Index by author
Plain Language Summaries of Articles in This Issue
Caroline R. Richardson
Background
The January/February edition of Annals of Family Medicine presents a research package highlighting the massive impact that COVID-19 has had on the family medicine landscape.
What This Study Found This edition includes original research papers on the alarming reduction in diagnoses of common chronic conditions such as diabetes and hypertension in Spain, as compared to the number of diagnoses 3 years prior to the pandemic; a family medicine residency team that collaborated to increase vaccination rates among low-vaccine use communities; and the development of a virtual extension program to support primary care teams in the community. Additionally, this edition of Annals features research exploring the impact of the telehealth transition on caregivers and the troubling decline in manuscript submissions by female researchers as compared to their male counterparts in Annals of Family Medicine after the onset of COVID.
Implications
- This collection of COVID-19 impact articles presents concerning data about the impact of COVID-19 on primary care above and beyond the direct impact of the virus on the health of patients and health care teams, according to Annals Editor-in-Chief Caroline Richardson, MD, this edition’s editorialist. She goes on to say that research, innovation, and evaluation efforts will play a critical role in guiding policy and practice as we navigate a world with COVID-19.
Barriers to Guideline-Based Use of Proton Pump Inhibitors to Prevent Upper Gastrointestinal Bleeding
Jacob E. Kurlander and colleagues
Background Researchers explored the prescribing practices and barriers doctors face when deciding whether to implement gastroprotection through the use of proton pump inhibitors. They interviewed 5 primary care physicians, 4 cardiologists, 3 gastroenterologists, and 3 vascular surgeons within a single institution to produce qualitative results for this study.
What This Study Found Most primary care physicians, gastroenterologists, and vascular surgeons seldom prescribed gastroprotection. Cardiologists varied most in their use of proton pump inhibitor gastroprotection. Other health care professionals never prescribed proton pump inhibitors. Barriers revolved around knowledge, decision processes, and professional roles in prescribing proton pump inhibitors. Knowledge about prescribing guidelines was greatest among cardiologists and gastroenterologists and low among primary care physicians and vascular surgeons. Barriers operated differently across specialties.
Implications
- Multi-component interventions will likely be necessary to improve guidelines-based use of proton pump inhibitors to prevent upper gastrointestinal bleeding.
Laura Seewald and colleagues
Background US adults use technology-faciliated communication tools to form and maintain intimate relationships. For couples who report that digital tools have had at least a minor impact on their relationships, 74% report that these tools have had a positive impact. However, as digital tools become integrated into intimate relationships, intimate partner violence delivered by technological means has become a public health concern.
What This Study Found Results from a nationally representative sample of young men aged 18-35 in the US indicate that technology-facilitated abuse is common, with 38% of young men surveyed indicating that they either delivered, received, or both delivered and received technology-facilitated abuse in the last year. The majority of young men who reported experiences with technology-facilitated abuse both delivered and received abuse. This pattern is similar to patterns seen in non-technology–facilitated abuse male intimate partner violence.
Furthermore, the study found that men who reported ever having mental health care
visits, those who owned smartphones, and those who self-reported substance misuse
were more likely to both deliver and receive technology-facilitated abuse. Depression,
education level, and employment status were not found to correlate with technology-facilitated
abuse.
Implications
- With increased focus on screening for intimate partner violence in primary and emergency care settings, the authors argue for the expansion of intimate partner violence screening questions among male patients in the clinical setting to include technology-facilitated abuse. Clinicians can consider adapting intimate partner violence screening tools that have been validated among women, including the Partner Violence Screen and Index of Spousal Abuse, for assessment of intimate partner violence and technology-facilitated abuse among male patients.
