Table of Contents
PLAN-LANGUAGE SUMMARIES
Time for Family Medicine to Stop Enabling a Dysfunctional Health Care System
Kurt C. Stange
Background Kurt C. Stange, a family physician at Case Western Reserve University and founding editor of Annals of Family Medicine, writes an editorial in celebration of this publication’s 20th anniversary. Stange notes that at the time Annals of Family Medicine was created, those in primary care felt they should strive to prepare half of the health care workforce to provide a “basket of services'' for what was known as a “New Model of Practice.”
What This Study Found Twenty years later, Stange encourages primary care physicians to challenge the health
care system and invest in developing primary care. He argues that family physicians
need to stop enabling a dysfunctional health care system that devalues their profession.
He also believes family medicine should be revered for its ability to serve diverse
populations; should be respected for providing care that is altruistic, humanistic
and just; and that primary care physicians should be remunerated similarly to specialists.
He claims that in doing whatever it takes to integrate care into a disintegrating
health care system, primary care physicians are enabling and sustaining an unsustainable,
unfair and ineffective system. It is a system that asks doctors to meet business goals
while putting patients second?a recipe for burnout and a sense of being undervalued,
he asserts. “How ironic is it that we take the most complex task in medicine?integrating,
personalizing, and prioritizing care for whole people?try to cram it into 10 minutes,
and pay those doing this work less than those providing narrow technical care?” Stange
writes.
He suggests that his fellow family physicians focus their practice on delivering the
highest quality care for a feasible number of people and to let growing demand drive
needed systemic changes. Stange asserts that it is time to invest in developing primary
care that serves as the foundation of an effective, sustainable, and fair health care
system. Fragments of change are already occurring, he notes, with physicians who see
both advantaged and disadvantaged patients; those who work in physician-led accountable
care organizations; and in a new generation of primary care physicians who want to
have the fairness, balance and health in their own lives that they seek for their
patients.
Implications
- Stange concludes that family physicians can show the kind of care that fosters health and healing through relationships with patients and communities, and can be the change they want to see.
Denise Campbell-Scherer
Background Professor Denise Campbell-Scherer, MD, PhD, a member of the faculty of Medicine and
Dentistry at the University of Alberta, writes this issue’s editorial about four papers
focusing on addressing the challenges of obesity and diabetes on population health
and well-being.
The highlighted papers provide new insights into obesity, which affects approximately
42% of people in the United States and increases the likelihood of being diagnosed
with other health conditions. Two papers (Saslow et al and McCarthy et al) focus on
dietary changes, which can help to control not only obesity but other conditions such
as hypertension and diabetes.
What This Study Found One paper (Saslow et al) compared the DASH (Dietary Approaches to Stop Hypertension)
diet to a very low carb diet for hypertension in patients who also had diabetes or
pre-diabetes and obesity. A second paper (McCarthy et al) compared the effects of
the MyPlate diet that focused on fruit and vegetable consumption and a calorie counting
strategy—on weight loss, blood sugar, hypertension, and diabetes, as well as feeling
of satiety and satiation as a means of weight loss and management.
A third paper (Perrault et al) described clinical interventions—or lack thereof—for
adult patients seen in primary care who have a BMI of 25 or higher. Among 160,000
patients, only 12 percent received a weight-prioritized visit; fewer than six percent
had a weight-related referral, and only 334 were prescribed anti-obesity medications.
This suggests that there is a greater need for clinical intervention addressing obesity
in the primary care setting.
A fourth paper (Foss et al) analyzed the disparities in diabetes care between rural
and urban patients. The study found that rural patients have worse diabetes outcome
attainment than urban patients. Campbell-Scherer finds a common element across all
four studies in that people who are in vulnerable circumstances such as poverty struggle
with obesity management. They also don’t receive the help that can address obesity
and related diseases.
Implications
Jashvant Poeran and colleagues
Background Researchers interviewed primary care clinicians to identify trends, facilitators
and barriers in implementing and using telemedicine technologies in response to the
COVID-19 pandemic. They interviewed 25 leaders from primary care practices from the
Patient-Centered Outcomes Research Institute’s PCORnet project. Leaders represented
87 primary care practices in New York, Florida, North Carolina and Georgia.
What This Study Found The team identified four common themes among the surveyed primary care clinicians: 1) The ease of telemedicine adoption depended on the prior experiences of both patients and physicians with virtual health platforms; 2) Regulation of telemedicine varied across states and impacted roll-out processes differently; 3) Visit triage rules remain unclear post-COVID; and 4) Positive and negative impacts of telemedicine on physicians and patients. Additionally, clinicians identified opportunities to ease challenges, including the establishment of visit triage guidelines, adequate staffing and scheduling protocols.
