Report: July/August 2020 Annals of Family Medicine tip sheet

Why are memories attached to emotions so strong?

A Majority of U.S. Men Want Their Doctors to Ask About Intimate Partner Violence

Nine out of 10 U.S. men ages 18 to 35 support health care providers asking about intimate partner violence, according to new survey analysis. Data from a 2014 nationally representative survey showed that while most men support health care-based intimate partner violence screenings, only about 10 percent reported being asked by their doctor. Men who reported lower levels of education were most likely to be asked, but support for screenings varied by race and past experience with such violence. Black non-Hispanic men were less likely to think doctors should ask. Victims of intimate partner violence were more likely to support screening. The study notes that overall, about 17 percent of the 916 respondents reported experiences of physical violence with their partners, and a majority of men–56 percent–said they had been both a victim and perpetrator. Authors note that, “When young men seek health care with their primary care physician, those health care encounters offer opportunities to identify intimate partner violence.” Understanding the attitudes and experiences of men may help primary care clinicians tailor their conversations, support and referrals.

Prevalence of Intimate Partner Violence and Beliefs About Partner Violence Screening Among Young Men

Tova B. Walsh, PhD, et al

University of Wisconsin-Madison, School of Social Work, Madison, Wisconsin

LGBT-Friendly Primary Care Practices Improve STD and HIV Screening Rates for Vulnerable Populations

This report–describing the first national quality improvement collaborative focused on providing culturally affirming care for LGBT people–finds that making primary care practices more LGBT-friendly and inclusive may improve STD and HIV screening rates among this vulnerable population. The goal of the Transforming LGBT Care program was to help highly motivated community health centers implement LGBT-affirming care by providing infrastructure for training, collaboration, knowledge sharing, leadership buy-in and practice change. Ten federally qualified health centers were selected to participate in the year-long program. Small care teams were formed at each site, and those teams received coaching, training and facilitation from the program’s staff, much of which was conducted virtually. By the end of the program, estimated HIV screening of LGBT patients at eight of the reporting sites rose from 14.8 percent to 30.5 percent, with increases in STD screenings as well. Most participating centers had improved their electronic health record system to allow for sexual orientation and gender identity documentation, but very few reported improvements in documenting the sexual histories of LGBT patients. The authors of the program’s quality improvement study note, “Ultimately, federally qualified health centers and other primary care organizations have an opportunity and a responsibility to provide equitable care to people of all sexual orientations and gender identities. Even small changes to health care practices may make a large difference for people burdened by health disparities and discrimination.”

Transforming Primary Care for Lesbian, Gay, Bisexual, and Transgender People: A Collaborative Quality Improvement Initiative

Bruce W. Furness, MD, MPH, et al

Centers for Disease Control and Prevention, Atlanta, Georgia

New Prescribing Rules in France Result in Decreased Prescribing of One Type of Sedative-Hypnotic Drug for Insomnia

In France, the implementation of new prescribing rules for the sedative-hypnotic drug zolpidem led to an important and immediate decrease in use. This decline was partially compensated for by a rise in the use of a nonbenzodiazepine drug called zopiclone. In 2017, French health authorities made it mandatory to use a secure prescribing form for zolpidem, which is a popular insomnia drug in France and one of the drugs most involved in falsified prescribing and diversion. A time-series analysis of national prescription drug reimbursement records from 2015 to 2018 shows the positive impact of France’s regulations, with prescribing of zolpidem cut in half when comparing rates before and after the policy change. Nearly equal and opposite increases in zopiclone were seen during this same time period. The change in prescribing policies resulted in a shift to the alternative drug zopiclone–a trend that has been seen amongst prescribing restriction efforts, including restrictions on benzodiazepines.

