Table of Contents

Plain Language Article Summaries

Ann Fam Med 20(2)

The Issue in Brief

Implementing High-Quality Primary Care: To What End?

Robert L. Phillips, Jr

Background Robert L. Phillips, Jr., MD, MSPH, executive director of the American Board of Family Medicine and the Center for Professionalism & Value in Health Care, contributes an editorial highlighting the importance of three manuscripts in this edition of Annals, which provide unique perspectives on the National Academies of Sciences, Engineering, and Medicine 2021 report, “Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care.” Phillips is a co-author of the NASEM report, which is the first of its kind in 16 years to discuss strategies to support the survival of primary care.

What This Study Found Phillips writes that all three papers (Rodriguez et al, Henry et al, and Bierman et al) in the March/April edition of Annals of Family Medicine amplify the report’s assertion that primary care is a common good and that it requires more functional and research resources to improve health and health care.

Implications

• Phillips recommends that family medicine leaders work with legislators to introduce simple legislation directing the National Institutes of Health to create a Center for Primary Care, something he believes will serve as a foothold for the largest and least studied platform for health care to receive more research funding.

Tribute to Annals of Family Medicine Associate Editor John Frey

John Holkeboer

Background John Holkeboer, senior editorial coordinator of Annals of Family Medicine, writes a tribute to John Frey, MD, who is moving on after 14 years of service as associate editor for Annals. Frey's career has included such posts as Residency Director at UMass Medical School (1973-1979), Editor-in-Chief of Family Medicine (1984–91), President of the STFM (1998–99), and Professor and Chair at University of Wisconsin–Madison Department of Family Medicine (1993–2006), among other activities and posts.

What This Study Found A recurring theme of John’s contributions to the Family Medicine discipline is a strong feeling for the art within the science. In 2017, John launched and became lead editor of the Innovations in Primary Care feature, a forum for novel ideas based on the lived experience of those providing person- and relationship-centered, community-engaged primary care. John's creativity and leadership met a longstanding need for information that can make a difference on patient care's frontlines.
In 2019, Frey was crucial to helping a new Annals’ editorial team find their footing. In 2020, during the challenging first months of the global SARS-CoV-2 pandemic, his tireless work reviewing manuscripts and article queries were instrumental in creating an urgently needed COVID-19 preprint collection on the AnnFamMed.org website.

Implications

Physicians' Choice of Board Certification Activity Is Unaffected by Baseline Quality of Care: The TRADEMaRQ Study

Lars E. Peterson and colleagues

Background Researchers studied whether physicians reviewing their quality measures and peer comparisons would increase the probability of their choosing continuing medical accreditation activities that would address their individual quality gaps. The primary outcome that was studied was whether the selected activity reflected a quality area for which the physician scored lower than their peers. The secondary outcome they studied was time spent by physicians reviewing their quality measures dashboard.

What This Study Found Nearly 20% of the sample didn’t complete a certification activity during the study. Almost a quarter of physicians in the intervention arm never reviewed their quality dashboard. Only 27% of certification activities were completed in clinical areas where the physician’s quality of care was below average, and there was no difference between intervention and control groups. Of the 45.4% of physicians who viewed their dashboard, they typically did so two weeks before engaging in the activity. The median time spent reviewing the dashboard was 82 seconds.

Implications

Racial and Ethnic Disparities in Acute Care Use for Pediatric Asthma

Jorge Kaufmann and colleagues

Background According to a new and novel study, Latine children who prefer speaking Spanish are more likely to visit a community health center for their acute asthma symptoms than their non-Hispanic white peers. Alternatively, non-Hispanic Black children are more likely to receive asthma-related care in an emergency department than their non-Hispanic white peers.

What This Study Found The authors observed no differences between groups in asthma-related inpatient admissions. The effects of poverty may have been greater for Black children in the study, of which 73% of an Oregon-Medicaid subsample continuously lived below 138% of the federal poverty level. This was compared to 54%-58% in the other groups. The authors hypothesize that higher levels of poverty may have influenced health care utilization, as well as other factors beyond affordability, including perceived racial discrimination and trust in community health clinics.

Implications

Clinic Factors Associated With Mailed Fecal Immunochemical Test (FIT) Completion: The Difference-Making Role of Support Staff

Melinda M. Davis and colleagues

Background Colorectal cancer is preventable with screenings such as colonoscopy and fecal immunochemical tests, but only 66% of the U.S. population was up to date in 2018. The percentage dips lower at 44% in federally qualified health centers, which serve low-income, racially diverse populations. Home-based, self-administered colorectal cancer screening programs have been shown to reach broader and more diverse populations than in-office screening and may reduce disparities among populations that are disproportionately affected. However, sample return rates vary widely by patient, type of screening intervention and clinic characteristics.