Implications
implementation. While unique benefits were acknowledged, experiences differed based on state regulations and learning curves for de novo programs. Importantly, future needs include formal triage guidelines and specific staffing and scheduling protocols.
William J. McCarthy and colleagues
Background Researchers hypothesized that focusing on satiety (feeling free of hunger) and satiation
(feeling satisfied with a meal) through the consumption of fruits and vegetables may
be better targets for weight loss success. The researchers compared the impact of
two diets — Diabetes Prevention Program Calorie Counting versus MyPlate — on satiation
(feeling satisfied with a meal), satiety (feeling free of hunger) and on body fat
composition in primary care patients. Two hundred and sixty-one overweight, adult,
low-income Latina patients, participated in the randomized control trial over a 12
month period. Over the course of the study, community health workers conducted two
home education visits; two group education sessions; and seven telephone coaching
calls for each participant over a six-month period. The researchers measured satiation
and satiety, as well as waist circumference and body weight among participants. These
measures were assessed at the beginning of the trial and again at six- and 12-month
follow-up visits.
What This Study Found The researchers found satiation and satiety scores increased for participants on both diets. Both MyPlate and Calorie Counting participants reported higher quality of life and emotional well-being, as well as decreased waist circumference and high satisfaction with their assigned weight loss program. MyPlate participants experienced lower systolic blood pressure at a six month follow-up visit although this was not sustained over the 12-month trial period.
Implications
"Three Good Things" Digital Intervention Among Health Care Workers: A Randomized Controlled Trial
Katherine J. Gold and colleagues
Background Researchers tested a digital version of a positive psychology intervention called
“Three Good Things” (3GT) among health care workers to assess whether gratitude practice
improved well-being. Two hundred and twenty-three participants—all of whom were based
at a single, large academic medicine department—were randomized to an immediate intervention
or delayed intervention control group. During the study, participants received text
messages three times per week, prompting them to document three things for which they
were grateful.
Participants completed surveys measuring levels of depression, positive affect, gratitude,
and life satisfaction at the study’s launch and then one month and three months post-intervention.
Control group participants completed additional measures at months four and six after
completing the delayed intervention. They used linear mixed models to compare intervention
and control groups and to look at the effects of department role, gender, age, and
time on outcomes.
What This Study Found The intervention group and control group showed no significant differences in depression, gratitude, or satisfaction with life scores at months 0, 1, or 3. For depression and gratitude, scores in the intervention group were favorable immediately after the intervention but gains had been mostly lost by month 3 and were not significant. Measures of positive affect were significantly different between groups over time, particularly in the first month when the intervention group had more than a two-point jump in scores (versus 0.25 jump for the control group) that was statistically significant at the 0.05 level. However, gains had mostly disappeared by month 3. There were no differences in self-reported mental and physical health ratings between groups.
Implications
Community Support Persons and Mitigating Obstetric Racism During Childbirth
Elle Lett and colleagues
Background The purpose of this study was to assess whether the presence of community support persons (CSPs), with no hospital affiliation or alignment, mitigates acts of obstetric racism during hospitalization for labor, birth, and immediate postpartum care. The team conducted a cross-sectional cohort study, measuring 3 domains of obstetric racism as defined for, by, and with Black birthing people: 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 (weaponization of societal stereotypes and scripts in service provision that reproduce gendered anti-Black racism in the hospital). They used a novel, validated instrument, the Patient-Reported Experience Measure of Obstetric Racism (the PREM-OB Scale suite), and linear regression analysis to determine the association between CSP presence during hospital births and obstetric racism.
What This Study Found Analyses were based on 806 Black birthing people, 720 (89.3%) of whom had at least 1 CSP present throughout their labor, birth, and immediate postpartum care. The presence of CSPs was associated with fewer acts of obstetric racism across all 3 domains, with statistically significant reductions in scores in the CSP group of one-third to two-third SD units relative to the no-CSP group.
Implications
Randy Foss and colleagues
Background Mayo Clinic researchers conducted a study within their health care system to identify
factors associated with quality of care among rural and urban patients with diabetes.
The study evaluated patient attainment of a five-component diabetic care metric, known
as the D5 metric. This metric includes no tobacco use, hemoglobin A1C <8%, blood pressure
<140/90, statin use, and aspirin use. Researchers considered age, sex, race, Adjusted
Clinical Group score (a series of mutually exclusive, health status categories defined
by morbidity, age, and sex), insurance type, primary care clinician type, and health
care use data. Researchers analyzed records from 45,279 patients with diabetes receiving
treatment from primary care providers. 54.4% of these patients lived in rural locations.
