Press Releases

29 - October - 2024 - Annals of Family Medicine: New Publications Highlight the Challenges and Resilience of Health Care Professionals in Conflict Zones: Insights from Israel and the Palestinian Territories

PROVIDENCE, R.I., Oct. 29, 2024 /PRNewswire/ -- Annals of Family Medicine has released five new articles ahead of its November-December 2024 issue, focusing on the role of family physicians working in conflict zones. These publications examine how the Israeli–Palestinian conflict impacts health care professionals and their communities. 

Editorial: "The Human Face of War"

In this editorial, Caroline R. Richardson, MD, editor-in-chief of Annals of Family Medicine, emphasizes the importance of remembering, supporting, and giving voice to health care professionals and their patients who are living and working under horrifying conditions.

Research Brief: "The 2023 Terror Attack on Southern Israel: Well-Being and Burnout Among Health Care Personnel Treating Traumatized Evacuees"

Authored by Dikla Agur Cohen, MD, MSc, and Merav Sudarsky, MD, this study examines the well-being, resilience, and burnout of health care personnel treating severely traumatized evacuees following the Oct. 7, 2023, terrorist attack in southern Israel. This research addresses a crucial gap in understanding personnel's emotional resilience and guiding interventions to enhance well-being and improve patient care quality.

Essay: "We Haven't Even Started Crying Yet: Caring For the Family Under Occupation and War in the Occupied Palestinian Territories"

The current war in Gaza has dramatically worsened conditions in the Occupied Territories of Palestine. A family physician and her team in the southern West Bank describe their challenges and give voice to physicians they interviewed to better understand the professional and personal challenges of living and working during the uncertainty of war. This essay captures the fragmented health care system and resource limitations under occupation and the emotional and physical toll on clinicians and their families striving to maintain care for their communities in the face of the continuous threats of violence with the Gaza war. This article is authored by Beesan Maraqa, MD, MPH; Ameed Taher, MD; Husam Dweik, MS5; Ahmad Abu Hadwan, MS5; and Therese Zink, MD, MPH.

Essay: "Healing Amidst Conflict: The Perspective of an Israeli Family Physician During Wartime"

Dikla Agur Cohen, MD, MSc, reflects on her experience volunteering at a primary care clinic near the Dead Sea following the Oct. 7 attack. This essay highlights the immense responsibilities shouldered by family doctors in providing trauma-informed care and emotional support during times of intense fear and displacement.

Special Report: "Family Medicine in Times of War"

Authored by Jeffrey M. Borkan, MD, PhD, this special report examines the role of family physicians in the Israel–Hamas conflict and other current wars. The report explores how lessons learned from these situations can inform future practices in family medicine and highlights the need for family physicians to be prepared to handle both the immediate and long-term effects of war.

"There are clinicians and staff who risk their lives to show up for work every day, trying to care for their communities—families welcoming new babies, and individual patients just trying to manage their diabetes or get help for their anxiety," Dr. Richardson notes in her editorial, urging readers to remember the "regular people" behind the headlines: clinicians risking their lives daily to care for their communities amid relentless challenges.

24 - September -2024 - Annals of Family Medicine: Blood Pressure Control Intervention Including Remote Monitoring Doubles Success in Underserved Patients with Hypertension

PROVIDENCE, R.I., Sept. 24, 2024 /PRNewswire/ -- A new study published in Annals of Family Medicine, titled "Digital Innovation to Grow Quality Care Through an Interprofessional Care Team (DIG IT) Among Underserved Patients With Hypertension," demonstrates the effectiveness of a digital health intervention in significantly improving blood pressure control among underserved patients. The DIG IT program, which combines remote monitoring with team-based care, more than doubles the success rate in achieving blood pressure goals compared to standard care. 

 
This is a visual abstract showcasing key findings from the study.
This is a visual abstract showcasing key findings from the study.

 

Underserved communities are at higher risk for uncontrolled high blood pressure (hypertension), which can lead to heart disease and higher death rates. To address this, researchers evaluated effectiveness of a remote monitoring program called DIG IT at a Federally Qualified Health Center (FQHC) in Orange County, California. The study focused on patients aged 40 and older with uncontrolled hypertension, comparing 70 patients in the DIG IT program with a historical control group of 70 patients who received standard care without digital tools. Over three months, researchers tracked blood pressure readings and heart disease risk scores in both groups.

 

Key Findings:

  • Patients in the DIG IT program saw their systolic blood pressure drop by an average of 31 points. This is compared to a reduction of just 15 points in the control group. Diastolic blood pressure decreased by 11 points in the DIG IT group, compared to a 5-point reduction in the control group.
  • The program led to a significant reduction in the estimated American College of Cardiology 10-year risk of heart disease. Patients in the DIG IT group showed twice the improvement compared to those in the control group.
  • Nearly 73% of patients in the DIG IT program reached their blood pressure goals within three months, compared to 37% in the control group.

The DIG IT program combined digital blood pressure monitoring, medication management, and an interprofessional care team of family physicians, nurse practitioners, clinical pharmacists, and IT specialists. Patients were loaned digital devices to monitor their blood pressure at home, with readings automatically synced to the clinic's electronic health record (EHR) system. This integration enabled the care team to monitor readings in real time and respond swiftly to elevated levels.

"In our study, clinical pharmacists provided patients with medication optimization through comprehensive medication management under a collaborative practice agreement," the study authors noted. "This allowed primary care clinicians additional time to attend to complicated cases that require in-depth assessments. Tailoring patient-centered care around patients' needs fosters not only interprofessional collaboration, but also shared decision-making between patients and clinicians to achieve positive outcomes."

Lead author Dr. Joyce Lee said, "Findings from this study showed that underserved patients can be empowered effectively in achieving timely targets when they are given the right tools and guidance to thrive. Technology-enabled care can transform how we manage certain chronic diseases for the better."

24-september-2024 - Annals of Family Medicine: Systematic Review Highlights Promise of High-Sensitivity Troponin in Diagnosing Acute Coronary Syndrome in Primary Care Settings

 

PROVIDENCE, R.I., Sept. 24, 2024 /PRNewswire/ -- Findings from a new systematic review, titled "Chest Pain in Primary Care: A Systematic Review of Risk Stratification Tools to Rule Out Acute Coronary Syndrome," published in Annals of Family Medicine, suggest that high-sensitivity troponin tests show promise in diagnosing acute coronary syndrome in primary care settings. However, further validation is required before these tests can be implemented in general practice.

 
This is a visual abstract showcasing key findings from the study.
This is a visual abstract showcasing key findings from the study.

 

Chest pain is a common but challenging symptom for general practitioners to evaluate, as it can be caused by both serious conditions like acute coronary syndrome. This systematic review assessed the effectiveness of available risk stratification tools in helping general practitioners rule out acute coronary syndrome in patients with chest pain.

 

Study Overview

Researchers included 14 studies in the review. They assessed the accuracy of clinical decision rules and troponin point-of-care tests, both conventional and high-sensitivity, regarding acute coronary syndrome and major adverse cardiovascular events. When possible, test characteristics were compared to the unaided clinical judgment of general practitioners. The studies involved adult patients presenting with chest pain, aiming to identify which tools could most effectively help general practitioners rule out acute coronary syndrome in primary care settings.

Key Findings

  • Clinical decision rules: While some of the clinical decision rules without troponin improved safety, none consistently outperformed unaided general practitioner judgment in ruling out acute coronary syndrome.
  • Conventional troponin: Conventional troponin as a standalone test did not meet the desired diagnostic accuracy, making them less reliable in primary care settings (sensitivity <70%).
  • High-sensitivity troponin: High-sensitivity troponin tests showed the highest diagnostic accuracy, with sensitivities of 83.3% to 100% and negative predictive values of 98.8% to 100%. However, further validation in primary care is needed before recommending widespread use.

Accurately diagnosing acute coronary syndrome is critical to prevent unnecessary hospital referrals, reducing health care costs, and ensuring timely treatment. The authors noted, "Finding a tool that exceeds the GP's accuracy might be challenging, since unaided clinical judgment is already reasonably good with a sensitivity of 75% to 100% and specificity of 18% to 79%. Best diagnostic accuracy might therefore be achieved by combining the GP's risk assessment with a stratification tool instead of using risk stratification tools as standalone tests."

 

28-August-2024 - Annals of Family Medicine: New Research Reveals Major Disconnect Between Patient Expectations and Experiences in Long COVID Care

 

PROVIDENCE, R.I., Aug. 28, 2024 /PRNewswire/ -- As post-COVID-19 Conditions or "Long COVID" continues to challenge millions of Americans, a new study published in Annals of Family Medicine reveals that patients frequently face barriers and frustrations when seeking care. The study, titled "Challenges in Receiving Long COVID Care: A Qualitative Interview Study Among Primary Care Patients About Their Expectations and Experiences," shows a major disconnect between the expectations of long-COVID patients and the realities of the U.S. health care system.

Between 2022 and 2023, researchers conducted 20 interviews with primary care patients from a long COVID triage clinic at the University of Utah, analyzing 19 of these interviews. Participants averaged 54 years old, and 53% were female. Most participants were first infected with COVID-19 in 2020 (32%) or 2021 (47%). In this qualitative study, authors sampled exclusively primary care patients in the U.S., offering unique insights into the challenges these patients face.

Key Findings:

Patient Expectations: Participants described two main categories of expectations: those for their practitioners and those for treatment. Patients expected their primary care practitioners to be knowledgeable about post-COVID Conditions and attentive to their individual conditions. For treatment expectations, patients expected to engage in collaborative processes with their practitioner.

Patient Experiences: The study revealed two types of patient experiences. Positive interactions with practitioners occurred when providers were honest and validating, while negative experiences were marked by patients feeling dismissed or discouraged. Additionally, patients described significant challenges in navigating the fragmented U.S. health care system, particularly in coordinating care, treatment, testing, and payment.

"While many systemic barriers are largely out of providers' control, validation and continuous support from PCPs, alongside coordinated care and communication among the care team, might improve care quality for patients with long COVID," the authors write.

Despite facing numerous barriers and frustrations, patients expressed a strong desire to collaborate with their health care providers to improve treatment outcomes. Primary care practitioners and other health care professionals can better align patients' experiences with their expectations by listening to their concerns, validating their symptoms, and advocating for their needs. These actions are essential for delivering patient-centered, effective care and ultimately improving health outcomes for long-COVID patients.

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28-August-2024 - Annals of Family Medicine: Men At Risk for HIV Who Use PrEP Have Higher Rates of Gonorrhea Compared With Those Who Do Not Use PrEP

PROVIDENCE, R.I., Aug. 28, 2024 /PRNewswire/ -- A new study published in Annals of Family Medicine has found an increased rate of gonorrhea incidence among gay, bisexual, and other men who have sex with men (GBM) in Ontario who use pre-exposure prophylaxis (PrEP) compared to non-users. Titled "Self-Reported PrEP Use and Risk of Bacterial STIs Among Ontarian Men Who Are Gay or Bisexual or Have Sex With Men," this research sheds light on the complex relationship between PrEP use and the incidence of bacterial sexually transmitted infections (STIs). The study emphasizes the need for comprehensive sexual health services for those taking PrEP.

PrEP is an antiviral treatment that suppresses the HIV virus but has no effect on bacterial infections such as gonorrhea, chlamydia, and syphilis. While there is concern that PrEP use may be associated with an increase in bacterial sexually transmitted infections (STIs) among GBM, the reasons for this association are complex. This study aimed to explore the relationship between PrEP use and the rates of bacterial sexually transmitted infections over time.

Researchers used data from the iCruise Study, an online longitudinal study conducted between July 2017 and April 2018. The study included 659 randomly selected GBM participants who completed weekly diary surveys over a three-month period. The survey tracked instances of chlamydia, gonorrhea, and syphilis infections, measuring infection rates as the number of infections per 100 months of participant observation time.

Key Findings:

A total of 535 participants were included in the final analysis, contributing 1,623.5 person-months of data. Among these participants, 13.1% (70 participants) reported using PrEP during the study period.

  • PrEP use was linked to a higher rate of gonorrhea: The initial analysis suggested that the rate of gonorrhea among PrEP users was four times higher than among non-users, with an incidence rate ratio of 4.00 (95% confidence interval: 1.67–9.58). After conducting a bias analysis to account for potential inaccuracies in self-reported data, the association remained, though it was somewhat less pronounced. The adjusted analysis showed that rates of gonorrhea were still higher among PrEP users, with a median incidence rate ratio of 2.36 (simulation interval: 1.08–5.06).
     
  • There was no significant increase in the rates of chlamydia or syphilis among PrEP users.