Increasing Capacity for Treatment of Opioid Use Disorder in Rural Primary Care Practices
Linda Zittleman and colleagues
Background Researchers studied the implementation of a multilevel program called Implementing Technology and Medication Assisted Treatment Team Training in Rural Colorado (IT MATTTRs). The program included a practice-focused intervention to improve the awareness, adoption, and use of buprenorphine to treat opioid dependence and opioid use disorder (OUD). Four hundred and forty-one team members from 42 practices in Colorado received team training and support. Treatment components that support team-based care as well as clinicians’ obtaining the Drug Enforcement Agency waiver needed to prescribe buprenorphine for OUD, were assessed before and after training implementation.
What This Study Found Prior to training, practices reported having an average of 4.7 treatment-related components, such as patient consent forms or a urine drug testing protocol, in place. Practices reported an average of 13 components at 12 months post-intervention. The proportion of participating practices providing or referring patients for treatment increased from 18.8% to 74.4%, and the number of people with a prescription for buprenorphine in the rural Colorado study region was significantly greater over a 4-year period (87%) compared to the rest of the state (65%).
Implications
- IT MATTTRS training for primary care teams in OUD treatment with buprenorphine addresses elements beyond the required clinician waiver training to make implementation a reality. It effectively increased implementation and treatment delivery in Colorado.
Impact of Team-Based Care on Emergency Department Use
Tara Kiran and colleagues
Background Researchers sought to assess the impact of team-based care on emergency department
use in physicians transitioning from fee-for-service to capitation payment in which
practices are paid a fixed monthly fee for taking care of a panel of patients.
The authors compared annual emergency department visit rates of approximately 2.5
million patients from Ontario, Canada, before and after the transition from an enhanced
fee-for-service to either a team or a non-team blended capitation model. Specifically,
they compared team and non-team emergency department visit rates in big cities, small
towns and rural areas.
What This Study Found In all 3 environments, there was a slower increase in emergency department visits for team patient care relative to non-team patient care after the transition. This slower increase in ED use occurred even after taking into account differences in patient age, sex, neighborhood, income, recent registration and comorbidity. Although the analysis showed an overall increase in emergency department visits, the rate of increase was lower among patients who transitioned to a team-based, capitated primary care practice than those who transitioned to a capitated practice without an inter-professional team.
Implications
- Findings are consistent with evidence supporting the role of extended health care teams in improving service delivery. Adoption of team-based primary care may reduce emergency department use. However, further research is needed to understand optimal team composition and roles.
COVID-19 and Gender Differences in Family Medicine Scholarship
Katherine M. Wright and colleagues
Background Researchers from Northwestern University’s Feinberg School of Medicine and Rush University conducted a bibliometric analysis of Annals of Family Medicine to explore how the COVID-19 pandemic has impacted submission rates based on gender.
What This Study Found Examining submission rates from January 1, 2015 to July 15, 2020, the study authors
found that women represented 46.33% of all manuscript submissions. They found that
the overall volume of submissions increased during COVID-19 as compared to pre-pandemic
months though submissions increased by 122% for men and 101% for women.
In the early months of the pandemic, 244 submissions were authored by men (58.5%)
versus 173 submissions authored by women (41.5%). Throughout the pandemic, men submitted
more original research articles and research briefs compared to women.
Implications
- Since the beginning of shelter-in-place orders, women scientists have experienced a significant decrease in work productivity in comparison to men. This may mean that in the future, they are less likely to be promoted within their field. Academic medical centers should reevaluate promotion and tenure considerations to reflect the shift in education and clinical needs in response to COVID-19. Additionally, more supportive policies around parental leave, childcare, and tenure extensions are needed, which may help mitigate challenges faced by women researchers during the pandemic.
Tammy C. Hoffmann and colleagues
Background Overprescription of antibiotics has led to resistant bacteria, which are becoming more difficult to treat. The problem is particularly concerning in Australia, which has high rates of antibiotic prescriptions, the majority of which are written in the primary care setting. In this clustered, randomized trial, researchers piloted and evaluated a series of work aids to allow doctors to more easily talk with their patients about the benefits and risks of different antibiotic prescriptions. The aids consisted of a double-sided document presenting the options of managing the condition with and without antibiotics, and the evidence-based benefits and harms of each option, as well as a 15-minute video-delivered training.