39.9% of rural patients and 43.2% of urban patients (P<0.001) met all five D5 criteria.
What This Study Found Rural patients were significantly less likely to have attained all metric goals than
urban patients (AOR 0.93 [95% CI 0.88-0.97]). Compared to patients in urban areas,
rural patients had fewer outpatient visits (mean visits 3.2 vs 3.9, P<.0001) and fewer
endocrinology visits (5.5% vs 9.3%, P<.0001). Researchers concluded that rural patients
had worse diabetic quality outcomes than their urban counterparts, even after adjusting
for other contributing factors and despite being part of the same integrated health
system. The team speculated that decreased visit frequency and specialty involvement
in the rural setting were possible contributing factors to this disparity.
Patients with an endocrinology visit during the study period were less likely to meet
metric goals (0.80 [95% CI 0.73-0.86]). The reason for this could be that seriously
ill patients are typically referred to endocrinologists. The number of outpatient
visits was positively associated with metric goal attainment (1.03 [95% CI 1.03, 1.04]).
Implications
Emil L. Sigurdsson and colleagues
Background Researchers from Iceland trained a machine learning model with artificial intelligence to triage patients with respiratory symptoms before the patients visit a primary care clinic. To train the machine learning model, the researchers used only questions that a patient might be asked about before a clinic visit. Information was extracted from 1,500 clinical text notes that included a physician's interpretation of the patient's symptoms and signs, as well as reasons for clinical decisions made during the consultation, such as imaging referrals and prescriptions. Patients were categorized into one of five diagnostic categories based on information in clinical notes. Patients from all primary care clinics in the capital area of Iceland were included. The model scored each patient in two extrinsic datasets and divided patients into 10 risk groups. The researchers then analyzed selected outcomes in each group.
What This Study Found Patients in risk groups 1-5 were younger, had lower rates of lung inflammation, were less likely to be re-evaluated in primary and emergency care, were less likely to receive antibiotic prescriptions or chest X-ray referrals, as compared to higher risk groups 6-10. The lowest five groups contained no chest X-rays with signs of pneumonia or a pneumonia diagnosis by a physician.
Implications
Leigh Perreault and colleagues
Background After finding that few to no clinicians provided weight management care, researchers
developed a weight loss tool called PATHWEIGH. This tool was designed to remove clinician
barriers in providing patient care that addressed weight. Early success with the tool
led to PATHWEIGH being implemented in the health system’s 57 primary care clinics.
Researchers describe the characteristics of patients to determine the current state
of weight management efforts in 57 primary care clinics. Patients included in the
analysis were 18 years and older; had a body mass index (BMI) of more than 25 kg/m2;
and had had a weight-prioritized visit between March 17, 2020 and March 16, 2021.
Twelve percent (n=20,383) of patients that matched these criteria during this baseline
period had a weight-prioritized visit.
What This Study Found Overall, patients who had had a weight-prioritized visit had a mean age of 52 years (SD=16), 58% women, 76% non-Hispanic whites, 64% with commercial insurance, and a mean BMI of 37 kg/m2. Documented referral for weight-related concerns was low (<6%) and only 334 prescriptions for anti-obesity medications were noted. Even though most patients were privately insured, referral to any weight-related service or prescription of anti-obesity medication was uncommon.
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Implications
Laura R. Saslow and colleagues
Background Adults with hypertension, prediabetes, or type 2 diabetes, and who are overweight or obese, are at an increased risk of serious health complications. However, experts disagree about which dietary patterns and support strategies should be recommended. Researchers randomized 94 adults with the aforementioned conditions, using a 2 x 2 diet-by-support factorial design, comparing a very low-carbohydrate (VLC) or ketogenic diet versus a Dietary Approaches to Stop Hypertension (DASH) diet. Additionally, they compared results with and without extra support activities, such as mindful eating, positive emotion regulation, social support and cooking education.
What This Study Found Using intent-to-treat analyses, the VLC diet led to greater improvement in estimated
mean systolic blood pressure (SBP; –9.8 mmHg vs. –5.2 mmHg, P =.046), greater improvement
in glycosylated hemoglobin (HbA1c; –.4 % vs. –.1 %, P = 0.034), and greater improvement
in weight (–19.14 lbs vs. –10.33 lbs, P = 0.0003), compared to the DASH diet. The
addition of extra support did not have a statistically significant effect on outcomes.
Implications
Brian G. Arndt and colleagues<;
Background Amid an uptick in publications looking to quantify the electronic health record (EHR) workload faced by clinicians, researchers propose three recommendations to ensure the accuracy and replicability of research in this space.