Individuals who choose to take PrEP are at higher risk for gonorrhea and should be regularly tested and treated to manage this risk effectively. The findings of this study highlight the importance of investing in sexually transmitted infection testing, risk reduction, secondary prevention measures such as Doxycycline Post-Exposure Prophylaxis (a preventive treatment to reduce the risk of bacterial STIs after potential exposure), surveillance, and partner management alongside PrEP to reduce bacterial STI transmission effectively.  This approach is necessary regardless of whether the increased risk is due to pre-existing factors or potential behavior changes associated with PrEP use. 

23-July-2024 - Annals of Family Medicine: New COVID-19 Research Studies Provide Latest Insights into Post-COVID Conditions, Potential Treatment, and Impact on Primary Care and Telehealth Utilization

PROVIDENCE, R.I., July 23, 2024 /PRNewswire/ -- The latest issue of Annals of Family Medicine features three important studies shedding light on various aspects of COVID-19, from potential treatment to the prevalence of post-COVID conditions to the impact on primary care and telehealth utilization. These studies offer critical insights for health care professionals and policymakers as they navigate the ongoing challenges posed by the pandemic.

Study 1: National Study Shows Moderate Burden of Post-COVID Conditions in Primary Care

 
This systematic review aimed to summarize published evidence on the efficacy, effectiveness, and safety of nirmatrelvir/ritonavir for COVID-19 and assess the robustness of the evidence from randomized controlled trials and real-world
This systematic review aimed to summarize published evidence on the efficacy, effectiveness, and safety of nirmatrelvir/ritonavir for COVID-19 and assess the robustness of the evidence from randomized controlled trials and real-world
The COVID-19 pandemic not only exacerbated existing disparities in health care in general but likely worsened disparities in access to primary care. This study aimed to quantify the nationwide decrease in primary care visits and increase in telehealth utilization during the pandemic and explore whether certain groups of patients were disproportionately affected.
The COVID-19 pandemic not only exacerbated existing disparities in health care in general but likely worsened disparities in access to primary care. This study aimed to quantify the nationwide decrease in primary care visits and increase in telehealth utilization during the pandemic and explore whether certain groups of patients were disproportionately affected.
This study examines the prevalence of post-COVID conditions among adult patients diagnosed with COVID-19 across the United States from 2020-2021, comparing them to those with influenza-like illness and those who had regular wellness visits but no COVID-19.
This study examines the prevalence of post-COVID conditions among adult patients diagnosed with COVID-19 across the United States from 2020-2021, comparing them to those with influenza-like illness and those who had regular wellness visits but no COVID-19.

 

This study was conducted by researchers from Stanford University, the CDC, the American Board of Family Medicine Foundation, and the Institute for Healthcare Policy and Innovation at the University of Michigan. Titled "Post-COVID Conditions in US Primary Care: A PRIME Registry Comparison of Patients With COVID-19, Influenza-Like Illness, and Wellness Visits," the study examined the prevalence of post-COVID conditions among adult patients diagnosed with COVID-19, comparing them to those with influenza-like illness and those who had regular wellness visits but no COVID-19. The American Family Cohort, a unique and geographically diverse research dataset derived from the American Board of Family Medicine's PRIME Registry, was used to examine data from the years 2018 to 2021.

Main Results:

  • Patients with COVID-19 had a higher prevalence of breathing difficulties, type 2 diabetes, fatigue, and sleep disturbances compared to those with influenza-like illness. However, all prevalence differences were less than 3%.
     
  • There were no significant differences in the monthly increase of new health conditions between patients with COVID-19 and those with influenza-like illness.
     
  • Patients with COVID-19 had a higher prevalence of breathing difficulties and type 2 diabetes compared to patients who had regular wellness visits but did not contract COVID-19.

Understanding the types and prevalence of post-COVID conditions helps health care professionals diagnose and treat these conditions more effectively, potentially reducing long-term health issues and improving patient care.

Study 2: Nirmatrelvir/Ritonavir Shows Potential in Reducing COVID-19 Hospitalizations

The systematic review, titled "Nirmatrelvir/Ritonavir Regimen for Mild/Moderately Severe COVID-19: A Rapid Review With Meta-Analysis and Trial Sequential Analysis," aimed to evaluate the efficacy, effectiveness, and safety of the antiviral drug combination nirmatrelvir/ritonavir for treating mild to moderately severe COVID-19 in non-hospitalized patients at risk of worsening symptoms, hospitalization, and death. Researchers examined both randomized controlled trials and real-world observational studies.

Main Results:

  • Randomized Controlled Trials and Real-World Studies: Nirmatrelvir/ritonavir significantly reduced hospitalizations.
  • Real-World Studies: Nirmatrelvir/ritonavir significantly reduced all-cause mortality.
  • Randomized Controlled Trials: There were no significant differences in reducing worsening severity, viral clearance, adverse events, serious adverse events, or all-cause mortality, although trial sequential analysis suggested that the current total sample sizes for these outcomes were not enough for conclusions to be drawn.

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The nirmatrelvir/ritonavir regimen reduced COVID-19 hospitalizations with mild to moderately severe COVID-19. The data on all-cause mortality and other secondary outcomes is mixed.

Study 3: Pandemic's Impact on Primary Care: Significant Drop in Visits and Uneven Telehealth Use Across Patient Groups

This study, titled "The Disproportionate Impact of Primary Care Disruption and Telehealth Utilization During COVID-19,"aimed to quantify the nationwide decline in primary care visits and the increase in telehealth utilization and explore the impact on different patient groups. Primary care electronic health record data from the American Family Cohort was used to examine three outcomes from March 2019 to March 2021. Researchers looked at the percentage change in total visit volume, change in in-person visit volume, and telehealth conversion ratio (how much care was delivered via telehealth, defined as the number of pandemic telehealth visits divided by the total number of pre-pandemic visits).

Main Results:

  • The primary sample included 1,652,871 patients with 8,833,434 visits from 408 practices and 2,328 clinicians.
  • During the pandemic, decreases of 7% in total and 17% in in-person visit volume were observed, as well as a 10% telehealth conversion ratio (defined as the number of pandemic telehealth visits divided by the total number of prepandemic visits)
  • Pediatric and Asian patients, as well as those with comorbidities, experienced the largest declines in visit volume, while telehealth usage was highest among Hispanic patients and those in urban areas.

These findings underscore the need to enhance telehealth infrastructure and address barriers in rural and underserved areas to ensure equitable access to care during future disruptions. The findings also emphasize the importance of maintaining primary care access during future disruptions to prevent long-term health consequences and exacerbation of existing health care disparities.

23-July-2024 - Annals of Family Medicine: Structural Racism in Newborn Drug Testing: New Study Highlights Disparities and Calls for Policy Changes 

PROVIDENCE, R.I. — New research published in the latest issue of Annals of Family Medicine provides greater insights into racial disparities in newborn drug testing practices that disproportionately impact Black birthing parents and their newborns. The study, conducted by researchers at the University of Michigan, provides a critical examination of how structural racism influences these inequities and calls for urgent policy changes to address the issue.

The qualitative study, titled "Structural Racism in Newborn Drug Testing: Perspectives of Health Care and Child Protective Services Professionals" explores the knowledge, attitudes, and experiences of health care and Child Protective Services (CPS) professionals regarding newborn drug testing practices.

Key findings include:

  • Levels of racism beyond the hospital contributed to higher rates of drug testing of Black newborns.
  • Variations in hospital policies lead to racialized application of state laws and subsequent CPS reporting.
  • Health care professionals’ knowledge of the benefits and harms of CPS reporting on Black families influenced their testing decision making.

Health care professionals recognized structural racism as a driver of disproportionate newborn drug testing. However, their beliefs, lack of knowledge, and skill limitations were barriers to dismantling power structures impeding systems-level change. Reflecting on the results of their study, the authors urge the need for institutional and policy changes to shift the focus from biologic testing to a more holistic approach that supports both the birthing parent and the child. Recommendations include implementing family-centered substance use treatment and enacting state and federal policy reforms to prevent unnecessary CPS reporting when there is no evidence of child abuse or neglect. Putting their recommendations into practice, study authors Dr. Shetty and Dr. Oshman are currently advocating for state policy change as part of a coalition named safe mi. Safe mi is a coalition of academic, legal, health care experts and researchers advocating for substance use treatment for pregnant people that centers families, eliminates health disparities, and connects parents to systems of support. Safe mi aims to reform reporting laws to shift focus to treatment.

An accompanying editorial, “Stop Testing Black Babies!,” featuring perspectives from physicians with expertise in racism, trained in OB/GYN, urogynecology, medicine/pediatrics, allergy/immunology and family medicine, underscores the importance of addressing structural racism in newborn drug testing. The editorialists argue that ingrained stereotypes and inconsistent hospital policies lead to biased testing and harmful referrals to CPS. They advocate for the adoption of maternal questionnaires over newborn drug testing and the establishment of clear, consistent policies to ensure equitable treatment.

The editorial also highlights the Substance Abuse Disorder and Family Engagement (SAFE) in Recovery Act as a legislative effort to support families and reduce unnecessary separations. The editorialists call on health professionals and policymakers to recognize and address the biases in newborn drug testing practices to restore trust between Black families and health systems.

To hear more from the researchers about this important study, tune in to the latest episode of the Annals of Family Medicine Podcast where lead authors Dr. Carol Shetty and Dr. Lauren Oshman discuss this study in detail. Listen to the podcast episode here.

Additional Resources:

28-May-2024 - Annals of Family Medicine: New Articles Highlight Team-Based Innovations That May Reduce Burnout and Improve Primary Care Efficiency 

PROVIDENCE, R.I. — Annals of Family Medicine is excited to announce the publication of three innovative articles in the latest May/June 2024 issue that introduce team-based approaches to improve primary care efficiency and address physician burnout, a critical issue impacting health care quality and delivery. These articles present novel strategies in primary care and academic settings that aim to improve workflow and efficiency while potentially mitigating burnout.

Team-Based Management of High-Priority Messages Shown to Reduce Physician Burnout

In this article, a clinical team from the University of Michigan's Department of Family Medicine describes a system to manage high-priority in-basket messages collaboratively. Physicians shared inbox access and rotated the workload, reportedly reducing feelings of burnout. This approach aims to ensure urgent patient concerns are promptly addressed without overwhelming individual physicians.

Utilizing Medical Assistants to Manage Patient Portal Messages Shown to Support Practice and Physician Efficiency

Dr. Jennifer N. Lee, MD, and her team at Penn Family Care, part of the Department of Family Medicine and Community Health at Penn Medicine, introduced a model where certified medical assistants triage and distribute incoming patient messages. This initiative reduced the number of messages sent directly to primary care physicians by 40%, improving practice and clinician efficiency. Medical assistants maintained high response rates, potentially alleviating the burden on physicians and supporting a team-based care model.

Harmonizing Academic Missions in Family Medicine: One Department’s Experience

This theory article presents a case example from the University of Minnesota Medical School, where the Department of Family Medicine and Community Health created a shared vision of harmonized missions. Historically, faculty had experienced care, education, and research missions as separate and isolated from each other, with ongoing tension as they were pulled in different directions by competing tasks and interests. The article highlights the department’s specific strategies for harmonizing missions, such as creating a harmonization group and applying simple rules for mission alignment. This approach improved faculty well-being and increased scholarly output, providing a model for a learning and adaptive health system.

Why It Matters

Physician burnout is a critical issue affecting healthcare delivery, patient outcomes, and clinician well-being. These articles emphasize the importance of team-based care, workflow innovations, and systematic changes. Innovations that optimize team-based care may achieve both improved clinical effectiveness and reduce physician burnout.

Articles Cited:

Team-Based Management of High-Priority In-Basket Messages

Gregory Shumer, MD, MHSA, Anup Bhandiwad, MD, MS, John Holkeboer, Lauren Marshall, MPH, MPP

Utilizing Medical Assistants to Manage Patient Portal Messages

Jennifer N. Lee, MD, Laura Kurash, MD, Max Yang, Joseph Teel, MD, FAAFP

Harmonizing the Tripartite Mission in Academic Family Medicine: A Longitudinal Case Example 

C. J. Peek, PhD, Michele Allen, Katie A. Loth, Peter G. Harper, Casey Martin, James T. Pacala, Angela Buffington, Jerica M. Berge, PhD, MPH, LMFT, CFLE

25-March-2024 - Annals of Family Medicine: New Research Demonstrates That a Highly Successful Electronic Health Record (EHR) Optimization Can Be Conducted at the Departmental Level

Providence, R.I. –  A new study published in the March/April 2024 issue of Annals of Family Medicine shows researchers at the Department of Family and Community Health at Joan C. Edwards School of Medicine, Marshall University, alongside the institution's Information Technology team, have made substantial strides in Electronic Health Record (EHR) optimization. This collaborative effort not only showcases a successful department-level quality improvement process but also sets the stage for health care systems nationwide to reimagine their relationship with technology.