What This Study Found Shared decision-making tools, provided to 122 general practitioners from 27 practices, did not reduce acute respiratory infection-related antibiotic dispensing more than usual care. However, general practitioners’ knowledge of relevant benefit-harm evidence increased significantly after the intervention.
Implications
- The patient decision aids should be made available for use in consultations as they were acceptable and useful, according to the most intervention group general practitioners; contributed to improved GP knowledge of relevant evidence; and appeared to be associated with a greater extent of shared decision making in consultations.
Alyna T. Chien and colleagues
Background With behavioral health problems on the rise among children in the United States, primary care practices are often the first stop for families seeking care needed to treat conditions like depression, anxiety, and substance use disorders. In order to treat these patients, primary care practices must navigate a patchwork of rapidly changing standards of care, siloed human resources, and shifting payment models. This study attempts to quantify how difficult it is for practices to obtain pediatric medication advice, evidence-based psychotherapy, and family-based therapy in this context.
What This Study Found Researchers determined that more than 85% of the practices included in the study found it difficult to obtain help with evidence-based elements of pediatric behavioral health care. The percent experiencing difficulty was similar between system-owned and independent practices, but was lower for Medicaid Accountable Care Organization practices for medication advice (80% vs 89%) and evidence-based psychotherapy (81% vs 90%). Differences were not significant for family-based treatment (85% vs 91%).
Implications
- The study illustrates that significant barriers exist to pediatric behavioral health treatment across the primary care landscape, regardless of institution size, clinic ownership, or payor mix. Policy changes may be necessary to address these barriers.
Anna L. Steeves-Reece and colleagues
Background Researchers from Oregon Health & Science University created an 11-session COVID-19
Extension for Community Outcomes (ECHO) program, which served as a telementoring education
model for clinicians involved in the ongoing COVID-19 pandemic. They encouraged interactions
between the participants via a chat box. Researchers used the text extracted from
chat box interactions to assess how communications within the statewide program identified
and fulfilled some of the clinicians’ needs during the pandemic.
Researchers conducted a qualitative analysis of 11 chat box transcripts and explored
the context of clinicians’ needs, as conceptualized by Maslow’s hierarchy of needs.
What This Study Found Steeves-Reece et al identified 3 key content themes from clinicians using the chat
box: answers and trustworthy information; practical resources; and affirmation and
peer support. The chat box supported many clinicians’ needs, including the ability
to ask questions and provide comments during this rapidly changing health care environment.
Implications
- 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. While interactive virtual education programs may be helpful, greater investments in both public health and primary care are fundamental for supporting clinicians’ ability to respond in a crisis.
Erin L. Kelly and colleagues
Background Researchers sought to understand the strategies that clinical and administrative staff at primary care practices use to manage challenges faced by the primary care workforce under strain by an ongoing state of emergency due to the COVID-19 pandemic. Researchers conducted short, semistructured, qualitative interviews among 33 staff members from 8 practices within a single health care system.
What This Study Found Participants said that they had to adapt every aspect of primary care service delivery
for COVID-19--such as patient scheduling, switching to telehealth visits, and increased
sanitation responsibilities--which significantly increased their job demands. New
skill development opportunities and sense of purpose during this period increased
a sense of pride in some staff members and most teams reported greater support and
patience within their practices. Participants also learned to reframe their responsibilities
as a necessity during the pandemic. Management support also helped. However, as the
pandemic has continued, staff reported that they experienced more feelings of burnout.
Implications
- Understanding the impact of the pandemic on health care clinicians could potentially allow health organizations to support workforce well being, prevent burnout, and sustain the quality of patient care.