What This Study Found Patients in 15 clinics within one urban FQHC participated in a trial aimed at optimizing colorectal cancer screening. Each patient was mailed a fecal immunochemical test (FIT) to be performed at home and returned to the doctor’s office via mail or in person. Researchers examined clinic-level factors associated with higher and lower FIT completion rates, including staffing patterns, availability of educational materials, and the availability of on-call patient support and troubleshooting. Clinics with higher FIT completion rates were found to have added staff to support the effort; provided patients with staff-led education upon providing FIT tests; or helped patients resolve barriers to FIT screening. Clinics with lower rates of FIT completion were found to be lacking in such support.

Implications

Diagnostic Accuracy of the Telephone Interview for Cognitive Status for the Detection of Dementia in Primary Care

Herrer Abdulrahman and colleagues

Background Researchers in the Netherlands conducted a study to evaluate the validity of a simple telephone survey widely used to screen for dementia. The survey, known as the Telephone Interview for Cognitive Status, has proved valid among patients in memory clinics and symptomatic residents in retirement communities. TICS includes 11 survey questions assessing several cognitive domains including orientation, attention, memory impairment, language, ability to plan, organize and carry out actions, and mathematical skills. Responses are then scored, with final results ranging from 0 to 41 points. A score of less than 30 represents a positive screen for dementia.

What This Study Found In the population studied, the TICS survey performed well as a low-cost diagnostic screening instrument for detecting dementia in at-risk populations in the family medicine setting. Abdulrahman et al’s study was unique in that it was administered to primary care patients who had been enrolled in a dementia prevention trial that ended four years earlier. All participants in this TICS screening study were free of dementia at the end of the previous trial.

Implications

Social Risk Factors and Desire for Assistance Among Patients Receiving Subsidized Health Care Insurance in a US-Based Integrated Delivery System

Leah Tuzzio and colleagues

Background Mounting research has shown how social health factors can place people at risk for poor health outcomes. Family physicians and their teams are increasingly called upon to assist patients who struggle with basic needs, such as housing, food and transportation. A new study from Kaiser Permanente Washington Health Research Institute in Seattle, which leads Kaiser Permanente’s Social Needs Network for Evaluation and Translation (SONNET), documented the prevalence of these social risks and assessed patients’ desire for assistance from the health system to address their needs.

What This Study Found Among the findings, 48% of study participants reported one or more social risks, with housing instability the most prevalent (70%). Participants with social risks were twice as likely to report having ‘fair’ or ‘poor health’ – even though they were similar demographically to people who didn’t have social risks. Although 90% of participants believed that health systems should assist patients at risk, 14% who reported having social risks also reported more discomfort being screened for social risks than the 5% who reported no risks. Among those with one to two social risks, only 27% desire assistance from the health system.

Implications

Failure of the Problem-Oriented Medical Paradigm and a Person-Centered Alternative

James W. Mold

Background James W. Mold, MD, MPH, the George Lynn Cross emeritus professor of Family and Preventive Medicine at University of Oklahoma Health Sciences Center, writes about the failing, problem-oriented care that most clinicians use. He poses the question, "What if instead of asking, 'What’s the matter with you?' we first asked, 'What matters to you?'"

What This Study Found Mold advocates for a paradigm shift, one that humanizes care while guiding the application of medical science to meet the unique needs and challenges of individuals seeking care. He writes that each person has unique vulnerabilities, resources, circumstances and experiences, values, and priorities, making reductionism and excessive standardization detrimental to patients’ health.

Implications

Best Practices for COVID-19 Mass Vaccination Clinics

Andrew Pinto and colleagues

Background Researchers synthesized peer-reviewed studies and guidelines on mass vaccination clinics to provide practical guidance for primary care clinicians as they plan, implement and expand efforts to vaccinate communities against COVID-19. The authors identified and synthesized the findings of 46 reports, manuals and peer-reviewed papers that addressed the planning of mass vaccination clinics prior to, and in the context of, the COVID-19 pandemic. Key considerations include management, logistics, infection control, human resources, adverse events following immunization, documentation, supplies and waste, vaccine storage and handling, and communications. This report also provides suggestions for primary care clinicians to better address challenges around vaccine supply and vaccine hesitancy.

What This Study Found This study documented the success of primary care clinicians in delivering COVID-19 vaccines within vulnerable and hard-to-reach communities. Many studies show improved vaccine uptake and confidence when family physicians and nurses strongly recommend vaccination, share personal anecdotes, and speak confidently about its safety and benefits. Many studies show improved vaccine uptake and confidence when family physicians and nurses strongly recommend vaccination, share personal anecdotes, and speak confidently about its safety and benefits.

Implications

Conceptualizing, Contextualizing, and Operationalizing Race in Quantitative Health Sciences Research

Elle Lett and colleagues

Background Patients in the U.S. experience notable differences in health outcomes across racial groups, but new research aims to shift the conversation by examining how researchers themselves account for these differences. Health equity strives to achieve the highest level of health for all people. It requires valuing everyone equally and fully acknowledging the links between health disparities and systemic racism. This is especially important in medical research, since researchers may unknowingly or unintentionally propagate harmful narratives and stereotypes of biological characteristics or cultural inferiority.