The study, "Optimization of Electronic Health Record Usability Through a Department-Led Quality Improvement Process," details a four-month, department-wide project conducted by members of Marshall University’s Department of Family and Community Health with their school’s Information Technology (IT) team to improve the usage of EHR software. Through the formation of eight multidisciplinary workgroups focusing on specific workflow problems, the department successfully identified and implemented 124 EHR-related optimizations. Each optimization was tracked under one of four categories: Accommodation, Discovery, Creation, and Modification — with just over 20% being Creation or Modification optimizations under IT's domain. Nearly 80% did not require IT fixes, with 43.5% identified as Discovery optimizations—solutions that were already in the EHR but of which users were unaware.

 

The widespread adoption of EHRs was expected to improve communication among clinical and administrative staff and ensure the standardization, quality, and safety of care. EHR usage, though, often comes with increased administrative burdens, negative clinician emotions, attenuated workflow communication, clinician burnout, and medical errors. This study addresses some of these challenges, demonstrating that some major usability improvements are attainable with sufficient knowledge of the EHR interface and ongoing collaboration between users and IT professionals.

 

Complementing this study, an editorial from the Warren Alpert Medical School of Brown University, "Friend or Foe? Helping Health Care Leadership Reimagine a Healthy EHR Relationship," underscores the need for a radical shift in health care systems' approach to technology. Highlighting successful technological implementations in other industries and within health care itself, such as the Department of Veterans Affairs’ VistA system, the editorial calls for hospital leadership to reflect on their institutions’ relationship with EHRs and to view technology as a core competency.

 

The study by Adam M. Franks, MD, and colleagues, with accompanying editorial insights from Meylakh Barshay, AB, a medical student at Brown University, and Caroline R. Richardson, MD, who serves as the editor for the Annals of Family Medicine, advocates for a holistic and integrated approach to EHR usage. By prioritizing user training and technological investment, health care systems can transform EHRs from sources of frustration into powerful tools for enhancing care delivery and clinician well-being.

 

Articles cited:

Optimization of Electronic Health Record Usability through a Department-Led Quality Improvement Process Adam M. Franks, MD, Charles Clements, MD, Tammy Bannister, MD Adrienne Mays-Kingston, MD Ashley Beaty, MSN, RN-BC Alperen Korkmaz, Med, John A. Parker Jr, MD Stephen M. Petrany, MD

 

25-January-2024 - Annals of Family Medicine: The risk of death during or shortly after childbirth is higher for people in the US than in other developed countries. Researchers studied implentation of an innovative program to connect high-risk postpartum patients to primary care providers to improve care and reduce risk.

Providence, R.I. –  In a new article published in Annals of Family Medicine, researchers assessed a quality improvement learning collaborative’s (QILC) intervention to link high-risk prenatal patients with primary care. The aims of the study were twofold: to measure the impact of the intervention on postpartum and primary care utilization for high-risk prenatal patients and to explore the Federally Qualified Health Center (FQHC) participants’ experiences of working with a QI collaborative.

Using information from patient’s health records, 19 clinics within the six participating FQHCs identified high-risk prenatal patients who delivered between January and June 2021. High-risk conditions included pregestational diabetes, gestational diabetes, gestational and chronic hypertension, and depression. The QI intervention implemented a patient registry and conducted direct patient outreach for six months after delivery to connect patients to primary care.

The primary outcome was the change in proportion of high-risk patients with a documented primary care visit within six months postpartum, while the secondary outcome was the change in proportion of patients with a documented postpartum visit within six weeks post-delivery. The former measure increased from 25% to 72%, while the latter went from 83% up to 91%. At the conclusion of the intervention, all six FQHCs had successfully implemented processes for coordinating their maternal and primary care. However, post-implementation, only five chose to continue following the new processes they had developed.

Maternal mortality rates continue to rise across the United States, with non-Hispanic Black birthing people being disproportionately affected—in 2020, they were almost three times more likely to die than non-Hispanic White birthing people. As many deaths occur postpartum, transitioning from prenatal to primary care and remaining engaged in care throughout the first year are critical preventive steps.

The researchers found that, by both quantitative and qualitative measures, FQHC participation in this QILC intervention significantly improved postpartum and primary care utilization for high-risk prenatal patients, albeit with challenges resulting from institutional and structural factors. Greater resources are necessary to ensure sustainability.

An accompanying editorial argues that “future studies must include patient voices as these are the most often overlooked and the most important in the conversation. It is the voices of patients that will illuminate further pragmatic pathways to address the maternal health crisis in the United States and identify ways to improve health outcomes for high-risk pregnant people and their families in the long-term.”

Articles cited:

A Mixed Methods Evaluation of a Quality Improvement Model to Optimize Perinatal and Primary Care in the Community Health Setting. Jena Wallander Gemkow, MPH, BSN, RN, Ashlee Van Schyndel, MPH, Renee M. Odom, MPH, Ananya Stoller, MPH, PMP, Lisa Masinter, MD, MPH, MS, Ta-Yun Yang, MS, Patricia A. Lee King, PhD, MSW, Abigail C. Holicky, MPH and Arden Handler, DrPH, MPH

From Cradle to Grave: Health During Pregnancy and Over a Lifetime. Carolyn F. Pearce and Mary Beth Sutter

28-November-2023 - Annals of Family Medicine: Papers Explore how Technology is Changing Medical Practice and how Doctors are Adapting

Providence, R.I. – From the ability to conduct clinical visits online to utilizing artificial intelligence to effectively diagnose patients, technology has changed how all doctors practice medicine. One published paper in the November/December issue of Annals of Family Medicine explains how AI-driven technology presents new opportunities for more effective patient care while a second paper describes the interplay between fulfillment of basic psychological needs at work and technology use in maintaining clinician well-being.  

In a six-month observational study and corresponding paper titled, “Home Monitoring of Asthma Exacerbations in Children and Adults using AI-Aided Stethoscope,” researchers examined the use of artificial intelligence on 149 home-monitored asthma patients of various ages in Poland. They first identified the critical measurable symptoms of asthma exacerbation. They then queried to what extent an AI-aided home stethoscope could support detection of asthma exacerbations, especially in young children.

The researchers used standard certified medical devices to take measures of certain asthma symptoms (pulse oximeters for peripheral capillary oxygen saturation and peak flow meters for expiratory flow) in study participants over 5 years old.

For more subjective, auditory symptoms, a Conformité Européenne-certified StethoMe, an AI-based home stethoscope, recorded sounds from standard chest points of all study participants and transferred the sound files to a cell phone app. The recordings were automatically analyzed by an AI module and then generated results (pathological sound intensities, heart rate, respiratory rate, inspiration-to-expiration duration ratio), which were displayed in the app.

Physicians analyzed all data via an online platform to identify exacerbation occurrences. Ultimately, results suggest that while taking multiple measures is preferable, AI analysis of home stethoscope recordings alone can efficiently detect asthma exacerbation in patients of all ages, including children under 5 years old.

The researchers concluded that the StethoMe can be a useful tool for optimizing patient-doctor collaboration via telemedicine. For children under 5, the authors argue that it could significantly facilitate asthma monitoring by their parents and caregivers. 

In a separate study, Canadian researchers examined how virtual care during the COVID-19 pandemic has impacted primary doctors’ basic psychological needs and subjective well-being. Their paper is titled, “Family Physician Motivation and Well-Being in the Digital Era.”

The team examined how autonomous (vs. controlled) motivation among family physicians impacted their subjective well-being when shifting to virtual care and whether satisfaction vs. frustration of their basic psychological needs for autonomy, competence, and relatedness, mediated that relationship. The researchers gathered qualitative data by surveying 156 family physicians in Alberta, Canada. The questionnaire measured motivational quality towards using virtual care, workplace psychological need fulfillment, and subjective well-being.

The authors found that primary care doctors who felt that they had little choice in using virtual care had lower well-being, and frustration of their workplace needs for autonomy, competence, and relatedness, fully mediated that relationship. Conversely, basic workplace psychological need satisfaction -- though not autonomous motivation towards using virtual care -- was associated with higher well-being.

The findings suggest that when family physicians’ motivation towards using virtual care is less self-determined, it will lead to poorer subjective well-being because of basic psychological need frustration. 

Articles cited:

Home Monitoring of Asthma Exacerbations in Children and Adults Using AI-aided Stethoscope. Kamil Janeczek, Andrzej Emeryk, Eric Derom, Barbara Kuźnar-Kamińska, Anna Zelent, Mateusz Łukaszyk, Tomasz Grzywalski, Anna Pastusiak, Adam Biniakowski, Krzysztof Szarzyński, Dick Botteldooren, Jędrzej Kociński, Honotara Hafke-Dys (Link to come)

Family Physician Motivation and Well-Being in the Digital Era. Adam Neufeld, Oksana Babenko, Vishal Bhella

4-October-2023 - Annals of Family Medicine: International Group of Research Experts Establish Checklist Detailing Key Consensus Reporting Items for Primary Care Studies

Providence, R.I. – An international group of leading primary care researchers has developed the first research reporting guideline for primary care: Consensus Reporting Items for Studies in Primary Care (CRISP) Checklist. Built by and for the international, interdisciplinary community, it addresses the unique perspectives, approaches and research concerns of primary care. The checklist and the CRISP Statement appear as an online-first paper as part of the November/December 2023 issue of Annals of Family Medicine.

The CRISP Checklist outlines 24 items that describe the research team, patients, study participants, health conditions, clinical encounters, care teams, interventions, study measures, care settings, and implementation of findings/results in primary care. The goal is to improve the quality, usefulness and dissemination of reports of primary care research findings and results. The checklist aims to aid the application of study results to improve the process of care and health outcomes for patients and communities.

The CRISP Working Group reviewed the literature on primary care research reporting and the available guidelines focused on specific study designs They conducted a series of online surveys to assess the needs of a broad range of primary care researchers, practitioners, journal editors,  patients, and other research users worldwide. At each stage, the group refined suggestions for potential reporting items. Finally, they conducted a Delphi study to develop consensus on essential items for reports of primary care research, which are summarized in the CRISP Checklist.

A pilot test with researchers, authors, reviewers and patients demonstrated the usefulness of the checklist. The authors assert that the checklist is flexible to fit the wide variety of methods, study designs and topics in primary care research. A supplemental Explanation & Example Guide describes use of the checklist items.

The CRISP Checklist and guidelines have  been officially endorsed by the North American Primary Care Research Group (NAPCRG) and the World Organization of Family Doctors (WONCA).

The CRISP Working Group considers the checklist a living document that will evolve as more people use and test it. They welcome feedback through the CRISP website at www.crisp-pc.org.

Article Cited: Improving the Reporting of Primary Care Research: Consensus Reporting Items for Studies in Primary Care - the CRISP Statement, William R. Phillips, Elizabeth Sturgiss, Paul Glasziou, Tim olde Hartman, Aaron M. Orkin, Pallavi Prathivadi, Joanne Reeve, Grant M. Russell and Chris van Weel

18-September-2023 - Annals of Family Medicine: Researchers Describe Clinical Experiences of Transgender People, Recommend Strategies to Reduce Negative Health Consequences

Providence, R.I. -- Many transgender people experience mistreatment in healthcare encounters, which can include harassment, assault and denial of care. A new paper published in the September/October 2023 issue of Annals of Family Medicine describes the clinical experiences of transgender people. Study authors also present short-term and long-term strategies towards reducing oppression and its health consequences among this patient population.

“Understanding the experiences of transgender people when their gender identities are known to clinicians and the reasons transgender people may share, modify, or withhold information could yield important clinical insights,” the authors write.

Researchers from the Yale Cancer Center, Brown University, and the University of Rochester Medical Center held seven qualitative focus groups with 30 transgender adults living in North America. They identified four themes: 1) transgender people often perceive clinicians’ questions as voyeuristic, stigmatizing, or self-protective; 2) patients describe being pathologized, denied or given substandard care, or harmed when clinicians learned they are transgender; 3) transgender people frequently choose between risking stigma when sharing information and risking ineffective clinical problem-solving if clinicians do not have all the information about their medical histories; and 4) improving the safety of transgender people is difficult in the context of contemporary medical systems.

The authors conclude that transgender people often must choose between stigma and potentially suboptimal care. Given this, the authors recommend that family medicine clinicians 1) ensure that their questions are medically relevant and explain their medical relevance to patients; 2) avoid putting information in patients’ EHR that may be used to stigmatize them; 3) advocate for patients who are stigmatized by other clinicians; and 4) shift the medical culture by ensuring formal curriculum, guidelines, and patient-facing forms and documents are inclusive of transgender people.

