Completion of Home Colorectal Cancer Tests Improves With Patient Support
Colorectal cancer is preventable with screenings such as colonoscopy and fecal immunochemical tests, but only 66% of the U.S. population was up to date in 2018. The percentage dips lower at 44% in federally qualified health centers, which serve low-income, racially diverse populations. Home-based, self-administered colorectal cancer screening programs have been shown to reach broader and more diverse populations than in-office screening and may reduce disparities among populations that are disproportionately affected. However, sample return rates vary widely by patient, type of screening intervention and clinic characteristics.
In a new study, patients in 15 clinics within one urban FQHC participated in a trial aimed at optimizing colorectal cancer screening. Each patient was mailed a fecal immunochemical test (FIT) to be performed at home and returned to the doctor’s office via mail or in person. Researchers examined clinic-level factors associated with higher and lower FIT completion rates, including staffing patterns, availability of educational materials, and the availability of on-call patient support and troubleshooting. Clinics with higher FIT completion rates were found to have added staff to support the effort; provided patients with staff-led education upon providing FIT tests; or helped patients resolve barriers to FIT screening. Clinics with lower rates of FIT completion were found to be lacking in such support. The researchers concluded that adding non-physician staff to support patients throughout the entire FIT process may help improve the return rate of FIT screenings and reduce the rate of colorectal cancer-related illness and death in populations who are disproportionately affected by the disease.
Melinda M. Davis, PhD, et al
Oregon Rural Practice-based Research Network, Oregon Health & Science University, Portland, Oregon
Telephone Surveys May Aid in Earlier Diagnosis of Dementia
Researchers in the Netherlands conducted a study to evaluate the validity of a simple telephone survey widely used to screen for dementia. The survey, known as the Telephone Interview for Cognitive Status, has proved valid among patients in memory clinics and symptomatic residents in retirement communities. Abdulrahman et al’s study was unique in that it was administered to primary care patients who had been enrolled in a dementia prevention trial that ended four years earlier. All participants in this TICS screening study were free of dementia at the end of the previous trial.
TICS includes 11 survey questions assessing several cognitive domains including orientation, attention, memory impairment, language, ability to plan, organize and carry out actions, and mathematical skills. Responses are then scored, with final results ranging from 0 to 41 points. A score of less than 30 represents a positive screen for dementia.
In the population studied, the TICS survey performed well as a low-cost diagnostic screening instrument for detecting dementia in at-risk populations in the family medicine setting. TICS could also contribute to more efficient dementia-related medical management. Additionally, the researchers suggest that the tool may be particularly useful when face-to-face diagnostic screening is not feasible.
Herrer Abdulrahman, MD, et al, Radboud University Medical Center, Nijmegen, the Netherlands
Investments in Primary Care Research Can Help the Profession Realize its Full Potential
The 2021 National Academies of Sciences, Engineering, and Medicine report, “Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care,” discusses strategies to support the survival of primary care. It addresses financial health and recommends payment centered on people, not services. The report also emphasizes that primary care is a common good and should be accessible for every individual. It identifies five high level objectives with regard to payment, access, workforce development, information technology and implementation.
Researchers from the Agency for Healthcare Research and Quality underscore the critical role of research for successful implementation of the NASEM report and assert that primary care’s future rests upon strategic investments in primary care research to provide the evidence needed to enable primary care to realize its full potential. This research would emphasize whole person care in which clinicians engage patients and families in managing illness and promoting wellness, as well as payment models and technology to support them. The authors, led by the director of AHRQ’s Center for Evidence and Practice Improvement Arlene Bierman, M.D., M.S., believe that enhancing the community-centeredness of primary care would reduce and ultimately eliminate long-standing inequities in access, quality and outcomes of care.
Realizing the Dream: The Future of Primary Care Research
Arlene S. Bierman, MD, MS, et al
Agency for Healthcare Research and Quality, Rockville, Maryland
Health Equity Depends on Equitable Health Research Practices
Patients in the U.S. experience notable differences in health outcomes across racial groups, but new research aims to shift the conversation by examining how researchers themselves account for these differences. Health equity aims to achieve the highest level of health for all people. It requires valuing everyone equally and fully acknowledging the links between health disparities and systemic racism. This is especially important in medical research, since researchers may unknowingly or unintentionally propagate harmful narratives and stereotypes of biological characteristics or cultural inferiority.
This new paper provides recommendations on how researchers can more appropriately engage in quantitative scientific inquiry to better understand the impact of racism on adverse health outcomes. These recommendations include applying appropriate theoretical frameworks that accurately explain how social-structural factors might interact with a disease to produce results most important for achieving health equity; drawing upon Black, Indigenous, Latine and other community consults as experts to inform public health research; measuring elements of racism in research in both new and secondary datasets; and elevating Black, Latine and Indigenous scholars to leadership positions to conduct racial health equity research.