What This Study Found This new paper provides recommendations on how researchers can more appropriately engage in quantitative scientific inquiry to better understand the impact of racism on adverse health outcomes. These recommendations include applying appropriate theoretical frameworks that accurately explain how social-structural factors might interact with a disease to produce results most important for achieving health equity; drawing upon Black, Indigenous, Latine and other community consults as experts to inform public health research; measuring elements of racism in research in both new and secondary datasets; and elevating Black, Latine, and Indigenous scholars to leadership positions to conduct racial health equity research.

Implications

Implementing High-Quality Primary Care Through a Health Equity Lens

José E. Rodríguez and colleagues

Background Primary care, with its focus on both individuals and communities, could play a key role in addressing health inequities that have been exposed and exacerbated by the COVID-19 pandemic. However, the United States’s chronic underinvestment in primary care currently limits its ability to reduce health disparities.

What This Study Found Rodriguez et al apply a health equity lens to the five recommendations put forward in the 2021 National Academies of Science, Engineering and Medicine report, “Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care,” in hopes of advancing health equity by placing high-quality primary care at its center. The authors offer their perspectives, as well as strategies on how to operationalize NASEM’s five recommendations regarding the following: 1) Paying teams to care for people, not individual doctors; 2) Ensuring high-quality care is available to everyone in every community; 3) Training primary care teams where people live and work; 3) Designing information technology that serves patients, families and interprofessional care teams; and 5) Ensuring that high-quality primary care is successfully implemented.

Implications

Realizing the Dream: The Future of Primary Care Research

Arlene S. Bierman and colleagues

Background Researchers from the Agency for Healthcare Research and Quality respond to the 2021 National Academies of Sciences, Engineering, and Medicine report, “Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care”. This report discusses strategies to support the survival of primary care. It addresses financial health and recommends payment centered on people, not services. The report also emphasizes that primary care is a common good and should be accessible for every individual. It identifies five high level objectives regarding payment, access, workforce development, information technology and implementation.

What This Study Found In their response, AHRQ researchers underscore the critical role of research for successful implementation of primary care and to provide the evidence needed to enable primary care to realize its full potential. This research would emphasize whole person care in which clinicians engage patients and families in managing illness and promoting wellness, as well as payment models and technology to support them.

Implications

Health Equity: The Only Path Forward for Primary Care

Alison N. Huffstetler and colleagues

Background In 2020, 10 junior primary care physician leaders (three internists, three family physicians, and three pediatricians) provided their own perspectives on recommendations in the National Association of Sciences, Engineering, and Medicine’s report, “Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care.” The physicians were from various practice settings in the U.S., including academic, community and federally qualified health centers.

What This Study Found The group identified three themes: 1) The 4 Cs: Dr. Barbara Starfield’s original 4 Cs (first contact, continuity, coordination, and comprehensiveness) may not be inclusive of the needs of under-resourced communities; 2) Workforce: Diverse individuals are not sufficiently recruited and maintained in health care settings; 3) Payment Reform: Risk adjustment and value-based care will support equitable access and high-quality care to all communities.

Implications

The Food Box Pilot

Bery Engebretsen and colleagues

Background Beginning in 2018, members of Primary Health Care, Inc. in Des Moines, Iowa, used $10,000 in HRSA Federally Qualified Health Center supplemental funding to test the feasibility of providing food for patients with documented depression and food insecurity. They worked with a long-standing local food pantry to provide weekly food boxes for patients with moderately severe or severe depression, as well as food insecurity.

What This Study Found Sixteen of 24 patients lowered their depression scores.

Implications

Connecting Group Care Patients to Mental Health and Food Resources During the COVID-19 Pandemic

Catherine Wolcott and colleagues

Background Members of the Department of Psychiatry at the University of Colorado School of Medicine and the Department of Family Medicine at the Denver Health Hospital Authority adjusted the model of a Federally Qualified Health Center in Denver to offer virtual group visits, schedule families for individual medical visits, and screen patients for food insecurity and behavioral health needs.

What This Study Found Relationship-based, culturally congruent care allowed medical providers, group care coordinators, and psychologists to effectively pivot during the pandemic and offer support and resources to underserved families.

Implications

Adapting an In-Clinic Resource Navigator Program to a Virtual Referral Model

Kellia J. Hansmann and colleagues

Background Since 2016, the University of Wisconsin Health Northeast Family Medical Center has used a Community Resource Navigator Program, including the use of student navigators, to connect patients with community resources.The COVID-19 pandemic required staff to adopt a plan-do-study-act cycle to adapt the clinic’s social needs prescribing to a more flexible, virtual referral process.

What This Study Found The clinic adapted to the COVID-19 by integrating off-site community partners into telephone huddles, sending out shared health record reminders, and establishing telephone and/or email connections.

Implications