Article Cited: Transgender People’s Experiences Sharing Information with Clinicians: A Focus Group-Based Qualitative Study. Ash B. Alpert, Jamie E. Mehringer, Sunshine J. Orta, Tresne Hernandez, Emile Redwood, Lexis Rivers, Charlie Manzano, Roman Ruddick, Spencer Adams, Jae Sevelius, Emma Belanger, Don Operario, Jennifer J. Griggs

Related research in the September/October issue of Annals of Family Medicine:

Erythrocytosis in Gender Affirming Care With Testosterone. Alana Tova Porat, Meghan Ellwood, Marisa Rodina, Terence Rustia, Shokoufeh Dianat.

From Medicalization to Empowerment: New Horizons in Transgender Care. Mary-Frances E. Hall and Daphna Strousma. 

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25-July-2023 - Annals of Family  Medicine: Papers illustrate ways in which federal and insurance policies may negatively influence primary care practice

Ann Arbor, Mich. -- Two papers published in the July/August issue of Annals of Family Medicine address federal policy impact on Family Medicine practice. The first documents differences in how federal medical school loan repayment programs support doctors who want to practice in rural and underserved areas. The second describes the impact of differences in insurance reimbursement rates for identical care based on specialty and the implications of these differences on patient access to care.

Medical school debt repayment programs’ influence on family medicine practice

With the average medical school debt soaring to $200,000 over the last few decades, the escalating financial burden is driving concerns that medical students may opt out of lower-pay but high-value public service careers in Federally Qualified Health Centers (FQHCs), rural health clinics, and the Indian Health Service. Loan repayment programs — like the Public Service Loan Forgiveness (PSLF) program and the National Health Service Corps (NHSC) — play a vital role in facilitating the entry of aspiring doctors into the healthcare workforce by alleviating the burden of high educational costs.

Researchers from the American Board of Family Medicine (ABFM) and the University of Minnesota Medical School conducted a study to determine how the background of family doctors, particularly those from historically underrepresented groups, influenced their choice of medical school loan repayment programs and how this, in turn,  impacted the care they provide to patients.

By analyzing data from over 10,000 ABFM National Graduate Survey respondents, the authors examined differences in program participation, participant demographics, scope of practice, and the likelihood of serving medically underserved or rural populations. 

The study revealed a significant increase in participation in the PSLF program between 2016 and 2020, while participation in the NHSC program remained static. The authors note that heavily-indebted early career physicians are strongly attracted to PSLF because of the possibility of unlimited forgiveness as a debt mitigation strategy. Since an estimated 68% of health system employers qualify as non-profit for PSLF purposes, the program is broadly available to medical graduates regardless of practice specialty, geographic location, or practice pattern.

Physicians enrolled in the NHSC program were more likely to come from underrepresented groups; exhibited a wider scope of practice; and were more inclined to practice in rural areas (23.29% compared to 10.84% in PSLF). They also were more likely to practice in areas designated as Health Professional Shortage Areas (12.5% compared to 3.70% in PSLF), serving medically underserved populations (82.17% compared to 24.22% in PSLF).

The analysis conducted in this study suggests that PSLF may be less effective in supporting family physicians from underrepresented backgrounds and may also be less helpful in promoting a broader scope of practice or directing physicians to underserved settings compared to service-based loan repayment programs like NHSC. 

“These findings raise the question of whether the PSLF repayment mechanism may provide more support to demographically overrepresented groups than to those who are underrepresented in medicine amidst national calls to increase their inclusion in the physician workforce,” the authors write. “In a nation where a disproportionately low share of medical students hail from rural backgrounds and only 7% of physicians identify as Black or Hispanic/Latino, it is critically important to understand the contributions of medical education debt reduction to addressing these equity gaps.”

Under-funding family doctors for providing commensurate care

In a second paper, researchers investigated the reimbursement rates for HPV vaccine costs – the costliest of all routinely recommended pediatric vaccines -- among various medical practitioners, including pediatricians, family doctors, internal medicine doctors, and nurse practitioners. The team also examined whether the reimbursement amounts were associated with the number of HPV vaccine doses administered by these healthcare workers. They argue that adequate cost reimbursement by third-party payers is a critical enabling factor for providers to continue offering the HPV vaccine.

The study analyzed 2017-2018 data from 34,247 practitioners and found family physicians had on average the lowest net returns per dose ($0.34) and the lowest reimbursement rate at $211.33, while pediatricians had on average the highest returns ($5.08) and the highest reimbursement rate at $216.07. Average reimbursement rates for internists were $212.97; nurse practitioners at $212.91; and 'other' providers at $213.29.

Despite the low reimbursement rates, family practitioners have the second highest volume of HPV vaccination encounters after pediatricians. This presents financial and operational challenges for family doctors to stock vaccines.

The researchers also observed that a one-dollar increase in return was associated with a slight increase in HPV vaccine doses administered, particularly among family physicians (0.08% per dollar).

“While it may not be possible to increase reimbursement to the American Association of Pediatrics-recommended level ($263.74, i.e., a net return of +$40), a reasonable increase that can cover direct and indirect expenses (acquisition cost, storage cost, personnel cost for monitoring inventory, insurance, wastage, and lost opportunity costs) will reduce the financial strain on non-pediatric providers, encouraging them to stock and offer the HPV vaccine at their clinics,” the authors write.

Articles cited:

Service-Based Student Loan Repayment Program Impact on the Primary Care Workforce. Caitlin S. Davis, MD, MSc, Peter Meyers, MD, MPH, Andrew W. Bazemore, MD, MPH, and Lars E. Peterson, MD, PhD

Reimbursement for HPV Vaccine Cost in the Private Sector: A Comparison Across Specialties. Kalyani Sonawane; Yenan Zhu, MS; Yueh-Yun Lin, MS, Ruosha Li, PhD, Cara He, BS; David R Lairson, PhD, Ashish A Deshmukh, PhD, MPH

27-April-2023 - Annals of Family Medicine: Two Papers Describe How Developing Systems and Enhancing Education for Mifepristone Use Can Lead to Greater Abortion Medication Access

Dateline, 4/27/2023, Ann Arbor, MI

Media Contact: Adrieanna Norse, anorse@aafp.org

With increased national focus on availability of mifepristone, one of two drugs used for medical abortion, two new papers in the Annals of Family Medicine explore clinical innovations used by family doctors to increase access to the drug in the primary care setting. 

Approved by the FDA in 2000, mifepristone is used, along with misoprostol, to end a pregnancy in the first 10 weeks of gestation and in miscarriage management. While misoprostol is readily available, mifepristone distribution has been restricted.

Despite its documented safety, mifepristone is regulated by the FDA’s Risk Evaluation and Mitigation Strategy (REMS), which presents burdens for individual prescribers and limits its integration into primary care, where many patients seek help for unintended pregnancies.

One clinical innovation that could increase access to the drug in the family medicine context includes streamlining prescription ordering processes. Clinical researchers with the Department of Family Medicine and Community Health at the University of Minnesota Medical School, partnered with the university health system’s compliance department to create standard processes for ordering and documenting mifepristone administration, which adhere to the REMS requirements.

They established a single prescriber account to represent all system prescribers who met REMS requirements, allowing for centralized ordering and distribution by the pharmacy purchasing team. This process mirrors other standard operating procedures used by the health system to purchase other medications.

Another intervention used in two Chicago-area federally qualified health centers, titled, “Excellence in Providing Access to New Directions in Mifepristone Use” (ExPAND Mifepristone), took a different approach to expanding access to the mifepristone. This learning collaborative, developed by researchers from the University of Chicago, Chicago-based medical centers, and Harvard Medical School, focused on enhancing educational and training support services for primary care providers to use the drug for miscarriage management and abortion provision.

Prior to program implementation, clinicians and staff had little knowledge of mifepristone. After implementation and program completion, both clinics stocked and provided mifepristone for early pregnancy loss. However, significant barriers remained for use of the drug as part of abortion care. Providers at both program sites noted that stringent financial procedures to separate federal funds from those that support abortion procedures proved a significant challenge.

Despite these obstacles, the researchers believe that the participating clinics’ expanded ability to provide mifepristone for early pregnancy loss suggests that learning collaboratives could be an effective tool in improving access to comprehensive reproductive care.

Streamlining the Use of Mifepristone for Early Pregnancy Loss Across a Large Healthcare System Sets the Stage for Rapid Expansion of Medication Abortion Access in a Post-Roe Environment

ExPAND Mifepristone: Medical Management of Miscarriage and Abortion in FQHCs

11-April-2023 - Annals of Family Medicine: New paper finds that the presence of community support persons during Black birthing experiences is associated with less obstetric racism

Dateline, 4/11/2023, Ann Arbor, MI
Media Contact: Adrieanna Norse, anorse@aafp.org

A new study published in the Annals of Family Medicine has found that the presence of a community support person during labor reduces the likelihood of obstetric racism experienced by Black patients during hospitalization for labor, birth and immediate postpartum.

Thirty-seven Black cisgender women with a prior hospitalization of labor, a live birth, and immediate postpartum during one continuous episode of care, participated in in-person, qualitative focus groups. Eight hundred and six additional participants completed online surveys. Participants shared birthing experiences across 348 hospitals from Washington, D.C. and 34 states in the United States.

Using the PREM-OB Scale™, researchers measured three domains of obstetric racism: humanity (violation of safety and accountability, autonomy, communication and information exchange, and empathy); kinship (denial or disruption of community and familial bonds that support Black birthing people); and racism in the form of anti-Black racism and ‘misogynoir’ (i.e., weaponization of societal stereotypes and scripts in service provision that reproduce gendered anti-Black racism in the hospital).

Participants then documented whether they were accompanied by a community support person, which researchers defined as an individual present throughout labor, birth and postpartum care and with no hospital affiliation.

Researchers found that scores across all three domains of obstetric racism were higher in the group where no community support person was present. Additionally, their analysis found a greater decrease in disruption of kinship with the presence of a community support person during childbirth hospitalization.

Published during Black Maternal Health Week in the U.S. (April 11-17, 2023), the paper’s findings suggest an increasing need for Black birthing communities, hospitals, health plans, quality improvement and implementation scientists, as well as community advocates, to recognize the added value of community support persons throughout the Black birthing experience. 

“As physicians whose ethics of care prioritize patient, family and community health and well‐being, we strongly believe family medicine physicians can utilize their voice and power to activate and amplify the agency and self‐efficacy of Black birthing people in choosing the type and number of people they desire and deserve to be present with them during childbirth hospitalization” the authors write.

Presence of Community Support Persons During Black Birthing Experiences is Associated with Less Obstetric Racism. Elle Lett, Marie-Fatima Hyacinthe, Dána-Ain Davis, Karen A. Scott

12-January-2023 - Annals of Family Medicine: Researchers describe primary care physicians’ and patients’ concerns about digital detection surveillance of infectious diseases in China

Dateline, 1/12/2023, Ann Arbor, MI
Media Contact: Adrieanna Norse, anorse@aafp.org

A new study published today in the Annals of Family Medicine presents results of a qualitative interview documenting experiences with digital surveillance of infectious disease (including COVID-19) in China. The study, “Primary Care Physicians’ and Patients’ Perspective on Equity and Health Security of Infectious Disease Digital Surveillance,” can be accessed for free here.

Digital detection surveillance, a system comprised of a range of digital tools intended to provide benefits to healthcare providers and patients and prevent disease spread, was created in China in response to the COVID-19 pandemic.

The authors conducted in-depth interviews with 16 primary care physicians and 24 of their patients to explore perceptions and experiences of the digital detection system. The study was approved by the Institutional Review Board of the University of Hong Kong-Shenzhen Hospital in China. The interviewees reflected a range of ages, educational backgrounds, and clinical experiences from urban areas in northern and southern China.

Researchers identified five common concerns raised by primary care physicians and patients about the digital detection system:

  • Ambiguity around the need for informed consent about the usage of digital detection surveillance
  • The importance of autonomous decision-making
  • The potential for discrimination of vulnerable users who may have an infectious disease who are surveilled by the digital detection system
  • The risk of social inequity and divided care outcomes
  • Authoritarian institutions’ responsibility for maintaining health data security

Additionally, qualitative interview results also indicated that the adoption of digital detection surveillance would lead some patients to avoid the hospital for fear of either discrimination for their opinions or being forcibly quarantined. Respondents also largely believed that the elderly and young children were particularly vulnerable to the misuse of digital surveillance data.

As national and international health organizations look to establish ethical frameworks guiding the use of digital detection surveillance to reduce the spread of infectious diseases, the paper’s authors argue that patient protections should be explicitly addressed.