Impact of the COVID-19 Pandemic on Primary Health Care Disease Incidence Rates: 2017 to 2020
Antoni Sisó-Almirall and colleagues
Background New diagnoses of common chronic conditions have dramatically declined during the COVID-19 pandemic, according to a study analyzing variations in annual incidence rates of the main cardiovascular risk factors, chronic diseases, and some cancers in 2020, compared with 2017-2019.
What This Study Found Researchers found a reduction in newly reported diagnoses ranging from a 36% decline
for hypercholesterolemia diagnoses to a 50% decline of COPD diagnoses. Additionally,
the rate of diagnosis of anxiety disorders increased by 16% while the diagnoses of
alcohol use disorder decreased by 46%.
The authors believe that the decline of face-to-face patient visits for non-essential
care in response to the ongoing COVID-19 pandemic is largely responsible for this
alarming trend.
Implications
- Siso-Almirall et al write that 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.
Family Caregivers' Experiences With Telehealth During COVID-19: Insights From Michigan
Minakshi Raj and colleagues
Background Researchers administered an online survey to 90 family caregivers of older adults across the state of Michigan to assess their perceptions of the benefits and barriers of telemedicine. Of those caregivers surveyed who participated in a relative’s telehealth visit, less than half participated from the same audio/video connection. The majority of those caregivers perceived benefits of participating in the visits, many caregivers were not physically with their relative at the time of the appointment and therefore were unable to provide technical support.
What This Study Found Perceived benefits of telehealth included increasing access to care, continuity of care, limiting risk of exposure to COVID-19, and improving the relationship and rapport between their older relatives and care providers. Perceived barriers included concerns about their older relative’s ability to use telehealth technology independently, a loss of patient-provider rapport, and a decline in quality of care for chronic conditions requiring special types of medical technologies, a doctor’s touch, hands-on assessments, or close visual observation.
Implications
- The researchers argue that policies shaping telehealth should include family caregivers’ input and that the engagement of caregivers in telehealth visits may be critical for enhancing older adults’ ability to age in place.
Youths' Knowledge and Perceptions of Health Risks Associated With Unprotected Oral Sex
Tammy Chang and colleagues
Background Rates of sexually transmitted infections associated with oral sex are rising, yet less than 10% of youths report using protection. Researchers assessed more than 900 youths' knowledge of the risks of oral sex and barriers to using protection through the use of MyVoice, a national text message–based poll.
What This Study Found Barriers to using protection when engaging in oral sex included a lack of knowledge of the risks, limited access to and dissatisfaction with protection methods, and cultural norms. Many respondents knew that some STIs can be transmitted through unprotected oral sex, but many youths also underestimated the severity of risk associated with the act. Participants also reported a lack of information about adequate protection methods as barriers to their engaging in safe oral sex. Some respondents expressed a lesser concern for sexually transmitted infections as compared to pregnancy.
Implications
- Youths suggested that greater sex education, frank discussions about oral sex vs saying "don’t have oral sex," and normalized mentions in the media would increase their use of protection. Researchers concluded that programs tailored to decrease rates of sexually transmitted infections among youths should include education on the use of sexual protective devices in oral sex.
Linda C. Chyr and colleagues
Background Researchers from Johns Hopkins University conducted a systematic review to evaluate the availability, effectiveness, and implementation of models integrating palliative care in ambulatory care settings. They synthesized results from qualitative, mixed methods, and quantitative studies analyzing palliative care models for US adults with noncancer-related chronic illness or conditions such as advanced heart failure, advanced COPD, and end-stage renal disease.
What This Study Found The authors found that models for integrating palliative care in ambulatory care settings may have little to no effect on reducing overall symptom burden and were not more effective than usual care for improving health-related quality of life or depressive symptom scores. However, the models were more effective for increasing advanced directive documentation. They identified that patient preferences for appropriate timing of palliative care varied. They also identified costs, additional visits, and travel as barriers to implementing palliative care models
Implications
- Future research is warranted to advance the science of palliative care by identifying components, characteristics, and implementation factors that are critical to models for integrating palliative care in ambulatory care settings and that will improve patient-centered outcomes and incorporate patients’ perspectives on care delivery.