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What This Study Found Their recommendations include: 1) separating all time working in the EHR outside time scheduled with patients from time working in the EHR during time scheduled with patients, 2) including any time before or after scheduled appointments as “after-hours,” and 3) encouraging the EHR vendor and research communities to develop validated methods for measuring active EHR use. Attributing all EHR work outside time scheduled with patients to Work Outside of Work (WOW), regardless of when it occurs, will produce an objective and standardized measure better suited for use in efforts to reduce burnout, set policy, and facilitate research.
Implications
Sakina Walji and colleagues
Background Researchers looking to better understand patient experiences are turning to patient-guided tours (PGT) of health facilities, an approach drawn from the experience-based design literature. However, little research has assessed how patients with disabilities perceive the approach. In this qualitative study, 18 patients were asked to walk through the clinic as they would on a typical visit while describing their experiences. Patients’ experiences and perceptions of the tours were audiotaped and transcribed. Additionally, investigators took field notes and completed thematic content analyses.
What This Study Found Their findings support the value of PGT methodology in understanding the experiences of patients with disabilities in the clinic setting. Patients reported that walking through the facility elicited experiences that participants said they would not have recalled using other research methods. They also reported feeling empowered when leading investigators through the clinic space and guiding researchers to “see through their eyes.”
Implications
Andrew Bazemore and colleagues;
Background In this systematic review, the authors summarized the wide range of peer-reviewed
literature that links continuity of the doctor-patient relationship to health care
costs and care utilization.This information is important to establish continuity measurement
in value-based payment design.
The authors conducted a literature review of articles published between 2002 and 2022
about "continuity of care" and "continuity of patient care," as well as payor-relevant
outcome categories, such as cost of care, health care costs, total cost of care, utilization,
ambulatory care sensitive conditions (ACSC), and ACSC hospitalizations.
What This Study Found The authors found interpersonal continuity between the doctor and patient continues to be significantly associated with reduced health care costs and increased appropriate care utilization across the literature. Out of 83 studies, 18 examined the association between continuity and health care costs; 79 assessed the association between continuity and utilization. Studies from 2002 through 2022 reported significantly lower costs associated with interpersonal continuity. Overall, the authors found that much of the literature found that interpersonal continuity between the doctor and patient remains significantly associated with lower health care costs and more appropriate care utilization.
Implications
Three Thirty-Two AM: My Last Call
Sarina B. Schrager
Background Serena Schrager, MD, writes an essay about her decision to give up practicing obstetrics to focus on her outpatient practice. She worries about no longer practicing in a hospital setting and what that would mean for her identity as a family medicine physician. Balancing joy and stress while taking obstetrics calls had become challenging.
What This Study Found She realized that by limiting her practice scope, it would allow her to be present
with her other patients and to balance responsibilities of her own young adult children
and aging parents.
“The feeling of ‘rightness’ that I experience when seeing multiple generations of
a family embodies to me what family medicine is at its core,” she writes. “We are
patient centered, family centered, and community centered. We see people in the context
of their daily lives, not as medical problems. And that can be done no matter the
setting.”
Implications
How Can You Mend a Broken Heart?
Tanushree Nair
Background On the heels of a recent breakup, Tanushree Nair, DO, a second-year resident in the Department of Family Medicine at the University of Chicago, writes about a serendipitous encounter on Valentine’s Day with a woman in her 80s who embraced her own messy journey to finding love.
What This Study Found “I hadn’t expected the epitome of a successful dating life to come from someone my
grandmother’s age,” Nair writes. “Despite her age, this woman had managed to unlock
the door to love, while I was still struggling with the keys.”
Nair adds that she was deeply moved by her patient’s keen insight into her romantic
life and that it taught Nair a vital skill in both medicine and personal relationships?the
importance of being open to the unexpected.
Implications
Arts and Poetry in the Clinic: A Novel Approach to Enhancing Patient Care and Job Satisfaction
Tan Q. Nguyen
Background Family physicians Nguyen and Shapiro document their experiences incorporating arts and poetry into their practice at the University of California-Irvine’s Federally Qualified Health Center in Orange, California. Through the program, Nguyen provides short training sessions to other providers and medical assistants on how to incorporate art and literature into their interactions with patients, with ongoing training that incorporates best practices. The authors posit that patients and clinicians benefit from exposure to a poem, drawing or other art forms.
What This Study Found Anecdotal feedback suggests that the inclusion of arts-based activities in the clinic makes patients feel welcomed and at home. Additionally, clinicians and staff experience greater job satisfaction.
Implications