Table of Contents
The Issue in Brief
Ann Fam Med 19(5)
The Issue in Brief
Addressing the Use of Teams in Primary Care
Jose E. Rodriguez and Therese Zink
Background In this editorial, authors Rodriguez and Zink call for rapid recruitment and upskilling of interprofessional teams to meet future primary care needs across the U.S as called for in the National Academies of Sciences, Engineering, and Medicine’s report on Implementing High-Quality Primary Care.
What This Study Found The authors provide a high level overview of articles in this edition of Annals, addressing potential solutions to the problem of burnout and pay equity for all members of the primary care team, including medical assistants (Vilendrer et al; Shaw et al), and a paper exploring how information technology and artificial intelligence can assist with pre-visit planning and the need for rigorous evaluation of these technologies in patient-physician relationship support (Holdsworth et al). Additionally, the authors suggest turning to the approach used in the education of MAs and community health workers, training community members in their communities to serve their communities, to meet NASEM’S directive to carefully expand and diversify health care teams.
ImplicationsImplementing diverse teams will require further research and may be approached in various ways. Rodriguez and Zink suggest multiple directions, including examining if a diverse team impacts patient care and outcomes to the same degree as provider-patient race concordance, and how diversification can be expanded beyond the lowest paying jobs in health care.
Implementation of a Hearing Loss Screening Intervention in Primary Care
Melissa DeJonckheere and colleagues
Background Researchers present clinicians’ perspectives on the implementation process for appropriate referrals for hearing loss (HL) screening. The authors implemented a prompt in the electronic health record to remind clinicians to consider audiology referral for patients 55 and older and then observed clinic processes and conducted semi-structured interviews with family medicine clinicians who interacted with the technology. Data was analyzed using thematic, framework and mixed methods integration strategies. The team interviewed 27 clinicians and conducted 10 field observations.
What This Study Found Thematic analyses resulted in six themes including: 1) the prompt was “overwhelmingly” easy to use and was accurate; 2) clinician considered the prompt an effective way to increase awareness of patients about HL; 3) clinician and staff buy-in was vital in implementing the prompt; 4) clinicians prioritized the prompt during annual visits; 5) medical assistant involvement in workflow varied by health system, clinic and clinician; and 6) the prompt resulted in more conversations with patients about HL.
ImplicationsGiven that integration of the screening prompt varied, further research is needed to understand how to leverage clinician and staff buy-in and whether implementation of a new clinical prompt has a sustained impact on HL screening and patient outcomes.
Yiska Loewenberg Weisband and colleagues
Background Researchers from Hebrew University-Hadassah in Jerusalem and Cardioinfantil Foundation, Cardiology Institute in Bogota, Colombia, conducted a repeated, cross-sectional study to examine whether breast, colorectal and cervical cancer screening rates in women differed by age and socioeconomic position , and whether screening rates and socioeconomic disparities changed following the introduction of a primary care-based national quality indicator program. The study included all female Israeli residents in age ranges appropriate for each screening assessed, in 2002-2017, with a cohort of more than 1.5 million records. Screening rates were highest for breast cancer (70.5%), followed by colorectal (64.3%) and cervical cancer (49.6%).
What This Study Found Following the introduction of relevant quality indicators, breast and colorectal cancer screening rates increased, with greater reductions in disparities for breast cancer. In contrast, the rates for cervical cancer screening showed no change because this cancer was not included in the initial quality indicators.
ImplicationsThe recent introduction of a cervical cancer screening indicator may increase participation and reduce disparities, as was seen in breast and colorectal cancer screenings.
COVID-19 Personal Protective Equipment in the Home: Navigating the Complexity of Donning and Doffing
José Pereira and colleague
Background Researchers describe a protocol for donning and doffing personal protective equipment in home settings for health care professionals who must interact with patients potentially infected with COVID-19. This protocol addresses gaps in COVID-19 related guidelines, specifically the process of donning and doffing PPE during home visits while supplementing PPE guidelines and protocols.
What This Study Found To create the protocol, the researchers used an interactive, rapid-prototyping approach. A small workgroup created preliminary drafts, drawing upon hospital-based protocols and modifying them while undertaking simulations. They received wider input by conducting two webinars — one regional in the Hamilton, Ontario, Canada area with palliative clinicians and another that included clinicians from across Canada. Researchers also consulted a group of infectious disease experts.
ImplicationsIn addition to PPE-related equipment like gloves and surgical masks, the protocol recommends additional materials including two pails for transporting supplies, plastic bags, hand sanitizer, disinfectant wipes, and printed, easy-to-use checklists. Additionally, the team created a “how to” video to accompany the protocol, which includes guidance on how to prepare for a home visit; entering the home; leaving the home; post-visit and reprocessing.