Conceptualizing, Contextualizing, and Operationalizing Race in Quantitative Health Sciences Research
Elle Lett, PhD, MBiostat, MA, et al
Center for Health Equity Advancement, Perelman School of Medicine, and the Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, Pennsylvania; Center for Applied Transgender Studies, Chicago, Illinois
Early Career Physicians Identify Health Equity as Key Driver for Change and Sustainability of Primary Care
In 2020, 10 junior primary care physician leaders (three internists, three family physicians, and three pediatricians) provided their own perspectives on recommendations in the National Association of Sciences, Engineering, and Medicine’s report, “Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care.” The physicians were from various practice settings in the U.S., including academic, community and federally qualified health centers.
The group identified three themes: 1) The 4 Cs: Dr. Barbara Starfield’s original 4 Cs (first contact, continuity, coordination, and comprehensiveness) may not be inclusive of the needs of under-resourced communities; 2) Workforce: Diverse individuals are not sufficiently recruited and maintained in health care settings; 3) Payment Reform: Risk adjustment and value-based care will support equitable access and high-quality care to all communities.
The participating physicians support the NASEM report’s priorities and focus on achieving health equity. They also advocate for the extension of the original 4 Cs paradigm to include convenience, cultural humility, structural competency and community engagement. “We believe in investing in local communities and recruitment programs to stimulate diverse individuals to serve in health care,” the authors write. “Finally, we support a blended, value-based care model with adequate risk adjustment for social complexity.”
Health Equity: The Only Path Forward for Primary Care
Tracey L. Henry, MD, MPH, MS, Alison Huffstetler, MD, and Jacqueline B. Britz, MD, MSPH, et al
Virginia Commonwealth University, Richmond, Virginia
Racial and Ethnic Disparities Drive Emergency Room Use for Acute Asthma Symptoms in Children
According to a new, first-of-its-kind study, Latine children who prefer speaking Spanish are more likely to visit a community health center for their acute asthma symptoms than their non-Hispanic white peers. Alternatively, non-Hispanic Black children are more likely to receive asthma-related care in an emergency department than their non-Hispanic white peers. The authors observed no differences between groups in asthma-related inpatient admissions.
The effects of poverty may have been greater for Black children in the study, of which 73% of an Oregon-Medicaid subsample continuously lived below 138% of the federal poverty level. This was compared to 54%-58% in the other groups. The authors hypothesize that higher levels of poverty may have influenced health care utilization, as well as other factors beyond affordability, including perceived racial discrimination and trust in community health clinics. Ensuring adequate care in clinics may be key to mitigating disparities in asthma outcomes. At the same time, more research is needed to better understand why Black children are less likely to seek care in a clinic as opposed to the emergency room.
Racial and Ethnic Disparities in Acute Care Use for Pediatric Asthma
Jorge Kaufmann, MD, MS, et al
Department of Family Medicine, Oregon Health & Science University, Portland, Oregon
Health Equity-Informed Public Policies Can Help Reduce Existing Inequities and Ensure High Quality Primary Care
Primary care, with its focus on both individuals and communities, could play a key role in addressing health inequities that have been exposed and exacerbated by the COVID-19 pandemic. However, the United States’s chronic underinvestment in primary care currently limits its ability to reduce health disparities. In this new article, Rodriguez et al apply a health equity lens to the five recommendations put forward in the 2021 National Academies of Science, Engineering and Medicine report, “Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care,” in hopes of advancing health equity by placing high-quality primary care at its center. The authors offer their perspectives, as well as strategies on how to operationalize NASEM’s five recommendations regarding the following: 1) Paying teams to care for people, not individual doctors; 2) Ensuring high-quality care is available to everyone in every community; 3) Training primary care teams where people live and work; 3) Designing information technology that serves patients, families and interprofessional care teams; and 5) Ensuring that high-quality primary care is successfully implemented.
“As we move towards the next stages of primary care reform, having a health-equity informed public policy will be key to reduce and eliminate existing health inequities and ensure provision of high-quality primary care,” the authors write.
Implementing High-Quality Primary Care Through a Health Equity Lens
José Rodríguez, MD, FAAFP, et al
Redwood Health Center and University of Utah Health, Salt Lake City, Utah
American Board of Family Medicine Leader Advocates for New Entity to Research and Guide Primary Care Delivery in U.S.