Primary Care Physicians’ and Patients’ Perspective on Equity and Health Security of Infectious Disease Digital Surveillance, William Chi Wai Wong, Ivy Yan Zhao, Ye Xuan Ma, Wei Nan Dong, Jia Liu, Qin Pang, Xiao Qin Lu, Alex Molassiotis, Eleanor Holroyd. 

28-Nov-2022 - Dutch Researchers Explore Reasons for Lack of Follow-Up After Positive FIT, Suggest Personalized Counseling from Family Practitioners May Help

Dateline, 11/28/2022, Ann Arbor, MI
Media Contact: Adrieanna Norse, anorse@aafp.org

While the screening by Fecal Immunochemical Test (FIT) can detect colorectal cancers early, successful treatment depends on patients undergoing follow-up colonoscopies after testing positive. The original research paper, Reasons for no colonoscopy after an unfavorable screening result in Dutch colorectal cancer screening: a nation‐wide questionnaire in the November/December 2022 edition of Annals of Family Medicine examines the reasons why some patients don’t seek follow-up care after a positive FIT test.

A better understanding of why individuals do not follow-up has global implications for all individuals at risk of colorectal cancer (CRC) as it is best treated early.

The Netherlands started implementation of the two-step Dutch CRC screening program in 2014. All individuals aged 55-75 receive a FIT and an information sheet by mail. Those having a positive FIT (indicating an increased risk of CRC) receive the result plus a prescheduled appointment for consultation to discuss the follow-up colonoscopy by mail.

In this study, the researchers distributed a survey among 4,006 individuals who had received a positive FIT. Of the 2,225 respondents, 730 reported not having undergone a follow-up colonoscopy. Of those, 404 (55%) reported a contraindication for colonoscopy, including chronic illness, or having had a recent colonoscopy.

Other reasons individuals opted against follow-up care included:

  • Having difficulty deciding to undergo colonoscopy or not
  • Lack of opportunity to discuss the FIT outcome with their doctor
  • The belief that the test result is a false positive
  • The perception of having low estimated CRC risk
  • Having trust in their own ability to self-detect CRC
  • A belief that polyp removal was ineffective
  • The perception that colonoscopies are uncomfortable

The strongest driver to follow-up with colonoscopy after a positive screening was the belief that a patient’s family physician would support their decision. Given that a lack of knowledge, misperception of CRC risk, and/or decision‐making difficulties hinder follow-up, the authors argue that improving knowledge and offering personal guidance might prove beneficial for FIT‐positive individuals. They suggest personalized counseling from family practitioners may help.

Reasons for no colonoscopy after an unfavorable screening result in Dutch colorectal cancer screening: a nation‐wide questionnaire.
Lucinda Bertels, Kristel M. van Asselt, Henk C.P.M van Weert, Evelien Dekker, Bart J. Knottnerus

26-Sept-2022: Family Medicine doctor offers solutions to challenges facing primary care in special report

Dateline, 9/28/2022, Ann Arbor, MI
Media Contact: Janelle Davis, JDavis@aafp.org

In a new special report, a family doctor and policy advocate with over 50 years of experience highlights current challenges for primary care and proposes increased spending within the profession. The report is published in the current issue of Annals of Family Medicine and is authored by Thomas Bodenheimer, MD, MPH, professor emeritus of the Department of Family and Community Medicine at the University of California San Francisco.

Bodenheimer argues that low rates of national health expenditures dedicated to primary care, coupled with an ever increasing patient to clinician ratio – estimated at around 2,100 per clinician – has led to an increase in physician burnout and decreased patient access to care.

The United States has spent significantly less on primary care than other industrialized, Organisation for Economic Co-operation and Development (OECD) countries. In 2016, 5.4% of total health expenditures in the U.S. were directed towards primary care, compared to 7.8% in 22 other OECD countries. Additionally, increasingly complex and numerous electronic health record documentation requirements and declining numbers of new primary care doctors are widely cited as significant challenges for the field.

Bodenheimer proposes various solutions:

  • Increasing primary care spending through state level legislation.
  • Eliminating the pay gap between primary care physicians and specialists.
  • Developing multidisciplinary teams to care for large patient panels.

“With adequate primary care spending and powerful teams, primary care can become accessible to patients and joyful to all,” Bodenheimer concludes.

In an accompanying editorial, by John M. Westfall, University of Colorado School of Medicine and Alison Huffstetler, Department of Family Medicine and Population Health at Virginia Commonwealth University, the authors find Bodenheimer’s arguments compelling, writing, “The U.S. does not spend enough money to support primary care settings, train the primary care workforce, and this leads to lack of time to spend with patients on the care that really matters,” adding that increased spending should be focused on team support, resources, technology and income equity for primary care clinicians.

Revitalizing Primary Care, Part 1: Root Causes of Primary Care’s Problems and Revitalizing Primary Care, Part 2: Hopes for the Future
Thomas Bodenheimer
It Will Take a Million Primary Care Team Members
John M. Westfall, Alison N. Huffstetler

26-Jul-2022: Emerging Research Documents Changing Landscape of Electronic Health Records in Primary Care

Five articles highlight expanding role of EHRs in primary care, impact on doctor-patient relationships.

Dateline, 7/26/2022, Ann Arbor, MI
Media Contact: Janelle Davis, JDavis@aafp.org

In Use of the Electronic Health Record During Clinical Encounters: An Experience Survey, researchers conducted a survey to assess the impact of EHR practices on doctor-patient communication. Describing experiences with EHRs during clinical encounters, most clinicians reported less eye contact with patients (80%), listening less carefully (54%), and less focus (65%). Only one-third of clinicians thought patients saw EHR use as a positive experience.

However, most patients surveyed (91.7%) reported positive experiences with EHR use. Patients reported clinicians provided sufficient eye contact (96.8%), listening (97.0%), and clinician focus (86.7%). The authors argue this gap in experiences indicates clinician stress and burnout with patient data documentation and the need to address clinicians' user experience of EHR.

In Communication Gaps Persist Between Primary Care and Specialist Physicians, researchers studied the impact of the Comprehensive Primary Care Plus (CPC+) model, which leverages EHRs to increase information sharing between primary care physicians and specialists about referred patients.

The authors found gaps in communication between primary care physicians and specialists have persisted over the last decade. They argue that although EHR technology was developed to improve care coordination, physicians do not always intentionally engage in communication on referrals and consultations. This communication gap can impact patients negatively, increasing the likelihood of delayed diagnoses, unnecessary testing, and patient and physician dissatisfaction.

However, opportunities to improve patient outcomes through EHRs do exist. In Impact of Home Blood Pressure Data Visualization on Hypertension Medical Decision Making in Primary Care, new research explores how clinicians might incorporate at-home blood pressure readings into a patient's EHR to help control hypertension.

The researchers developed and implemented a visualization tool that combines clinical and home blood pressure readings, and displays aggregated data in a single chart within each patient's EHR. Through analyzing doctor-patient interactions, researchers found that the visualization tool promoted shared decision-making in hypertension management in the primary care setting.

The article Designing and Implementing an Electronic Health Record–Embedded Card Study in Primary Care: Methods and Considerations describes how EHRs can help streamline data collection in the clinic. The authors report on the development and implementation of EHR-embedded digital surveys to replace paper-based surveys at community health centers. The research team developed a digital alternative to paper studies to reduce complexity and costs for users, and to facilitate rich analyses by linking participant responses to clinic and patient data.

In an accompanying editorial, Uplifting Primary Care Through the Electronic Health Record, Anthony Sunjaya notes that health care is rapidly becoming digital, helping to increase patient engagement in their own care, and improve primary care research. "However, we need to be able to measure these benefits through fit-for-purpose metrics in order to motivate practices to adopt them," he writes. Best practice goals for these metrics can then be developed and their integration linked to reimbursement, as well as other rewards for the benefit of clinicians, patients, and health systems.

Use of the Electronic Health Record During Clinical Encounters: An Experience Survey
Ellen C. Meltzer et al.
Communication Gaps Persist Between Primary Care and Specialist Physicians
Lori Timmins et al.
Impact of Home Blood Pressure Data Visualization on Hypertension Medical Decision Making in Primary Care
Deborah J. Cohen et al.
Designing and Implementing an Electronic Health Record–Embedded Card Study in Primary Care: Methods and Considerations
Arwen Bunce et al.
Uplifting Primary Care Through the Electronic Health Record
Anthony Paulo Sunjaya

24-May-2022: Mayo Clinic research identifies health care access challenges of rural patients

Mayo, University of Louisville School of Medicine researchers present intervention recommendations, including technology adoption for care, data collection

Dateline, 5/24/2022, Ann Arbor, MI
Media Contact: Janelle Davis, JDavis@aafp.org

Rural residents face immense challenges to accessing health care services for chronic health conditions such as diabetes and cancer, which are associated with higher rates of disease-attributable deaths. Authors from the Mayo Clinic and the University of Louisville School of Medicine in Kentucky have just published a paper in Annals of Family Medicine that aggregates findings from 62 different studies to find commonalities in the health care experiences of patients with chronic conditions in U.S. rural settings.

Their paper is titled, “Rural Patient Experiences of Accessing Care for Chronic Conditions: A Systematic Review and Thematic Synthesis of Qualitative Studies.”

First author Elizabeth H. Golembiewski, PhD, M.P.H., of the Knowledge and Evaluation Research Unit at Mayo Clinic in Rochester, Minn., and her co-authors reviewed studies involving 1,354 unique participants. The greatest proportion of studies (24.2%) was focused on the experience of patients with cancer, followed by behavioral health (16.1%); HIV (14.5%); and diabetes (12.9%). 

Diabetes and cancer, as well as other chronic conditions, are more prevalent in rural communities compared to urban and suburban areas. The researchers found that important cultural, structural and individual factors influence the rural patient experience of health care access and utilization, including:

  • Financial, time and physical costs associated with travel
  • Concerns with overburdening their support systems with frequent transportation requests
  • Frustration with lack of continuity due to frequent clinical rotations
  • Perceptions that local care is suboptimal
  • Culturally-enforced stigmas against seeking care

Golembiewski et al believe their findings can inform policies and programs that may improve access to care through culturally-appropriate interventions.

“Improving access to health care in rural communities is a national imperative,” the authors assert, adding that future research should explore the role of telehealth and other remote technologies to address patient access challenges and to collect patient care data.

Rural Patient Experiences of Accessing Care for Chronic Conditions: A Systematic Review and Thematic Synthesis of Qualitative Studies
Elizabeth H. Golembiewski, Derek L. Gravholt, Victor D. Torres Roldan, Eddy P. Lincango Naranjo, Sebastian Vallejo, Andrea Garcia Bautista, Christina M. LaVecchia, Christi A. Patten, Summer V. Allen, Soumya Jaladi and Kasey R. Boehmer

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25-Apr-2022: Researchers develop online guide to help family medicine doctors discuss vaccine hesitancy with patients

Dateline, 4/25/2022, Ann Arbor, MI
Media Contact: Janelle Davis, JDavis@aafp.org

A team of public health specialists from the University of Calgary School of Public Policy has developed an interactive, web-based guide to help family doctors better speak to a wide range of patient concerns related to the COVID-19 vaccine.

The researchers – which include Myles Leslie, PhD, Nicole Pinto, MSc, and Raad Fadaak, PhD – document the process their team used to create and disseminate a conversation guide for health care providers in a new publication now available in Annals of Family Medicine. The paper, titled, “Improving Conversations with COVID-19 Vaccine Hesitant Patients: Action Research to Support Family Physicians” can be found on AnnFamMed.org here: https://www.annfammed.org/content/early/2022/04/22/afm.2816

The online guide was created for and with family medicine practitioners, who often serve as the first point of contact for patients seeking COVID-19 treatment or have questions about how to protect themselves and their loved ones. To ensure the guide was relevant to health care providers, Leslie et al conducted qualitative interviews with primary care doctors in multiple Canadian provinces. The data gathered through these interviews was then used to identify commonly held beliefs, attitudes and perceptions that impact a patient’s willingness to receive the vaccine. “This attention to clinical experience was central to achieving buy-in from our participants,” the team wrote.

The research team found that clinicians were frequently encountering many of the same reasons for hesitancy from their patients including concerns around safety; interactions with comorbidities; conspiracy theories; religious or moral obligations; and past traumas experienced in the medical setting.

Using this information, researchers created several provider resources to better counsel vaccine-hesitant patients, in direct response to each potential concern. These are free to the public and include tips for clinicians, patient-provider conversation scripts, and resources to help navigate conversations about COVID-19 vaccines with hesitant patients.

The guide also outlines four steps to help practitioners have better conversations with vaccine hesitant patients, emphasizing the physician’s role as an ally on the patient’s health journey. Steps include engaging with patients; affirming patient concerns; asking permission before sharing information; and evoking future risks to motivate patients to reconsider vaccine hesitancy.  