Jonathan G. Shaw and colleagues
Background The authors assessed the effectiveness of Primary Care 2.0, a team-based model that includes an increase in the medical assistant-to-primary care physician ratio; advanced practice provider integration; expanded medical assistants’ roles; and utilization of an extended interprofessional team to support medical assistants. Researchers conducted a prospective, quasi-experimental evaluation of staff and clinician team development and wellness survey data, comparing the program to conventional clinics within Stanford Healthcare. They surveyed staff and clinicians prior to model launch and again at nine, 15- and 24-month intervals post-launch. The team also assessed secondary data, including cost, quality metrics and patient satisfaction via routinely collected operational data.
What This Study Found Results indicated that team development significantly increased in the Primary Care 2.0 clinic and was sustained across all three post-implementation intervals. Among the wellness domains, only “control of work” approached significant gains but was not sustained. Burnout showed early trends towards improvement post-implementation but never reached statistical significance and the trend was not sustained over 24 months. Adjusted models confirmed an inverse relationship between team development and burnout. Secondary outcomes, which included cost, quality and patient satisfaction, generally remained stable between intervention and comparison clinics, with labor costs decreasing over the four fiscal years post-launch.
ImplicationsThe Primary Care 2.0 model of enhanced team-based primary care demonstrates a path to increased team development, which could play a role in protecting health care professionals against burnout, but is not sufficient in preventing it.
Laura M. Holdsworth and colleagues
Background A Stanford-based group of authors explored barriers to implementation, evidence of impact and potential use of artificial intelligence and non-AI tools to support pre-visit planning. Based on previous research, AI and non-AI tools may improve the effectiveness, efficiency and experience of care. The team used an environmental scanning approach involving a literature review; key informant interviews with pre-visit planning experts in ambulatory care; and a public domain search for technology-enabled and AI solutions that support pre-visit planning. They synthesized findings using a qualitative matrix analysis.
What This Study Found The authors found 26 unique pre-visit planning implementations in the literature and conducted 16 key informant interviews. Key informants reported that many pre-visit planning barriers are human effort-related and see the potential for non-AI and AI technologies to support certain aspects of pre-visit planning. They also identified eight examples of commercially-available technology-enabled tools supporting pre-visit planning, some with AI capabilities. However, few of these technologies have been independently evaluated.
ImplicationsThe study concluded that pre-visit planning activities, driven by humans and modifiable by technology, may become more important and powerful, and should be rigorously evaluated.
Stacie Vilendrer and colleagues
Background Medical assistants have seen their roles expand as a result of team-based primary care models. Unlike their health care provider colleagues, however, financial incentives are rarely a part of MA compensation. Researchers conducted an exploratory evaluation to understand MAs’ attitudes toward financial incentives and their perceived control over common population health measures. The study team conducted semi-structured focus groups across 10 clinics based in three institutions in California and Utah. They analyzed MA perceptions of experienced and hypothetical financial incentives, their potential influence on workflow processes, and the level of control related to population health measures to identify emerging themes.
What This Study Found MAs reported little direct experience with financial incentives. A hypothetical bonus representing 2-3% of average annual base pay was reported as acceptable and influential in improving consistent performance during patient rooming workflow. MAs also indicated that relatively small financial incentives would increase their motivation and quality of care.
Hanne A. Boon and colleagues
Background Researchers conducted a systematic review to assess the diagnostic value of certain physical symptoms that children may display that could indicate a urinary tract infection. The team performed literature reviews of the most prominent medical research databases for studies reporting specific diagnostic accuracy data for clinical signs and symptoms compared to the use of urine cultures in children 18 and younger. For each clinical feature, the team calculated the likelihood ratios and predictive values for UTI. Researchers conducted several analyses to do this. Of the almost 11,000 studies they accessed, 35 studies of moderate to high quality were included and provided information on 58 clinical symptoms and six prediction rules.
What This Study Found The team found that only circumcision, diaper rash and stridor (a high-pitched vibrating, breathing sound in the throat, caused by a possible airway obstruction) are useful for ruling out UTI and that body temperature or fever duration have limited diagnostic value. Presence of cloudy urine, malodorous urine, hematuria, no fluid instake, suprapubic tenderness, and loin tenderness increase the probability of UTI.
ImplicationsPhysicians should not restrict urine sampling to children with unexplained fever or specific features suggestive of a urinary tract infection.
Voice Assistants and Cancer Screening: A Comparison of Alexa, Siri, Google Assistant, and Cortana
Steven Lin and colleagues
Background Researchers compared four widely used voice assistants — Amazon Alexa, Apple Siri, Google Assistant and Microsoft Cortana — to determine the quality and accuracy of responses to questions about cancer screening. The study was conducted using the smartphones of five investigators. Each voice assistant received two independent reviews. The primary outcome was each device’s response to the query, “Should I get screened for (type of) cancer” for 11 cancer types. The researchers assessed the assistants’ ability to 1) understand the queries; 2) provide accurate information through web searches; and 3) provide accurate information verbally. The team compared the assistants’ responses to the U.S. Preventive Services Task Force’s cancer screening guidelines. A response was deemed accurate if it did not directly contradict guideline information and if the response included a starting age for screening consistent with the guidelines.