Sam's Story: The Financial and Human Costs of Disjointed Logics of Care
Jennifer Karlin
Background Family physician Jennifer Karlin, MD, PhD of the University of California, Davis, calls on fellow primary care physicians to redefine the boundaries of medical interventions to include social determinants of health. She documents the experiences of her former patient Sam, who initially sought treatment for hepatitis C, but required additional social support for a substance abuse disorder and insecure housing.
What This Study Found Together, Dr. Karlin and Sam developed a care plan, with Sam’s assurances that he would not miss an appointment and would take his medications. Sam remained sober and had kept all of his appointments with Dr. Karlin for a year. However, after he was hospitalized for endocarditis requiring an aortic valve replacement, his long-term discharge plan to a rehabilitation center and later permanent housing ran afoul; Sam was denied transitional housing because he was on medically assisted therapy for his substance use disorder. The author describes this shortsighted decision to deny him housing due to his treatment for narcotics addiction as a defect in the social safety net, ultimately leading to Sam’s death.
Implications
- Karlin concludes that redefining the boundaries of medical intervention to include structures that support patients' social needs would not only prevent human and financial losses, it would address barriers to care faced by patients like Sam, who are considered among the most vulnerable patient population.
A Multidisciplinary Precision Medicine Service in Primary Care
Mylynda Massart and colleagues
Background In July 2019, the University of Pennsylvania Medical Center Health System launched the Primary Care Precision Medicine clinic to deliver genomic testing and services in the primary care setting. A multidisciplinary primary care team focused on how precision medicine can expand patient access to genetic services.
What This Study Found Since the program’s launch, staff has received 99 referrals from other primary care clinicians. Of these referrals, 61 were for genetic cancer risk assessment; 29 for pharmacogenomic testing; and 9 for validation and interpretation of direct-to-consumer testing.
Implications
- Their program provides what they feel is an innovative and accessible approach to offering intermediate genetic services care for primary care patients.
The Effect of a Shared Decision-Making Process on Acceptance of Colorectal Cancer Screening
Ethan M. Berke and colleagues
Background Using data from OptumLabs, researchers implemented a shared decision-making process to educate patients on risks, harms, and benefits of 3 options for colorectal cancer screening, whether it is in the clinic or by using a noninvasive screening test.
What This Study Found The study found that in-office shared decision-making processes for colorectal cancer screening, facilitated by information and guidance for clinicians, helps patients select the best screening test for themselves.
Implications
- The majority of patients selected less invasive, non-colonoscopy alternatives to colorectal cancer screening. The shared decision-making approach significantly increased screening rates.
Addressing COVID-19 Immunization Disparities Through Targeted Primary Care Outreach
Emmeline Ha and colleagues
Background Members of the Stanford-O’Connor Family Medicine Residency developed an outreach process in collaboration with a community health clinic in San Jose, California, to distribute COVID-19 vaccinations in January 2021.
What This Study Found They identified communities with low vaccination rates and patients in those communities who were not vaccinated. They attempted to contact 36 patients and successfully reached 20 patients. Fourteen of 15 referred unvaccinated patients received at least 1 dose of the vaccine through the clinic.
Implications
- Due to this successful innovation, an institutional, staff-based outreach program
has been initiated in the larger clinic population.
Targeted Advanced Home Care for Patients With Moderate or Severe COVID-19
Koki Kato and colleagues
Background Primary care doctors in Japan collaborated with public health and emergency response officials to organize rapid response measures to triage and treat at-home patients with COVID-19.
What This Study Found Primary care physicians and visiting nurses provided home visits and implemented home oxygen therapy and dexamethasone administration in individuals with severe COVID-19 cases. The team provided home visits for 17 patients during May 2021 when coronavirus cases soared in Sapporo, Japan.
Implications
- They hope their experience helps worldwide primary care teams to treat moderate and severe COVID-19 patients at home.