The guide is available at www.vhguide.ca.

Improving Conversations With COVID-19 Vaccine Hesitant Patients: Action Research to Support Family Physicians
Myles Leslie, Nicole Pinto and Raad Fadaak

01-Mar-2022: Researchers propose strategies to accurately characterize health inequities across racial groups in quantitative health sciences research

Dateline, 3/1/2022, Ann Arbor, MI
Media Contact: Janelle Davis, JDavis@aafp.org

A U.S.-based research team has proposed a rethinking in how dominant research paradigms are used to more appropriately account for differences in health outcomes across racial and ethnic groups in quantitative health sciences – conceptual approaches that are typically ignored and overlooked.

The paper, recently published in the Annals of Family Medicine, is titled “Conceptualizing, Contextualizing, and Operationalizing Race in Quantitative Health Sciences Research”. It is available for free download.

“To move forward in achieving racial equity, we must leave behind antiquated, unsubstantiated, and harmful conceptualizations of race and implement strategies that allow us to estimate the health impacts of systemic racism and ultimately dismantle it,” the authors write.

By conceptualizing health disparities as separate from the impacts of systemic racism, researchers propagate harmful narratives and stereotypes of biological characteristics or cultural inferiority, which hinder equity.

This approach has been historically common in health sciences literature. The authors emphasize that the presence of these narratives in COVID-19 literature, as well as in research about inequities in morbidity and mortality among Black individuals, incorrectly contribute to harmful stereotypes such as genetic susceptibility; greater risk tolerance or willful assumption of pandemic risk; or poor hygiene.

“Race should not be used as a measure of biological difference, but rather as a proxy for exposure to systemic racism,” the authors write. “We emphasize that an understanding of race that moves from physiological difference to a particular relationship to structural forces is foundational to high quality health equity research.”

Following a brief overview of the history of health equity research, the paper provides recommendations on how researchers can more appropriately engage in quantitative scientific inquiry to understand the impact of racism on adverse health outcomes:

  • Apply appropriate theoretical frameworks that accurately explain how social-structural factors might interact with a disease to produce results most important for achieving health equity.
  • Draw upon Black, Indigenous, Latine and other community consults as experts to inform public health research.
  • Measure elements of racism in research in both new and secondary datasets
  • Elevate 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, Emmanuella Asabor, Sourik Beltrán, Ashley Michelle Cannon, Onyebuchi A. Arah

16-Feb-2022: Three Responses to NASEM’s 2021 Primary Care Survival Report

Dateline, 2/15/2022, Ann Arbor, MI Media Contact: Janelle Davis, JDavis@aafp.org
 
Today in Annals of Family Medicine, three groups of U.S. and Canadian primary care researchers respond to the landmark 2021 National Academies of Science, Engineering, and Medicine (NASEM) report on the implementation of high-quality primary care, the first of its kind since 1996.
 
In three articles, the authors provide perspectives on the report’s five recommendations concerning payment, access, workforce development, information technology and primary care implementation.
 
Researchers from the Agency for Healthcare Research and Quality (AHRQ) assert that primary care’s future rests upon strategic investments in research that emphasizes whole person care, wherein clinicians engage patients and families in managing illness and promoting wellness. Author Arlene Bierman, the director of AHRQ’s Center for Evidence and Practice Improvement, and colleagues believe that enhancing the community-centeredness of primary care would reduce and ultimately eliminate long-standing inequities in access, quality, and outcomes of care.
 
Early career physicians led by Tracey L. Henry, MD write that the four C’s of patient care (contact, continuity, coordination and comprehensiveness) may not be inclusive of the needs of under-resourced communities, and that diverse individuals are not sufficiently recruited or maintained in health care settings. Regarding payment reform, they argue that risk adjustment and value-based care will support equitable access and high-quality care to all communities.

A third paper authored by Azza Eissa, MD and colleagues, states that chronic underinvestment in primary care has hindered its potential to improve health disparities in North America. Applying a health equity lens to the five recommendations advanced in the 2021 NASEM report, the researchers provide their own recommendations on how the profession might operationalize them, including paying teams, not individual doctors, to care for people; ensuring high-quality care is available to everyone in every community; training primary care teams where people live and work; designing information technology that serves the patient, family and the interprofessional care team; and ensuring high-quality primary care is implemented.

Implementing High-Quality Primary Care Through a Health Equity Lens
Azza Eissa, MD, PhD, et al.

Realizing the Dream: The Future of Primary Care Research
Arlene S. Bierman, MD, MS et al.

Health Equity: The Only Path Forward for Primary Care
Tracey L. Henry, MD, MS, MPH et al.

25-Jan-2022 Telementoring Program with Chat Box Feature Helps Meet Clinicians' Needs for Information, Resources and Peer Support

Dateline, 1/25/2022, Ann Arbor, MI, Media Contact: Janelle Davis, JDavis@aafp.org

Researchers from Oregon Health & Science University found that a clinician-focused, COVID-19 support program with a chat box feature not only provided primary care medical staff with timely clinical resources and care guidance, but it also offered other psychosocial supports.

The ECHO program, created in March 2020, included 11 sessions with researchers encouraging interactions among the hundreds of participants via a chat box. Their objective was to assess how chat box communications could provide support to clinicians during the pandemic.

Researchers conducted a qualitative analysis of text extracted from the sessions, exploring the context of clinicians’ needs, as conceptualized by Maslow’s hierarchy of needs, and adapted specifically for clinicians. Three key themes emerged: answers and trustworthy information, practical resources, and affirmation and peer support.

The chat box supported many clinicians’ needs during a rapidly changing healthcare environment, including the ability to ask questions and provide comments. Participants were able to create a community through chat box use where colleagues provided connection and validation, as well as a forum for discussing fears, concerns, and grievances.

Many participants also used the platform to marshal additional resources and support for patients from marginalized groups, or for those with special health needs. This patient advocacy role, the researchers note, is a demonstration of self-actualization, as defined by Maslow.

“Telementoring programs that provide opportunities for robust participant interactions – with their ability to both disseminate evidence-based information quickly and provide peer-to-peer support – should continue to play an integral role in responding to health crises in the future,” the authors write.

“Identifying and meeting clinicians’ needs during a pandemic, or any public health crisis, is critical for primary care as a discipline to reach its full potential,” they add, and includes the need for greater investment in both public health and primary care. These investments should include adequate personal protective equipment as well as furnishing the time to reflect on what has occurred thus far during the current pandemic and to better plan for any future health crises.

Clinicians’ Core Needs in a Pandemic: Qualitative Findings From the Chat Box in a Statewide COVID-19 ECHO Program
Anna L. Steeves-Reece, PhD candidate, MPH, MA, et al.

25-Jan-2022 COVID-19 Pandemic Triggers a Dramatic Decline in Diagnoses of Cardiovascular Risk Factors, Chronic Diseases and Some Cancers

Dateline, 1/25/2022, Ann Arbor, MI, Media Contact: Janelle Davis, JDavis@aafp.org

New diagnoses of cardiovascular risk factors, common chronic conditions and some cancers have dramatically declined during the COVID-19 pandemic, according to a study recently published online in Annals of Family Medicine.

Researchers note that the decline is not reflective of improved health outcomes but suggests that people are not receiving appropriate and timely health screenings that would diagnose these conditions early, when there is a greater chance of effective treatment and good health outcomes.

Researchers in Spain analyzed annual incidence rates of the main cardiovascular risk factors, chronic diseases, and some cancers in 2020, compared with data from 2017-2019. They found a reduction in newly reported diagnoses ranging from a 36% decline for high cholesterol diagnoses to a 50% decline in the diagnosis of pulmonary diseases such as chronic bronchitis and emphysema.

Comparing data from 2017-2019, the team found in 2020 significant reductions in the annual incidences of high blood pressure (40%), type 2 diabetes (39%), chronic kidney disease (43%), coronary heart disease (48%), non-cancerous enlarged prostate (38%), osteoporosis (40%), under-active thyroid (46%), non-cancerous colon polyps and tumors (42%), and serious forms of skin cancer (45%).

Additionally, the rate of diagnosis of anxiety disorders increased by 16% while the diagnoses of alcohol use disorder decreased by 46%.

The researchers believe that the decline of face-to-face patient visits for preventive and health promotion services in response to the ongoing COVID-19 pandemic is largely responsible for this alarming trend. Prioritization of COVID-19 care changed the physician-patient relationship to the detriment of face-to-face scheduled visits for chronic disease detection and monitoring, which fell by almost 41%.

“Returning to the level of detection and control of chronic diseases before the pandemic will require a substantial increase in primary care physicians and nurses; a return to face-to-face visits; a reorganization of telehealth; and the promotion of proactive care in patients who have the greatest comorbidities,” the authors write.

The Impact of the COVID-19 Pandemic on Primary Health Care Disease Incidence Rates: 2017 to 2020
Antoni Siso-Almirall, MD, PhD, et al.

25-Jan-2022 Team-based Primary Care, Coupled With Payment Reform, May Reduce Emergency Department Use

Dateline, 1/25/2022, Ann Arbor, MI, Media Contact: Janelle Davis, JDavis@aafp.org

In a new paper published in the Annals of Family Medicine, researchers observed an increase in emergency department use by patients whose physicians had transitioned from an enhanced fee-for-service payment model to either a team-based or non-team-based blended capitated payment model. However, post-transition period, this increase was seen to be smaller in those patients who received team-based care.

Under capitated payment models, practices are paid a fixed monthly fee for taking care of a specific group of patients rather than by the visit. Such models are designed to enable physicians to spend more time with patients; address multiple problems in an encounter; and better communicate with patients, family, and team members. care.

The researchers compared annual ED visit rates of approximately 2.5 million patients in Ontario, Canada, before and after the transition from an enhanced fee-for-service to either a team-based or a non-team-based blended capitation model. Data was collected between April 1, 2003, and March 1, 2017.

Specifically, they compared ED visit rates in big cities, small towns and rural areas following the payment transition between 2006 and 2013. In big cities, the ED visit rate increased by 2.38% per year for patients who received team-based care and 5.23% per year for patients who did not. These figures accounted for differences in patient age, sex, neighborhood, income, recent immigration status, morbidity and comorbidity. Similar trends were observed among patients in small towns and rural areas.

The paper’s authors assert that team-based care is a critical component of effective primary care and could help patients access primary care without having to rely on emergency departments for health issues.

Sharing care responsibilities within an interprofessional primary care team, coupled with payment reform, may improve patient care while also reducing family physician burnout.  
The research team includes members from the Institute for Clinical Evaluative Sciences (ICES); the Department of Family and Community Medicine and the MAP Centre for Urban Health Solutions at St. Michael’s Hospital; and the Department of Family and Community Medicine and the Institute of Health Policy, Management and Evaluation, both at the University of Toronto.

Impact of Team-Based Care on Emergency Department Use
Tara Kiran, MD, MSc, et al.

09-Nov-2021 Increasing Trust is Key to Addressing the COVID-19 Pandemic and Other Threats to Health

Dateline, 11/9/2021, Ann Arbor, MI, Media Contact: Janelle Davis, JDavis@aafp.org

As the COVID-19 pandemic continues to threaten the health of communities worldwide, and health care communities seek to administer COVID vaccines en masse, patients’ trust in the medical profession has never been more important.

However, patients’ trust in the medical profession – and clinicians’ trust in their own organizations – has dropped during the last 50 years.

Two articles published in the current issue of Annals of Family Medicine provide insights into how this trend has affected patient outcomes and what the health care community should do to increase trust both among clinicians and organizations, and patients and their clinicians.

Researchers from Hennepin Healthcare and the University of Minnesota, found that patients’ trust in their clinicians is connected to specific aspects of culture of the organization, and the level of trust their clinicians have in the health organization in which they work.

“Lack of trust in the medical profession has implications for patient care since research from past epidemics has shown that lack of trust decreases the likelihood of patients adhering to public health recommendations,” Linzer et al write. “It is critical to identify factors that will assist health systems to better understand how to create the most trust within their work environments.”
Linzer and his colleagues used baseline data from a randomized trial of interventions to improve clinician work life in 34 primary care clinics, to identify characteristics associated with high levels of clinician-organization and patient-clinician trust. These included:
•    An emphasis on quality
•    An emphasis on communication and information
•    Cohesiveness among clinicians
•    Shared values between clinicians and their leaders

Family physician and blogger Kenneth W. Lin, MD, MPH, of Georgetown University Medical Center concurs with Linzer et al in an accompanying editorial piece.

Lin says increased patient trust in health care is crucial to paving a way forward through the current pandemic. “As mass vaccination campaigns have stalled, recommendations from trusted primary care clinicians have become critical to overcoming vaccine hesitancy,” he writes.