Impact of Secured Prescription Implementation for Zolpidem on Hypnotics Use in France: A Time-Series Analysis on National Data

Nicolas Rousselot, MD, MSc, et al

University of Bordeaux, Department of General Practice, Bordeaux, France

Machine Learning Accurately Predicts Who’s Who in the Health Care Workforce

Until recently, economists, policy makers and workforce experts have relied on outdated and inaccurate snapshots of the U.S. physician workforce, making it especially difficult to predict the need and availability of health care services across the country. Data about each physician’s area of specialty is collected at the beginning of their career and is rarely updated, increasing the potential for outdated information about who is providing care for our nation’s population. In this study, Wingrove et al examine how machine learning algorithms may allow for more real-time, accurate descriptions of the medical workforce, including professions that do not formally collect specialty data like physician assistants and nurse practitioners. Algorithms also can identify physicians in new and evolving interdisciplinary positions. One such learning model from the Robert Graham Center and the University of Pittsburgh was trained to identify a majority of medical specialties with 95 percent accuracy. The model was fed data from clinical encounters in the form of procedures and prescriptions billed by Medicare from 2014 to 2016. The models were less accurate at predicting some specialties, like neurosurgery and physical medicine and rehabilitation. But overall, the model correctly predicted 70 percent of physician’s practice type within five percentage points of their actual count, including primary care and specialties such as emergency medicine, cardiology, gastroenterology and radiology.

Using Machine Learning To Predict Primary Care and Advance Workforce Research

Peter Wingrove, et al

University of Pittsburgh, School of Medicine, Pittsburgh, Pennsylvania and the Robert Graham Center for Policy Studies in Family Medicine and Primary Care, Washington, DC

COVID-19 Makes Clear the Need to Address Social Determinants of Health

In this editorial, University of Michigan public health experts Julia Wolfson and Cindy Leung argue that the COVID-19 pandemic has made glaringly apparent the structural conditions that underlie inequities in our nation’s health. Race and ethnicity, housing, income, occupation and chronic health conditions are all key factors that influence one’s ability to safely weather highly infectious disease pandemics like COVID-19. Unlike the novel coronavirus strain, these social, economic and structural factors are not new. The authors argue, “An opportunity exists to use the unfolding crisis to advocate for structural changes to a system that has long perpetuated disparities.” Wolfson and Leung draw together four articles in the July-August 2020 issue of the Annals of Family Medicine that emphasize social determinants of health and highlight the calls to action for primary care.

An Opportunity to Emphasize Equity, Social Determinants, and Prevention in Primary Care

Julia A. Wolfson, PhD MPP, et al

University of Michigan, School of Public Health, Departments of Health Management and Policy and Nutritional Sciences, Ann Arbor, Michigan

The Five Phases of Pandemic Care for Primary Care

The authors present a roadmap for necessary primary care practice transformations to care for patients and communities during the COVID-19 pandemic. Changes to U.S. primary health care will occur in five phases, according to the authors. The first three phases describe the transformation of primary care to accommodate COVID-19 testing and triage, as well as virtual visits and targeted outreach to patients with chronic conditions that put them at greater risk of COVID-19 complications. Many U.S. communities are grappling with the fourth phase, recovery after acute care, as primary care provides rehabilitation and recovery services to COVID-19-positive patients after hospital discharge. The fifth phase of the authors’ model addresses the indirect consequences of this pandemic, including worsening mental health, substance misuse, delay of patient’s traditional care, as well as social and environmental health risks like domestic violence, housing, and food and financial insecurity. The paper provides a framework and strategies to spur long-term change and evolution of the U.S. health care system.

