were reported less frequently (48%, 22%, and 23%).

Conclusion: The complex interactions among factors, subthemes, and themes elucidate challenges in finding a universal strategy or implementing initiatives. The generated evidence maps indicated knowledge gaps to guide future research work.

This narrative essay explores the intersection of health care, politics, and identity from my perspective as a family physician on the day following the consequential and polarizing 2024 US presidential election. I recall and grapple with the profound grief, anxiety, and uncertainty expressed by my patients, particularly those from marginalized communities, as they face threats to their health care and very identities. These experiences highlight the tension between professional neutrality and our moral imperative to advocate for vulnerable populations.