What This Study Found Siri, Google Assistant and Cortana understood 100% of the queries, consistently generating a web search and/or verbal response, while Alexa was unable to understand or respond to any of the queries. Researchers also found that the top three links to additional resources provided by Siri, Google Assistant and Cortana provided information consistent with USPSTF guidelines roughly 70% of the time. However, the authors noted that the voice assistants’ responses to vocal queries were either unavailable or less accurate than text-based web searches, denoting room for improvement across all voice assistants.
ImplicationsThe study could have implications for users who rely on voice assistants to retrieve important health information and for those who are sight-impaired, less tech-savvy, or have low health literacy.
Shared Language for Shared Work in Population Health
C.J. Peek and colleagues
Background A large group of family medicine researchers, educators and clinicians propose a framework of definitions to clarify the similarities, differences and relationships between common terms used by those involved in population health, community health and “public health.”
What This Study Found A diagram of common population and community health terms for navigating the territory includes goals such as health, population health, and community health; realities such as social determinants, disparities and equity; and ways to get the job done such as care delivery, primary care, and public health, along with a broad zone of collaboration. This is designed to enable people to move forward in collaboration for health with less confusion, ambiguity and conflict.
ImplicationsShared language for shared work is important not only for division of labor, but for teaching clinicians, public health students and others to work effectively and collaboratively in different settings and to make the subject more intelligible for researchers, policymakers and funders.
Defining the "New Normal" in Primary Care
Kellia J. Hansmann and colleagues
Background The COVID-19 pandemic has forced health care organizations in the United States to transform themselves at an unprecedented rate, with a marked shift to telemedicine. Despite their rapid adoption of patient safety protocols and a shifting insurance landscape, many primary care offices face drastic decreases in revenue.
What This Study Found Primary care’s adaptations will need to go beyond virtual versions of the traditional office visit and redefine what it means to care for and support patients. Primary care physicians have an opportunity to shape the “new normal” and lead a paradigm shift at a time when our health care system needs it the most. The authors advocate for payment models that allow primary care to embrace innovations for patients to get the right care from the right team member at the right time, regardless of where the patient is located.
ImplicationsA return to the “old normal” would mean a continuation of existing disparities in health outcomes and health inequities. Hansmann et al write that beyond the chaos of a global pandemic is an opportunity for bold action that the health care system has needed for decades. Those in health care are well poised to embrace innovative strategies that provide the support and care all patients need where and when they need it.
Mourning My Patient, Mr Schwartz
Ruth Kannai and Aya Rice Alon
Background Ruth Kannai, MD, of the Department of Family Medicine at Ben-Gurion University of the Negev, Israel, writes an essay about her interactions and 20-year relationship with an elderly Holocaust survivor who, towards the end of his life, made repeated requests for her assistance in ending his life as he experienced worsening COPD and metastasized pancreatic cancer.
What This Study Found Dr. Kannai describes her interactions with her patient’s family members who had different opinions about how she should administer end-of-life care. Her narrative shares the emotions she experienced when her patient, Mr. Schwartz refused treatment for his medical conditions. She describes being moved by his honesty; feeling frustrated at her inability to offer him relief or a sense of meaning; and pensive as she reflects on existential issues regarding her role as a doctor and her relationships with her own loved ones.
ImplicationsDr. Kannai writes that she came to accept that even if she felt unable to help, the mere act of her showing up consistently for her patient was in fact a gift she could give him, “For he was able to at least express his despair and anger and not remain alone with it.” She allowed him to have an impact on her willingness to remain open to such personal connections, for this is what she calls the heart and soul of family medicine.
“I Need to Keep Me and My Mother Safe”: The Asylum Crisis at the US-Mexico Border
Elena Hill
Background Elena Hill, MD, MPH, a recent graduate of Boston Medical Center’s Family Medicine Residency Program, is a volunteer physician with the not-for-profit Refugee Health Alliance in Tijuana, Mexico.
What This Study Found Dr. Hill writes about the “hard” lessons she learned about the asylum process, or lack thereof, at the U.S.-Mexico border. She mentions a modern-day list of more than 15,000 asylum seekers who want a chance at a new life in the U.S. and tells the stories of three individuals who are seeking asylum. Due to a lack of transparency about how the asylum system works, thousands of families are stranded in Mexico without basic rights, including health care, she notes.
ImplicationsDr. Hill wants to make health care professionals aware of what she describes as a largely fabricated ‘asylum system’ and be an active faction in the fight for its reform.
Moving From In-Person to Telehealth Group Visits for a Mindful-Eating Healthy Nutrition Program
Jennifer K. Carroll and colleagues
Background COVID-19 required a transition from in-person to virtual team meetings.
What This Study Found With that transition, a mindful-eating and nutrition program experienced benefits and challenges of adapting technologies, interpersonal communications, accessibility, staffing and time for patients, staff and clinicians.