Female Caregivers Experience Disproportionate Financial Strain, Interpersonal Violence, Transportation Difficulties, and Housing Insecurity During COVID-19 Pandemic
The COVID-19 pandemic has negatively affected women caregivers more than women who are not caregivers. Researchers surveyed 3,200 English-speaking women caregivers and non-caregivers in the U.S. on a variety of health-related socioeconomic vulnerabilities including financial strain, food/housing insecurity, interpersonal violence and transportation difficulties. They asked them to identify which challenges they faced before and after the emergence of COVID-19.
Prior to the pandemic, 63% of caregivers and 47% of non-caregivers reported one or more socioeconomic vulnerabilities, with food insecurity the most prevalent in both groups (48% and 33% respectively). The emergence of COVID-19 magnified this gap, with caregivers more likely than non-caregivers to newly experience the aforementioned difficulties.
The authors call for response and recovery efforts to assist caregivers in managing and reducing food and housing insecurity, interpersonal violence and transportation challenges. Such actions may ultimately improve the health and well-being of both caregivers and those who depend on them.
Jennifer A. Makelarski, PhD, MPH, et al
The University of Chicago, Department of Obstetrics and Gynecology, Chicago, Illinois
Two Ways to Decrease Physician Burnout and Make Health Care More Equitable
In a two-part special report, Thomas Bodenheimer, MD, MPH, attributes increasing physician burnout and decreased access to care to two causes: low levels of primary care spending at the national level and too many patients for each doctor to manage. The average U.S. family physician cares for an estimated 2,200 patients, versus an average of 1,700 patients in European countries. All the while, the U.S. spends significantly less on primary care than other countries. According to the Organisation for Economic Co-operation and Development, the United States directs only 5.4% of total health expenditures toward primary care, compared to 7.8% in 22 other OECD countries. Additionally, the increased time physicians spend on administrative tasks, combined with the declining numbers of new primary care physicians also contributes to the profession's current challenges.
Bodenheimer proposes two solutions to improve the state of primary care in the U.S.:
- Increase primary care spending through state level legislation and by eliminating the pay disparity between primary care physicians and specialists.
- Support the development of multidisciplinary teams to care for large patient panels.
Revitalizing Primary Care, Part 1: Root Causes of Primary Care’s Problems and Part 2: Hopes for the Future
Thomas Bodenheimer, MD, MPH
Department of Family and Community Medicine, University of California, San Francisco
Black and Hispanic People With Disabilities Receive Less Preventive Care, Even With Private Health Insurance
A new study reveals inequities in the use of preventive care services among privately insured Black and Hispanic patients with disabilities compared with the general population. Researchers examined insurance claims data from 11,635 patients over a 10-year period to determine how often patients with cerebral palsy or spina bifida received important preventative care services like annual wellness visits, bone density scans, cholesterol assessment, and diabetes screenings.
While inequities in access to care are often attributed to existing gaps in insurance coverage and socioeconomic status, this study revealed barriers other than insurance coverage. For most preventive services, privately insured patients with spina bifida or cerebral palsy, regardless of ethnicity, accessed preventive services at lower rates than the general population. Of note, the researchers found that bone density screening rates were low across all patients with cerebral palsy or spina bifida, which is particularly concerning as patients with these conditions are at high risk for osteoporosis and fractures. Furthermore, Black and Hispanic patients with cerebral palsy or spina bifida were less likely to have an annual wellness visit than their white counterparts, and Black patients were less likely to be screened for bone density than white patients. The researchers did not find inequities in the use of other preventive services.
Elham Mahmoudi, PhD, et al
Department of Family Medicine, Michigan Medicine, University of Michigan, Ann Arbor
Nearly twice as many family physicians stopped work in the early pandemic compared to previous years
Family physicians in Ontario, Canada, faced significant challenges in the early months of the COVID-19 pandemic, including reduced revenue, decreased retention of office staff, difficulty obtaining personal protective equipment, and decreased morale. Researchers conducted two analyses using billing claims data to better understand the number and characteristics of physicians who stopped work in the first six months of the pandemic and whether more family physicians in Ontario stopped working during the COVID-19 pandemic compared to previous years.
The researchers found that 3.1% of physicians working in 2019 (385 out of 12,247 doctors) reported no billings in the first six months of the pandemic. Compared with other family physicians, a higher portion were aged 75 or older; had fee-for-service reimbursement; had a patient panel size of under 500; and worked less than other physicians in the previous year. The rate at which family physicians stopped working rose from an average of 1.6% for the years between 2010 and 2019 to 3% who stopped working in 2020.
Although the absolute number of physicians stopping work was small, the impact on patients and communities is substantial considering Canada, like the U.S., is experiencing a primary care physician shortage. If this trend holds true in other communities, the COVID-19 pandemic may have further exacerbated the primary care physician shortage.