Redesigning Primary Care to Address the COVID-19 Pandemic in the Midst of the Pandemic

Alex H. Krist, MD, MPH, et al

Virginia Commonwealth University, Department of Family Medicine and Population Health, Richmond, Virginia

A New Measure of Social Determinants of Health May Improve Cardiovascular Health Assessment at the County Level

The authors of this study developed a single risk score derived from multiple social determinants of health that predicts county-level cardiovascular disease mortality. Using data culled from government resources, they identified U.S. counties with a high risk of CVD based on a three-year average mortality rate. They used a 50 percent random sample of 3,026 counties to develop a risk score based on seven social determinants of health factors: proportion of non-white population, poverty rate, proportion of population without high school diploma, grocery store ratio, fast-food restaurant ratio, after-tax soda price and primary care physician supply. The remaining 50 percent of the counties served to validate the measure. The resulting index had better predictive performance for CVD burden than common single-measure area-level indexes (e.g., only measuring poverty). The authors conclude that their multivariable SDoH risk score can identify counties with high CVD risk and has the potential to improve CVD risk prediction and interventions for vulnerable populations at the county level.

Development and Validation of a County-Level Social Determinants of Health Risk Assessment Tool for Cardiovascular Disease

Young-Rock Hong, PhD, MPH, et al

University of Florida, College of Public Health and Health Professions, Department of Health Services Research, Management and Policy, Gainesville, Florida

International Conference on Social Determinants of Health in Primary Care Identified Actions for Change

In November 2019, clinicians, health administrators, educators and researchers from around the world gathered in Toronto to discuss how to best address social determinants of health from a primary care perspective. Participants developed starting points for accessible and feasible actions to improve health equity in their own primary care setting. They emphasized strategies to incorporate community members, especially those with lived experiences of discrimination, in the health care design team. Additionally, they highlighted the need to address structural determinants of health, including racism, capitalism and colonialism.

Improving Equity Through Primary Care: Proceedings of the 2019 Toronto International Conference on Quality in Primary Care

Tara Kiran, MD, MSc, CCFP, et al

University of Toronto and St. Michael’s Hospital, Department of Family and Community Medicine, Toronto, Ontario, Canada

Participants in CPC+ Are Diverse But Not Representative of All Primary Care Practices

This study analyzes patterns of participation in the Comprehensive Primary Care Plus initiative which is the largest voluntary primary care payment and delivery reform model tested to date. Of the nearly 20,000 primary care practices within the 18 regions selected by the Centers for Medicare and Medicaid Services for CPC+ implementation, 22 percent applied to participate. CMS accepted all applicants that met their minimum criteria, reflecting 15 percent of all primary care practices in the regions. Participation rates varied across the 18 regions from 2 percent to 34 percent. The Mathematica research team found that applicant practices, while diverse, were more likely to be larger, to be owned by a hospital or health system, to have experience with transformation efforts, and to be located in urban areas than practices that did not apply. Applicants also generally served slightly healthier and more advantaged Medicare fee-for-service beneficiaries. Overall, participating practices were not necessarily representative of all primary care practices in their region, underscoring the need to further engage practices that are small, independent, in rural areas, and lack experience with practice and payment transformation models, and the need to extrapolate evaluation results carefully.

Participation in the Comprehensive Primary Care Plus Initiative

Pragya Singh, PhD, et al

Mathematica, Princeton, New Jersey

Graduates of Family Medicine Residencies Are Likely to Enter and Remain in Family Medicine Practice

This study provides an overview of the characteristics of physicians who completed family medicine residency training from 1994 to 2017. It serves to update the only previous comprehensive national review of this kind, conducted in 1996, which covered family medicine graduates from 1969 through 1993. With only 10.9 percent of medical students entering family medicine residency training in 2016, and in light of the continuing shortage of family physicians, one goal of the new study was to determine whether family medicine residency graduates continue to practice in the field after residency. The study yielded moderately encouraging findings suggesting that family medicine residents are likely to remain in the primary care workforce.