Robert L. Phillips, Jr., MD, MSPH, executive director of the American Board of Family Medicine and the Center for Professionalism & Value in Health Care, contributes an editorial highlighting the importance of three manuscripts in this edition of Annals, which provide unique perspectives on the National Academies of Sciences, Engineering, and Medicine 2021 report, “Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care.” Phillips is a co-author of the NASEM report, which is the first of its kind in 16 years to discuss strategies to support the survival of primary care. All three papers (Rodriguez et al, Henry et al, and Bierman et al) amplify the report’s assertion that primary care is a common good and that it requires more functional and research resources to improve health and health care.
“I am grateful to the authors of all three papers for digesting the NASEM report and offering these important lenses on its relevance and potential value,” Phillips writes. “Recognition of primary care as an important strategy for improving health equity underpins the Secretary’s Initiative, and family medicine should use health equity as the leading message in its use of the report for advocacy.”
He concludes by recommending that family medicine leaders work with legislators to introduce simple legislation directing the National Institutes of Health to create a Center for Primary Care, something he believes will serve as a foothold for the largest and least studied platform for health care to receive more research funding.
Implementing High-Quality Primary Care: To What End?
Robert L. Phillips Jr., MD, MSPH
The Center for Professionalism & Value in Health Care and the American Board of Family Medicine Foundation, Washington, D.C.
Family Physician Proposes a Refocus from Problem-Oriented Medical Care to one That Considers Patient Health Goals
James W. Mold, MD, MPH, the George Lynn Cross emeritus professor of Family and Preventive Medicine at University of Oklahoma Health Sciences Center, writes about the failing, problem-oriented care that most clinicians use. He poses the question, “What if instead of asking, ‘What’s the matter with you?’ we first asked, ‘What matters to you?’” Mold advocates for a paradigm shift, one that humanizes care while guiding the application of medical science to meet the unique needs and challenges of individuals seeking care.
Mold believes that shifting the focus of care from clinician-identified abnormalities to person-relevant goals would elevate the role of patients; would individualize health care planning; encourage prioritization of care, support disease prevention and end-of-life planning; and facilitate teamwork between the patients and the primary care doctor. “Each person has unique vulnerabilities, resources, circumstances and experiences, values, and priorities, making reductionism and excessive standardization detrimental,” he writes.
Failure of the Problem-Oriented Medical Paradigm and a Person-Centered Alternative
James W. Mold, MD, MPH
University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
Physicians’ Use of Self-Assessment to Guide Quality Improvement Often Doesn’t Address Individual Gaps
Researchers studied whether physicians reviewing their quality measures and peer comparisons would increase the probability of their choosing continuing medical accreditation activities that would address their individual quality gaps.
The primary outcome that was studied was whether the selected activity reflected a quality area for which the physician scored lower than their peers. The secondary outcome they studied was time spent by physicians reviewing their quality measures dashboard.
Nearly 20% of the sample didn’t complete a certification activity during the study. Almost a quarter of physicians in the intervention arm never reviewed their quality dashboard. Only 27% of certification activities were completed in clinical areas where the physician’s quality of care was below average, and there was no difference between intervention and control groups. Of the 45.4% of physicians who viewed their dashboard, they typically did so two weeks before engaging in the activity. The median time spent reviewing the dashboard was 82 seconds.
The authors conclude, “We found that providing physicians their quality measures inside their certification portfolio did not drive their selection of certification activities. Multicomponent interventions with multiple touch points are likely needed to change physician behavior.”
Lars E. Peterson, MD, PhD, et al
American Board of Family Medicine and Department of Family and Community Medicine, College of Medicine, University of Kentucky, Lexington, Kentucky
Researchers Cull Practical Guidance, Lessons from Published Research on Setting Up COVID-19 Vaccine Sites
In this special report, researchers synthesized peer-reviewed studies and guidelines on mass vaccination clinics to provide practical guidance for primary care clinicians as they plan, implement and expand efforts to vaccinate communities against COVID-19. The authors identified and synthesized the findings of 46 reports, manuals and peer-reviewed papers that addressed the planning of mass vaccination clinics prior to, and in the context of, the COVID-19 pandemic. Key considerations include management, logistics, infection control, human resources, adverse events following immunization, documentation, supplies and waste, vaccine storage and handling, and communications. This report also provides suggestions for primary care clinicians to better address challenges around vaccine supply and vaccine hesitancy.
The authors note the documented success of primary care clinicians in delivering COVID-19 vaccines within vulnerable and hard-to-reach communities. Many studies show improved vaccine uptake and confidence when family physicians and nurses strongly recommend vaccination, share personal anecdotes, and speak confidently about its safety and benefits. The authors conclude, “As (COVID-19) vaccine rollout occurs in various countries, research will be required to identify the main factors for success to inform future pandemic responses.”