Where Trust Flourishes: Perceptions of Clinicians Who Trust Their Organizations and Are Trusted by Their Patients
Mark Linzer, MD, et al.
Trust and Relationships Remain at the Heart of Primary Care
Kenneth W. Lin, MD, MPH

09-Nov-2021: Routine Immunization Rates Must Be Recovered to Ensure Long-Term Population Health

Dateline, 11/9/2021, Ann Arbor, MI, Media Contact: Janelle Davis, JDavis@aafp.org

Across the U.S., rates of routine vaccinations for measles, chicken pox and tetanus have plummeted during the COVID-19 pandemic, with the greatest declines seen among the most vulnerable and underserved.  

In a new paper published in the November/December 2021 edition of Annals of Family Medicine, researchers examine routine vaccination data, give examples of organizations working to prevent disruptions to routine vaccination, and provide strategies for recovering vaccine rates.

Private claims data from three childhood vaccines, which include measles, mumps and rubella, diphtheria, tetanus, and acellular pertussis and polio, suggest that an estimated 9 million doses may have been missed in 2020, and up to a 26% drop in those vaccines between January and September of last year.

According to an analysis of immunization data from 10 states, researchers estimate more than a 60% decline in MMR vaccinations in children aged 2 to 8, and a 60% decline in HPV vaccinations from adolescents aged 9 to 12. Researchers compared data from March to May of 2020 to the same time frame in 2019.

“This has dire consequences to future population health and the potential to strain an already overtaxed health system,” the authors write.

The authors provide examples of how representatives from multiple health care sectors have addressed these vaccine declines, including interventions from local and state health departments, Medicaid programs, commercial health plans, medical societies, non-governmental organizations, the federal government, and community-based organizations.

Despite these efforts, the authors argue more needs to be done to get people caught up on routine vaccinations. Innovative models used to administer the COVID-19 vaccinations should also be used to restore routine vaccination rates.

Some recommended strategies to recover routine vaccination coverage rates include:

•    Coordinating across health and education sectors
•    Leveraging digital and mainstream media to drive awareness of important routine vaccinations
•    Expanding access points to vaccination services
•    Elevating trusted voices for vaccination
•    Securing sustainable funding for immunization infrastructure

“This recovery requires all stakeholders to drive awareness of the importance of routinely recommended vaccines, facilitate access to vaccination and build vaccine confidence,” the authors write.

Silent Consequences of COVID-19: Why It’s Critical to Recover Routine Vaccination Rates Through Equitable Vaccine Policies and Practices
Ava Skolnik, MPH et al.

09-Nov-2021: Person-Centered Primary Care Measure Shows Validity Across 35 Countries

Dateline, 11/9/2021, Ann Arbor, MI, Media Contact: Janelle Davis, JDavis@aafp.org

A new study published in the November/December 2021 issue of Annals of Family Medicine provides evidence that the Person-Centered Primary Care Measure, a tool used to evaluate patients’ primary care experiences, can reliably gather, and assess data across different cultural contexts.

According to the study, the PCPCM enables data collection with high comparability, despite differences in geography, culture, or language.

Authors of the study, “Measuring Primary Care Across 35 OECD Countries,” include Stephen J. Zyzanski, PhD; Martha M. Gonzalez, BA; Jonathan P. O’Neal, BS; Rebecca S. Etz, PhD; Sara R. Reeves, FNP-C, MBA; and Kurt C. Stange, MD, PhD.

“We aim to make the PCPCM available for use across diverse languages and countries, and to stimulate preliminary hypotheses about inter-country differences that can be examined in future research to guide policy and practice based on the natural experiment of different countries’ approaches to health care,” they write.

Developed in 2017, the PCPCM contains 11 questions (plus an optional question) that focus on the patient’s access to care, their relationship with their physician and their ability to reach health outcome goals. It also focuses on integrating, personalizing, and prioritizing care, among other aspects. Responses to these questions provide physicians and researchers with insight into outcomes associated with better health, equity, quality, and sustainable health care expenditures.

In 2019, researchers administered the PCPCM in 28 languages to 360 adults in each of the 35 participating countries. The team also assessed the PCPCM’s validity by looking at demographics and examining the number of years a survey participant had been with their primary care physician and practice.

“The solid reliability and validity of the PCPCM across different languages and countries, and the variability of responses across countries, call for further ecological and individual research,” the authors concluded, noting that the measure can be used to learn from the different approaches to health care across the participating countries.

Measuring Primary Care Across 35 OECD Countries
Rebecca S. Etz, PhD, et al.

14-Sep-2021: Voice Assistants' Responses to Cancer Screening Questions Prove Partly Effective, Reveal Room for Improvement

Dateline, 9/14/2021, Ann Arbor, MI, Media Contact: Janelle Davis, JDavis@aafp.org

In a new study appearing in the September issue of Annals of Family Medicine, researchers have compared four widely used voice assistants – Amazon Alexa, Apple Siri, Google Assistant and Microsoft Cortana – to determine the quality and accuracy of responses to cancer screening questions.

The article is titled, “Voice Assistants and Cancer Screening: A Comparison of Alexa, Siri, Google Assistant, and Cortana” with authors from Stanford University.

The study was conducted using the personal smartphones of five investigators. Each voice assistant was tested twice from different devices. The primary outcome noted in the final comparison was each device’s response to the question: “Should I get screened for (type of) cancer” for 11 cancer types.

Researchers assessed the assistants’ ability to understand queries; provide accurate information through web searches; and provide accurate information verbally. The assistants’ responses were compared to the cancer screening guidelines of the U.S. Preventive Services Task Force (USPSTF). A response was deemed accurate if it did not directly contradict USPSTF guidelines information and if it provided a starting age for screening consistent with the guidelines.

Siri, Google Assistant and Cortana understood 100% of the queries, consistently generating a web search and/or verbal response. However, Alexa was unable to understand or respond to any of the queries.
 
The researchers also found that the top three weblinks recommended by Siri, Google Assistant and Cortana provided information that aligned with USPSTF guidelines roughly 70% of the time.

Verbal response accuracy varied among the assistants. Google Assistant matched USPSTF guidelines 64% of the time, maintaining an accuracy rate similar to its web searches. However, Cortana’s accuracy of 45% was lower than its web searches. Siri was not able to provide a verbal response to any of the queries.

For all, verbal responses to queries were either unavailable or less accurate than those generated by manual web searches.

“This [research] could have implications for users who are sight-impaired, less tech-savvy, or have low health literacy as it requires them to navigate various webpages and parse through potentially conflicting health information,” the authors write.

Voice Assistants and Cancer Screening: A Comparison of Alexa, Siri, Google Assistant, and Cortana
Steven Lin, MD, et al.

13-Jul-2021: Primary Care Can Play an Important Role in Administering COVID-19 Vaccines, Providing Patient Information and Support

Dateline, 7/13/2021, Ann Arbor, MI, Media contact: Noa Kim, cczu@med.umich.edu

Primary care physicians can play a key role in helping maintain momentum in the COVID-19 vaccine rollout in the United States, given their historic role in providing other kinds of vaccinations, according to research conducted by members of the Robert Graham Center for Policy Studies in Family Medicine and Primary Care in Washington D.C.

The article, “Primary Care’s Historic Role in Vaccination and Potential Role in COVID-19 Immunization Programs,” appears in the current issue of Annals of Family Medicine.

In addition to administering COVID-19 vaccinations, the researchers note that primary care physicians can provide clinical and personal support to counter vaccine hesitancy and misinformation.

“COVID-19 pandemic recovery will require a broad and coordinated effort for infection testing, immunity determination and vaccination,” the researchers write. “Previous immunization delivery patterns may reveal important components of a comprehensive and sustainable effort to immunize everyone in the nation.”

The team used two information sources to determine where patients had traditionally received non COVID-related vaccinations and by whom. They looked at the number of Medicare Part B Fee-For-Service patients in 2017 and found that primary care physicians provided the largest share of services for vaccinations (46%), followed by mass immunizers (45%), then nurse practitioners/physician assistants (5%).

They also examined records from 2013 to 2017 from the Medical Expenditure Panel Survey (also known as MEPS), which collects data on the specific health services that Americans use; how frequently they use them; the cost of these services; and how they are paid for, as well as data on the cost, scope and breadth of health insurance held by and available to U.S. workers.

MEPS information showed that primary care physicians provided a majority of clinical visits for vaccination (54%).

“Primary care physicians have played a crucial role in delivery of vaccinations to the U.S. population, including the elderly, between 2012 and 2017,” the authors write. “These findings indicate primary care practices may be a crucial element of vaccine counseling and delivery in the upcoming COVID-19 recovery and immunization efforts in the United States.”

Primary Care’s Historic Role in Vaccination and Potential Role in COVID-19 Immunization Programs
Elizabeth Wilkinson, BA, et al.

11-May-2021: Psychotherapy and Pharmacotherapy are More Effective in Treating Depression when Paired Together in Primary Care

Dateline, 5/11/2020, Ann Arbor, MI, Media contact: Noa Kim, cczu@med.umich.edu
 
Most patients with depression are treated in primary care, and the majority of those patients prefer psychotherapy over treatment that includes medication (i.e., pharmacotherapy). Primary care physicians, however, are more likely to prescribe antidepressants to their patients suffering from depression.
 
Although studies have shown the effectiveness of psychotherapy in primary care patients, researchers haven’t yet examined the effects of psychotherapy compared with pharmacotherapy, combined treatment, and other clinical scenarios in primary care.
 
In a study published in the May/June, 2021 issue of Annals of Family Medicine, researchers examined the effects of psychotherapy compared with pharmacotherapy, combined treatment, care-as-usual, waitlist, and pill placebo in primary care patients.
 
The study is led by Pim Cuijpers, Ph.D., professor of clinical psychology in the Department of Clinical, Neuro and Development Psychology at Vrije Universiteit, The Netherlands, and includes collaborating authors from Japan, Spain, the U.K. and New Zealand.
 
The team integrated the results of 58 randomized controlled trials involving 9,301 patients. Included studies focused on major depression, persistent mood disorders (dysthymia), or both, as well as studies with patients who ranked high on self-rating depression scales.
 
In total, the researchers conducted 62 comparisons, including 56 papers about psychotherapy; 19 on the use of pharmacotherapy; five about combined therapies; 39 care as usual papers; six involving patients on a waitlist; and three involving patients receiving pill placebos.
 
Researchers concluded that both psychotherapy and pharmacotherapy were significantly more effective for depression than care as usual or waitlist control, with no significant difference seen between psychotherapy and pharmacotherapy. Combined treatment, however, particularly in studies that included cognitive behavioral therapy, was better than either pharmacotherapy or psychotherapy alone.
 
“Although the findings are not unique to primary care, they do indicate that combined treatment has the best effects, and that pharmacotherapy and psychotherapy have comparable effects,” the authors write. “Treatments in primary care must be organized so as to accommodate any of these treatments in response to patients’ preferences and values.”

Psychologic Treatment of Depression Compared With Pharmacotherapy and Combined Treatment in Primary Care: A Network Meta-Analysis
Pim Cuijpers, Ph.D., et al.

09-Mar-2021: Treating Incontinence in Primary Care: A Doctor Versus Mobile App Trial

Dateline, 3/9/2021, Ann Arbor, MI, Media contact: Noa Kim, cczu@med.umich.edu

Some women experiencing urinary incontinence may not be aware of effective treatments, experience shame, or think their symptoms are a normal part of life. A mobile app designed to help women manage urinary incontinence was as effective as in-person primary care treatment, according to new research from the Netherlands.

The pragmatic randomized controlled trial included 262 women with frequent stress incontinence, overactive bladder, or a mix of symptoms. Participants in the intervention group were assigned to use a standalone mobile app called URinControl, which offered pelvic floor muscle and bladder training exercises. Those in a control group received care-as-usual and were referred to their own primary care doctors who were broadly advised to follow the Dutch guidelines for primary care. The intervention group was also free to seek additional treatment from their primary care doctors.

After four months, women who used only the incontinence app and those who continued with standard care experienced similar results, with a decline in the severity of their incontinence symptoms, less frequent leakage and improved quality of life. Statistical analysis showed just over a one-half percentage point difference between the two groups' average decline in symptom severity. Neither treatment was superior to the other, and both groups showed improvements in outcome measures after treatment.

The authors conclude that primary care physicians can offer care-as-usual and/or app-based treatment to women seeking help for urinary incontinence. They write, "A patient might prefer the accessibility and ease of treatment in her own home, or may benefit from some of the integrated functions of the app."