Family Physicians Stopping Practice During the COVID-19 Pandemic in Ontario, Canada
Tara Kiran, MD, MSc, et al
Department of Family and Community Medicine, St. Michael’s Hospital, University of Toronto, Ontario, Canada
Community Health Workers in the Primary Care Setting Can Help Individuals With Diabetes Improve Their Health
The successful management of Type 2 diabetes can be difficult, especially for patients who are simultaneously facing poverty, lack of insurance, or difficult home and neighborhood environments. Researchers conducted a study in a Latine, inner-city cohort to evaluate whether adding a community health worker intervention, focused on trust-building and sensemaking, to primary care teams would promote long-term diabetes self-management. The study followed 986 patients referred to the program who participated in up to 12-week intervention, analyzed the outcomes of three different patient groups, assigned after the short intervention, over a four year period: those who had met with a CHW (outreach); those who were working with a CHW to identify barriers to self-management (stabilization); and those who demonstrated an ability to manage their blood sugar levels at home (self-care generativity).
All study participants who worked with a CHW — regardless of which group they were in at the end of the intervention — experienced a significant drop in HbA1c blood sugar levels. The 32% of patients who achieved self-care generativity showed a faster and sustained drop of HbA1c over the period of observation. The fact that 32% of these patients were empowered to control their diabetes is a powerful effect of a trust-building sense-making intervention, the authors note. These patients were also less likely to be hospitalized or require emergency department visits than the other two groups. The researchers observed no significant differences in rates of urgent care visits among patients at different stages. The team noted that the study is unique in that it is longitudinal (four years) where most CHW studies have follow-up periods of 6-12 months, and assert that the persistent effect of a relatively short intervention (12-week) is “unheard of” in primary care.
Community Health Workers as Trust Builders and Healers: A Cohort Study in Primary Care
Robert L. Ferrer, MD, MPH, et al
Department of Family and Community Medicine, Long School of Medicine, UT Health, San Antonio
Lower Education and Mild Cognitive Impairment May Hinder Successful Completion of Home Colorectal Screening Tests
While many patients find at-home colorectal cancer screening tests (known as Fecal Immunochemical Tests or FIT) more comfortable than those performed in the clinic, FIT collection is dependent upon the patient closely following provided instructions. This can be more difficult if the user has undiagnosed cognitive impairments. In a new study, researchers distributed a simple cognitive test alongside at-home FITs to 1,448 patients to determine if mild, undiagnosed cognitive impairment might be leading to an increase of invalid samples.
Eleven percent of completed FIT stool specimens were incorrectly collected, with approximately 25% of the erroneous samples submitted by individuals who screened positive for cognitive impairment. The most common collection errors included having too much stool in the vial; stool on the wrong end of the vial; and stool on the wrong side of the slide. Additionally, the researchers found that patients with an eighth-grade education level or less were also more likely to make errors in the collection process. The findings suggest that health care staff should consider the education level and cognitive function of patients before asking them to perform an at-home FIT test.
Jeanette M Daly, RN, PhD, et al
Department of Family Medicine, University of Iowa, Iowa City
Combined Human and Veterinary Services Enhance Primary Care Access for Homeless Youth and Their Pets
In 2018, a multidisciplinary team in Seattle created a combined clinical space to care for homeless youth and their pets. The One Health Clinic, based at New Horizons, a shelter for homeless youth in Seattle, provides concurrent primary health care and veterinary care to young people and their pets after a community needs assessment revealed pet ownership as a barrier to accessing health care services. The OHC is currently offered as a four hour session twice monthly, with both human and animal health addressed at each visit. According to the authors, “Many people experiencing homelessness own animals that provide emotional support and other health benefits… . This integrated model leverages the power of the human-animal bond to increase primary care access for individuals experiencing homelessness, many of whom prioritize care for their animals over care for themselves.” The OHC also provides opportunities for interdisciplinary learning between medical students, veterinary students, and other health professionals. The OHC offers a free toolkit of protocols and best practices for other groups interested in starting a One Health Clinic in the U.S. or Canada. Find it at www.onehealthclinic.org
Alice H. Tin, MD MPH, et al
Swedish Cherry Hill Family Medicine Residency, Seattle
Study Finds Most Doctor-Patient Interruptions are Cooperative and Can Enhance Interactions
Researchers in the Netherlands observed 84 primary care clinic visits among patients with common health concerns to determine when and how physicians and patients interrupt each other during consultations. Almost 83% of interruptions were cooperative, which preserved the content and flow of interaction and which, for instance, allowed the physician to establish common ground when a patient sought clarification. The researchers also found that the type of interruption was predicted by role, gender and phase of consultation. While male doctors were more likely to make an intrusive interruption than female doctors, male patients were less likely to make an intrusive interruption than female patients. Patients’ interruptions were more likely to be intrusive than physicians’ in the problem presentation phase of the appointment.