Best Practices for COVID-19 Mass Vaccination Clinics
Andrew D. Pinto, MD, CCFP, FRCPC, MSc, et al
Upstream Lab, MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge
Institute, St. Michael’s Hospital
Researchers Document Prevalence of Patients’ Social Risks and Their Desire for Health System Assistance
Mounting research has shown how social health factors can place people at risk for poor health outcomes. Family physicians and their teams are increasingly called upon to assist patients who struggle with basic needs, such as housing, food and transportation. A new study from Kaiser Permanente Washington Health Research Institute in Seattle, which leads Kaiser Permanente’s Social Needs Network for Evaluation and Translation (SONNET), documented the prevalence of these social risks and assessed patients’ desire for assistance from the health system to address their needs.
Among the findings, 48% of study participants reported one or more social risks, with housing instability the most prevalent (70%). Participants with social risks were twice as likely to report having ‘fair’ or ‘poor health’ – even though they were similar demographically to people who didn’t have social risks. Although 90% of participants believed that health systems should assist patients at risk, 14% who reported having social risks also reported more discomfort being screened for social risks than the 5% who reported no risks. Among those with one to two social risks, only 27% desire assistance from the health system. The findings in this article warrant careful attention, training of clinicians to explore unconscious bias, and system-level culture change. The authors conclude, “Health systems should work to increase the comfort of patients in reporting risks, explore how to successfully assist them when desired, and offer resources to address these risks outside the health care sector.”
Leah Tuzzio, MPH, et al
Kaiser Permanente Washington Health Research Institute, Seattle, Washington
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:
The Foodbox Pilot — Beginning in 2018, members of Primary Health Care, Inc. in Des Moines, Iowa, used $10,000 in HRSA Federally Qualified Health Center supplemental funding to test the feasibility of providing food for patients with documented depression and food insecurity. They worked with a long-standing local food pantry to provide weekly food boxes for patients with moderately severe or severe depression, as well as food insecurity. Sixteen of 24 patients lowered their depression scores. The team is currently working with a new coalition of organizations, including a Medicaid Managed Care Organization and a commercial fruit and vegetable supplier, to expand and further study this intervention
Bery Engebretsen, MD, et al
Primary Health Care, Inc.
Des Moines, Iowa
Adapting an In-Clinic Resource Navigator Program to a Virtual Referral Model — Since 2016, the University of Wisconsin Health Northeast Family Medical Center has used a Community Resource Navigator Program, including the use of student navigators, to connect patients with community resources. The COVID-19 pandemic required staff to adopt a plan-do-study-act cycle to adapt the clinic’s social needs prescribing to a more flexible, virtual referral process. They achieved this by integrating off-site community partners into telephone huddles, sending out shared health record reminders, and establishing telephone and/or email connections. Other clinics can use these strategies to reinforce meaningful, community-clinic partnerships that help patients overcome systemic and societal risk factors that are barriers to good health.
Kellia J. Hansmann, MD, MPH, et al
University of Wisconsin, School of Medicine and Public Health, Department of Family Medicine and Community Health, Madison, Wisconsin
Connecting Group Care Patients to Mental Health and Food Resources During the COVID-19 Pandemic — Members of the Department of Psychiatry at the University of Colorado School of Medicine and the Department of Family Medicine at the Denver Health Hospital Authority adjusted the model of a Federally Qualified Health Center in Denver to offer virtual group visits, schedule families for individual medical visits, and screen patients for food insecurity and behavioral health needs. Relationship-based, culturally congruent care allowed medical providers, group care coordinators, and psychologists to effectively pivot during the pandemic and offer support and resources to underserved families. Primary care clinics can create workflows that support the formation and utilization of trusted relationships (e.g., patient navigators, care coordinators, and behavioral health professionals) to reach vulnerable populations during and after the pandemic to promote collective recovery and resilience.
Catherine Wolcott, PhD, et al
University of Colorado School of Medicine, Department of Psychiatry, Aurora, Colorado
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Annals of Family Medicine is a peer-reviewed, indexed research journal that provides a cross-disciplinary forum for new, evidence-based information affecting the primary care disciplines. Launched in May 2003, Annals is sponsored by seven family medical organizations, including the American Academy of Family Physicians, the American Board of Family Medicine, the Society of Teachers of Family Medicine, the Association of Departments of Family Medicine, the Association of Family Medicine Residency Directors, the North American Primary Care Research Group, and The College of Family Physicians of Canada. Annals is published six times each year and contains original research from the clinical, biomedical, social and health services areas, as well as contributions on methodology and theory, selected reviews, essays and editorials. Complete editorial content and interactive discussion groups for each published article can be accessed free of charge on the journal’s website, www.AnnFamMed.org.
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