In the comparison of a mobile app to care-as-usual from one's doctor, the authors note that an app "will only be truly clinically relevant if we can demonstrate that it produces a better patient experience, or that it is less expensive than usual care, or yields significant long-term improvement."

App-Based Treatment in Primary Care for Urinary Incontinence: A Pragmatic, Randomized Controlled Trial
Anne M. M. Loohuis, MD, et al.

Jan 14, 2021: Crowdsourced Responses from Dermatologists on Twitter Found to be as Effective as Formal Telemedicine

Dateline, 1/11/2020, Ann Arbor, MI, Media contact: Noa Kim, cczu@med.umich.edu
 
At the start of the pandemic, many doctors on the front lines turned to Twitter and other social media platforms to find guidance and solace directly from their peers. In early 2020, information on COVID-19 had yet to be studied and published in peer-reviewed journals or printed in medical textbooks. Since then, social media has been characterized as both a boon to medical communities seeking real time information and a major driver of misinformation on the virus and its spread. A new study from researchers at the University of Paris provides support for social media as a potentially useful tool in the doctor’s diagnostic toolkit and a way for general practitioners with questions to connect to specialists who may have the answers.

In France, some general practitioners have turned to social media for help diagnosing common dermatological conditions. They post a deidentified photo of a skin condition to Twitter or MedPics, a private social networking site for doctors, and other clinicians can respond with their diagnosis. In a retrospective observational study, researchers compared the accuracy of using social media to crowdsource a dermatological diagnosis to the accuracy of asking a dermatologist using more traditional telemedicine methods. Researchers found that diagnoses suggested by doctors on social media generally agreed with teledermatology results, and diagnoses were even more strongly aligned when dermatologists were active in the crowdsourced response.  When the images posted to social media were reviewed by an expert committee of dermatologists, the researcher found that primary diagnoses from social media were accurate about 60% of the time, whereas teledermatology consultations were correct about 55% of the time, with no significant difference between the two studied methods.

These results suggest that social media can be as useful as teledermatology services for doctors when diagnosing common and minor dermatological conditions, but consultation with an expert dermatologist may still be necessary. The authors acknowledge that social media is less secure than standard medical communications technologies and that Twitter and other public platforms do not take the same measures to protect patients’ privacy.
 
Diagnostic Agreement Between Telemedicine on Social Networks and Teledermatology Centers
Alexandre Malmartel, MD and Sophia Serhrouchni, MD

Nov 11, 2020: Treating Opioid Addiction in Primary Care Benefits Both Patients and Cash-Strapped Medical Practices

Dateline, 11/10/2020, Ann Arbor, MI, Media contact: Noa Kim, cczu@med.umich.edu
 
Buprenorphine-based treatment for opioid addiction is in short supply in many areas of the United States. And while many physicians want to offer it, clinics are unsure how to offer buprenorphine therapy in a financially sustainable way. Cost and revenue analysis from a team of Harvard Medical School researchers finds that even cash-strapped primary practices in high-poverty rural and urban communities can offer financially sustainable buprenorphine-based opioid addiction treatment.
 
The team, led by Sanjay Basu, MD, PhD, a Harvard primary care physician and epidemiologist and Jonathan E. Fried, MD, MPH, an internal medicine resident at Brigham and Women's Hospital, interviewed practice managers and identified four common approaches to delivering buprenorphine-based treatment in primary care practices. The approaches differed based on who in the clinic delivered the majority of face-to-face care, the presence of nurse care managers, and whether care was delivered in traditional one-on-one or group settings.
 
The research team then used microsimulation modeling to identify the cost and financial benefit of delivering buprenorphine-based treatment in a variety of primary care settings, including Federally Qualified Health Centers (FQHC), non-FQHCs in both rural and urban high poverty areas,, and practices outside of high poverty areas. They found that all four approaches to care produced positive net revenue after the first year in a variety of practice settings, and net revenues were consistently highest for rural practices.
 
Physician-led treatment and shared medical visits, both of which relied on nurse care managers, consistently produced the greatest net revenue gains, generating from $29,000 to $70,000 per full-time physician per year across the practice types.
 
Additionally, net revenues were positive for all primary care practices that had at least nine patients in buprenorphine treatment per provider at any given time and no-show rates less than 34 percent. The findings suggest that in the current fee-for-service–dominated environment, offering office-based therapy for opioid addiction with buprenorphine can be a financially sustainable choice for cash-strapped primary care practices, despite hurdles.
 
Financing Buprenorphine Treatment in Primary Care: A Microsimulation Model
Jonathan E. Fried, et al.

Sep 15, 2020 Study Examines Long-Term Effects of Physician-Patient Relations on Functional Health

Dateline, 9/14/2020, Ann Arbor, MI, Media contact: Noa Kim, cczu@med.umich.edu
 
One aspect of quality medical care is the quality of physician-patient relations, according to a study from Case Western Reserve University published in the current issue of Annals of Family Medicine.
 
“The quality of physician-patient relationship warrants closer research,” the study authors write. “Prior studies have not yet clarified how changes in this fundamental relationship, occurring over time, impacts health outcomes.”
 
The research team classified patients into six mutually exclusive doctor-patient relationship trajectories over one year (from 2015 to 2016) and then looked for associations between trajectories and change in patient functional health after one year.
 
The authors utilized secondary data extracted from the Medical Expenditure Panel Survey (MEPS), which provides a nationally representative and “rich array of process and outcome data for health services research,” as they describe it. The survey asks questions such as “How often did doctors or other health providers listen carefully to you?” and “How often did doctors or other health providers explain things in a way that were easy to understand?”
 
Functional health outcomes were measured by the Short Form Survey (SF-12) quality of life questionnaire, a standard measure of how well a patient is faring in areas such as general health, physical functioning, and body pain.
 
Regardless of patients’ baseline relationship with their physician, improved relationship trajectories for the one-year interval were associated with improved functional health. Furthermore, both flat physician-patient trajectories and worsened relationship trajectories were associated with worsened functional health.
 
The results of this study demonstrate a correlation between physician-patient relationship trajectory and change in patient functional health outcomes.  However, correlation does not convincingly prove causation. Further intervention research is required to convincingly show that improving the physician-patient relationship trajectories result in improve functional health outcomes for patients.
 
“Relationship-centered care may be especially important among adults with a disproportionate burden of chronic diseases, who represent a growing subpopulation in the United States,” the authors write. “These findings may inform healthcare strategies and health policy aimed at improving patient-centered health outcomes.”
 
Assessing the Longitudinal Impact of Physician-Patient Relationship on Functional Health
R. Henry Olaisen, MPH, PhD, et al.

Jul 15, 2020: Study Finds Young Men Want to Discuss Intimate Partner Violence with Doctors

Dateline, 7/14/2020, Ann Arbor, MI, Media contact: Noa Kim, cczu@med.umich.edu
 
While stay at home orders have prevented the spread of COVID-19, they have also given rise to an increase in Intimate Partner Violence (IPV). Nearly a third of all Americans experience IPV within their lifetimes, according to the CDC.
 
A recent study published in the Annals of Family Medicine found that 90 percent of men believe healthcare providers should be open to discussing the topic of IPV as it pertains to their role as perpetrator, victim, or both. However, of the 916 men aged 18-35 surveyed in the study, only about 10 percent of participants had.
 
The study was conducted by Tova B. Walsh, Ph.D., of the School of Social Work at the University of Wisconsin-Madison, and researchers from the University of Michigan and the University of Chicago.
 
Men who reported lower levels of education were most likely to be asked about IPV. Support for discussing IPV with a healthcare provider varied by race and past experience with IPV. Black non-Hispanic men were less likely to think doctors should ask. Victims of intimate partner violence were more likely to support screening.
 
Walsh and her colleagues write that healthcare professionals are missing opportunities to identify and discuss IPV with men, and to step in with helpful interventions and referrals.
 
“Education, race/ethnicity, and history of involvement in physical IPV as perpetrator or victim were linked to beliefs about or experiences with being asked by a healthcare provider about IPV among this nationally representative sample of young men….Understanding these associations may aid primary care physicians in identifying male patients who have been perpetrators or victims of IPV, and addressing their needs for mental and behavioral health services, or referral to IPV advocacy organizations for intervention.”
 
The researchers suggest tailored identification and intervention methods to address beliefs about IPV among specific groups of young men, particularly those who disclose IPV perpetration but endorse less support for doctor interventions.
 
“Further research is needed to assess the best strategies for primary care physicians to use when identifying and responding to IPV among male populations,” the authors write.
 
Prevalence of Intimate Partner Violence and Beliefs About Partner Violence Screening Among Young Men
Tova B. Walsh, PhD, et al.

May 12, 2020: Lung Cancer Screening Study Shows Low Complication Rates with the Support of Coordinated Multidisciplinary Care Team

Dateline, 5/12/2020, Ann Arbor, MI, Media contact: Noa Kim, cczu@med.umich.edu

The benefits of routine lung cancer screenings have been hotly debated in the medical community. After reviewing a national trial published in 2011, the US Preventive Services Task Force introduced a recommendation for systematic low-dose CT lung cancer screenings for people at high risk. At the time, some leaders in the primary care community were not convinced that there was strong enough evidence in the initial trial to support routine screening. A new lung cancer screening cohort study from the Providence Cancer Institute in Portland, Oregon, conducted at a large integrated health system suggests that lung cancer screening in primary care is feasible. The study demonstrated low adverse event rates, and 70 percent of diagnosed lung cancer cases were detected at early stages in their development.

According to corresponding author John R. Handy Jr, MD, this trial confirms that lung cancer screening can be performed successfully and safely in a community setting and allaying concerns regarding generalizability of the original 2011 randomized controlled trial.

“Screening can be highly beneficial but can also create an illusion of benefits even when causing a net harm,” notes Mayo Clinic clinical epidemiologist Chyke A. Doubeni and colleagues, in an editorial response to the Handy et al study. The “window of net benefit” depends on a number of factors in the screening and treatment process, including “quality of CT images and quality of interpretation, disease prevalence in the population, patient health status, and the timeliness, safety, and effectiveness of treatment for abnormal screening results.”

Still, the authors write, “Family medicine is critical for increasing the reach of lung cancer screenings,” and primary care is an “ideal setting to improve access to screenings, particularly for underserved populations.” Therefore, family physicians should be engaged and equipped with guidance on best practices in lung cancer screenings and referrals.

Results of Lung Cancer Screening in the Community
John R. Handy, Jr, MD, HonD, et al

Lung Cancer Screening Guidelines Implementation in Primary Care: A Call to Action
Chyke A. Doubeni, MD, MPH, et al.

Mar 17, 2020: Intermittent Fasting for Diabetics: What We Can Learn from a Study of Muslims During Ramadan

A study of Muslim adults with type 2 diabetes found that those who followed an empowerment protocol with their health-care providers were able to fast safely during Ramadan.   

Dateline, 3/17/2020, Ann Arbor, MI, Media contact: Noa Kim, cczu@med.umich.edu

While intermittent fasting is growing in popularity worldwide as a diet and lifestyle choice, it has roots in religious practice around the world. During the month of Ramadan, observant Muslims abstain from food and drink from dawn to dusk. Many Muslims who have diabetes fast despite safety concerns.  

A team of health researchers at the National University of Singapore conducted a study of fasting adult Muslims with type 2 diabetes during Ramadan using a protocol for diabetes management called FAST, or “Fasting Algorithm for Singaporeans with Type 2 Diabetes.” The lead researcher Joyce Yu-Chia Lee, PharmD, now a professor at the University of California, Irvine, says, “FAST is one of the first tools that brings together Ramadan education, guidance for health care providers and elements of patient empowerment.” Trial participants who used the FAST protocol to manage their diabetes collaboratively with their health care provider saw no increase in the risk of hypoglycemic events, and greater improvements in glycemic control.

The FAST protocol seeks to empower diabetic patients who fast with culturally tailored education, dosing-modification information for patients and their doctors, and encouragement of blood glucose-monitoring before, during and after fasting. The researchers conclude that the use of tools like the FAST protocol can help observant Muslims with diabetes fast safely.

Dr. Lee notes that Muslim patients often fast without seeking medical advice “due to the fear or the fact that their healthcare providers would advise against fasting, as a diabetic.” Culturally sensitive tools like FAST fill a practice gap for health care providers and the growing number of diabetic patients who fast for religious reasons or are just considering fasting as a diet and lifestyle choice. She hopes that evidence from this trial could lead to the inclusion of culturally and religiously tailored diabetes management plans in standard practice guidelines.

Efficacy and Safety of Use of the Fasting Algorithm for Singaporeans With Type 2 Diabetes (FAST) During Ramadan: A Prospective, Multicenter, Randomized Controlled Trial
Joyce Yu-Chia Lee, PharmD, FCCP, BCPS, BCACP et al.