Characteristics of Family Medicine Residency Graduates, 1994-2017: An Update

Mingliang Dai, PhD, et al

American Board of Family Medicine, Lexington, Kentucky

Antibiotic Allergy Reporting May Lead to Antibiotic Resistance, Higher Costs and Decreased Patient Safety

Antibiotics are among the most commonly prescribed medications, but in determining the most appropriate prescription for a patient, doctors and pharmacists often rely on inaccurate records of the patient’s antibiotic allergies. Many records are incomplete, unclear or incorrect. They may have originated with a patient’s previous physician, or incompatible electronic medical record systems may have introduced errors. In turn, this may contribute to the development of antibiotic resistance, higher health care costs and decreased patient safety. This qualitative study by researchers in the Netherlands identifies problems with the antibiotic allergy reporting process that may point toward interventions for improving registration accuracy. Based on focus group discussions, the researchers suggest that developing a training module and primary care guidelines regarding the registration process, cleaning up existing records, and fostering better communication, both human and electronic, as potential ways to improve antibiotic allergy registrations.

Inappropriate Antibiotic Allergy Documentation in Health Records: A Qualitative Study on Family Physicians’ and Pharmacists’ Experiences

Eefje G.P.M. de Bont, MD, PhD, et al

Maastricht University, Department of Family Medicine, Maastricht, The Netherlands

Gender Disparities Identified in Robert Graham Center’s Published Research: First Steps Towards Gender Parity in Academic Authorship

Researchers affiliated with the Robert Graham Center for Policy Studies in Family Medicine and Primary Care conducted a descriptive bibliometric analysis to determine the gender ratio of scholarly authorship on publications by its researchers between 2008 and 2018. While the average gender ratio of RGC researchers across this period was 46.3 percent female to 56.4 percent male, gender disparities in authorship were much starker. For example, roughly two-thirds of 229 publications listed a male first author, and almost all had at least one male author. While the RGC team recognizes the limitations of a single-case study, their intention is to broaden the discussion about gender parity in authorship among academic medical researchers.

Trends in the Gender Ratio of Authorship at the Robert Graham Center

Elizabeth Wilkinson, et al

Robert Graham Center for Policy Studies in Family Medicine and Primary Care, Washington, DC

What Encourages–or Impedes–Primary Care Team Collaboration through Case Management?

While multiple recent studies have provided evidence of the benefits of case management, primary care teams have struggled to implement and sustain its use in their clinical practices. In this systematic review, researchers examine barriers to case management, as well as factors facilitating its implementation. Researchers conducted a comprehensive literature review of studies that address comprehensive case management from a primary care perspective. A thematic analysis revealed nine barriers and/or facilitators that emerge across different studies, representing the perspectives of diverse health care professionals across six countries. The nine categories are family context; policy and available resources; physician buy-in and understanding of the case manager role; relationship building; team communication practices; autonomy of case manager; training in technology; relationships with patients; and time pressure and workload. Moreover, the framework situates these barriers and facilitators relative to each other. The authors believe their results may be of interest to policymakers, health care professionals and researchers who may use this study as a starting point for further investigation.

Understanding Barriers to and Facilitators of Case Management in Primary Care: A Systematic Review and Thematic Synthesis

Catherine Hudon, MSc, MD, PhD, et al

University of Sherbrooke, Faculty of Medicine, Department of Family Medicine, Sherbrooke, Quebec, Canada

Innovations in Primary Care

Innovations in Primary Care are brief one-page articles that describe novel innovations from health care’s front lines. In this issue:

  • Population Mapping for Quality Improvement in a Neighborhood Health Center–Neighborhood Health Centers of the Lehigh Valley Federally Qualified Health Center uses HealthLandscape’s Population Health Profiler, a population-health mapping tool developed by the American Academy of Family Physicians, to better understand health disparities in their service area, to target resources for care in their community, and to conduct comparative research to improve health outcomes for their patients.
  • Neuropsychologist Consultations in a Primary Care Setting–A collaborative care model in which a neuropsychologist works closely with clinicians in a primary care setting improves patient access to cognitive assessments, allows patients to centralize their care, and reduces the burden on primary care clinicians as they manage patients with cognitive impairment.



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