A Quantitative Analysis of Physicians’ and Patients’ Interruptions in Clinical Practice
Ilona Plug, MA, Msc, et al
Centre for Language Studies, Radboud University, Nijmegen, The Netherlands
More Effective Facilitators Can Support Primary Care Organizational Change
Researchers analyzed data from a large-scale quality improvement initiative to determine which strategies for organizational change had the most impact on clinical outcomes. One hundred and sixty-two facilitators were assigned to 1,630 small- to medium-sized primary care practices across 12 states to support the implementation of operational improvements aimed at improving cardiovascular disease outcomes.
High-performing facilitators — defined as facilitators who had 75% or more of their assigned practices show improvement across measured health outcomes — were found to:
- Adapt recommended processes to local clinics
- Address organizational resistance
- Encourage critical thinking
- Promote accountability
- Effectively communicate their role
Effective Facilitator Strategies for Supporting Primary Care Practice Change: A Mixed Methods Study
Shannon M. Sweeney, PhD, MPH, et al
Department of Family Medicine, Oregon Health & Science University, Portland
New Study Addresses Barriers to Telemedicine Use Among Veterans Experiencing Homelessness
An interdisciplinary team of primary care providers implemented a quality improvement project to reduce barriers and increase the use and availability of telehealth consultations for military veterans experiencing homelessness. The team found that standardized video visit workflows, sustained education, and maximizing resources available at the VA proved essential to increasing video visit use. The proportion of video visits among telehealth visits doubled in 16 weeks from 4.8% to 10.3% and continued to increase during the following month (4.8% vs 12.9%).
Facing the Digital Divide: Increasing Video Visits Among Veterans Experiencing Homelessness
Alyson Prince, DNP et al
VA Greater Los Angeles Healthcare System, Los Angeles, California
Researchers Describe Novel Way to Identify Primary Care Workforce to Help Prepare for Future Workforce Needs
Health care stakeholders have long relied upon the American Medical Association’s Masterfile to identify physicians who practice primary care medicine. This approach has proven problematic because the AMA does not differentiate physicians with primary care training from physicians who practice true primary care. As a result, estimates of U.S. primary care capacity are inaccurate, at best. In order to ensure an adequate primary care workforce in the future, stakeholders must use data that accurately reflects which physicians (and other clinical staff) provide primary care. In this new study, researchers point to alternative data that can be used to accurately assess and predict future workforce needs.
Alison N. Huffstetler, MD, et al
Virginia Commonwealth University, Department of Family Medicine and Population Health, Richmond
In the Shadow of COVID-19, A Family Physician Rediscovers His Vocation By Remembering How a Wife Cared for Her Dying Husband
A family physician writes about how the incomprehensible commitment of an estranged wife for her terminally-ill husband recharged his capacity to care for others with what he calls “fathomless mercy.”
Timothy P. Daaleman, MD, MPH
Department of Family Medicine, University of North Carolina at Chapel Hill
Young Pediatrician Balances Meaningful Patient Relationships With Pain and Suffering
An early-career pediatrician reflects on her training to find she must learn to balance patient relationships with the grief she feels when experiencing suffering and loss. The author ponders, “Is there a perfect balance to the humanistic side of medicine? As physicians, where do we draw the line? What is the secret sauce to love your patient, but just not enough to break your heart?”
The Joy and Grief of Knowing Your Patient
Saba Fatima, MD
Kansas University School of Medicine, Wichita
Primary Care Medical Student Honors Traumatic Past With Plans to Return Home to Care for Community in Crisis
In this essay, a fourth-year medical student in training to be a primary care physician writes of her upbringing in a community plagued with poverty, substance abuse and gun violence. As she considered her future career in medicine, uncomfortable questions began to emerge. Where did she want to practice? What did she owe the community she grew up in? How could she balance personal safety with her desire to help the people she now describes as “tenacious, struggling and beautiful”?
Do I Return to the Community That Traumatized Me?
Minna Wybrecht, BA
University of Michigan Medical School, Ann Arbor
Primary Care Professionals Must Unite to Promote Funding, Training and Team Development to Sustain the Profession that Values Patient and Community Health
Two family physicians weigh in on a two-part special report by Thomas Bodenheimer, MD, MPH, published in this edition of the Annals of Family Medicine. Their editorial reinforces the need to address primary care funding shortfalls, lack of training opportunities, increasing patient panel sizes, and overburdened care teams, which impact patients and communities at large. They recommend raising primary care physician payment to match that of subspecialists, and to expand primary care teams to include professionals who can provide mental, emotional and behavioral health services, which are critical to maintaining public health..
It Will Take a Million Primary Care Team Members
John M. Westfall, MD, and Alison Huffstetler, MD
University of Colorado School of Medicine, Denver, and Virginia Commonwealth University, Department of Family Medicine and Population Health, Richmond
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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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