Table of Contents
PLAIN-LANGUAGE ARTICLE SUMMARIES
Rebecca S. Etz and colleagues
Background Researchers from Virginia Commonwealth University and Case Western Reserve University conducted weekly and monthly surveys of primary care clinicians to examine the use of telemedicine during the COVID-19 pandemic. The e-surveys were conducted between March 2020 and March 2022 and used convenience sampling. A total of 36 surveys were completed, with an average of 937 respondents per survey, representing clinicians from all 50 states and from multiple specialties.
What This Study Found Initially, respondents reported difficulties in implementing telemedicine, citing challenges with infrastructure and reimbursement mechanisms.
Implications
Personal Continuity and Appropriate Prescribing in Primary Care
Jettie Bont and colleagues
Background Researchers from the Netherlands conducted an observational study to determine the association between personal continuity and potentially inappropriate prescriptions (PIPs) by family physicians in older patients. PIPs can be categorized as potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs). The study utilized anonymized routine care data from 269,478 patients, receiving care in 48 Dutch family practices, from 2013 to 2018. They included all patients 65 and older with five or more contacts with their practice in six years, giving them a sample of 25,854 individuals. Personal continuity was measured using three established indices: Usual Provider Continuity (UPC); the Bice-Boxerman Continuity of Care Index (BBI); and the Herfindahl Index (HI). The prevalence of PIPs were determined using screening tools. To assess the association, they conducted analyses with and without adjustment for number of chronic conditions, age and sex.
What This Study Found Higher scores in BBI, HI and UPC were associated with a significant reduction in potentially inappropriate prescriptions. Within the UPC, BBI and HI measures, the mean personal continuity was 0.70 (0.19), 0.55 (0.24) and 0.59 (0.22), respectively. Among more than 25,000 patients the researchers examined, 72.2% and 74.3% had one or more potentially inappropriate medications (PIMs) or PPOs, respectively; and 30.9% and 34.2% had three or more PIMs or PPOs, respectively.
Implications
- Higher personal continuity is associated with more appropriate prescribing and argue that increasing personal continuity may improve quality of prescriptions and reduce harmful consequences.
Dana M. Petersen and colleagues
Background Researchers from Mathematica studied high-performing Comprehensive Primary Care Plus (CPC+) sites to identify key strategies that contributed to significant reductions in acute hospitalization rates. Researchers identified CPC+ practice sites with the highest likelihood of achieving substantial reductions in Medicare acute hospitalization rates between 2016 and 2018, and referred to them as "Acute Hospitalization Rate (AHR) high-performers." Afterwards, they conducted telephone interviews and within- and cross-case comparative analyses of 14 of these primary care practice sites, with the help of physicians, practice administrators, care managers, and other practice staff including nurses and pharmacists.
What This Study Found AHR high-performers credited various care delivery activities that aligned with three key strategies: (1) improving and promoting timely access to primary care, (2) identifying high-risk patients and providing enhanced care management tailored to their needs, and (3) expanding the range of services offered at the practice site. The AHR high-performers also recognized several factors that facilitated the implementation of these strategies, such as receiving enhanced payments through CPC+, prior experience in transforming primary care practices, utilizing data to identify valuable activities for specific patient subgroups, fostering teamwork, and benefiting from organizational support for innovation.
Implications
- Based on their findings, the researchers concluded that strengthening the local primary care infrastructure through practice-driven and targeted changes in access, care management, and comprehensiveness can support efforts to reduce incidence of acute hospitalizations.They encourage other primary care clinics to emulate these strategies, tailoring specific activities to fit their context, personnel, patient population and available resources.
Renato Nisihara and colleagues
Background Brazilian researchers conducted a cross-sectional study to explore the concerns of
caregivers of Brazilian girls with Down syndrome (DS) regarding gynecological aspects
of DS including menstruation, contraception and sexual practices. The study included
100 caregivers of females aged 9 years or older with DS who had reached menarche.
Participating caregivers completed a questionnaire about their concerns around puberty,
menstruation, sexuality and contraceptive methods.
What This Study Found Caregivers commonly expressed concerns around menstrual bleeding. Most caregivers (57%) reported that they would permit their child to engage in romantic relationships, including sexual relationships, with 2% of caregivers surveyed reported that their child had already engaged in sexual intercourse. According to information from surveyed caregivers, 14 of 78 (17.9%) individuals had used contraceptive methods, with weight gain being the most common side effect (43%).
Implications
- Women with DS had sexual development comparable to women without DS. These women are increasingly independent, which the authors argue makes it necessary to guide caregivers and primary care physicians on addressing difficulties related to menstruation, contraception and sexual practices.
Impact of Service-Based Student Loan Repayment Program on the Primary Care Workforce
Caitlin S. Davis and colleagues
Background Researchers from the American Board of Family Medicine and the University of Minnesota
Medical School investigated whether participation in medical school repayment programs
impacted the care family physicians provided to patients post graduation. By analyzing
data from over 10,000 American Board of Family Medicine 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.
What This Study Found The study revealed a significant increase in participation in the Public Service Loan Forgiveness (PSLF) program between 2016 and 2020, while participation in the National Health Service Corps (NHSC) program remained unchanged. 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). In contrast, PSLF primarily supported physicians intending to work in public service.
Implications
- The analysis conducted in this study suggests that PSLF may be less effective in supporting family physicians from underrepresented backgrounds, promoting a broader scope of practice, and directing physicians to underserved settings compared to service-based loan repayment programs like NHSC.
Lori Uscher-Pines and colleagues
Background Researchers explored how primary care physicians who have some familiarity with medications for alcohol use disorder (MAUD) make prescribing decisions and identify reasons for the underuse of MAUD in primary care. They interviewed 19 primary care physicians who had recently prescribed MAUD to patients in an outpatient setting. These physicians were selected from a large online database of medical professionals.
What This Study Found Participating physicians reported several challenges in prescribing MAUD: (1) they had somewhat negative personal beliefs about the effectiveness of medications and the likelihood of patient adherence; (2) they faced competing demands in primary care that made prescribing medications a lower priority; and (3) there were few positive norms or expectations regarding the use of these medications. To make MAUD prescribing a smaller component of their practice, physicians followed certain "rules of thumb" to select specific patients for these medications. These included recommending the medications to patients who seemed the most motivated to reduce drinking; those with the most severe AUD; and those who were also receiving other treatments for AUD.
Implications
- Considering that primary care physicians face barriers in prescribing medications for alcohol use disorder, including negative beliefs about medication effectiveness and patient adherence, competing demands in primary care, as well as limited positive norms, the authors call for increased focus on the study and development of standardized selection requirements to initiate MAUD.
Jonathan Fitzsimon and colleagues
Background In an effort to increase access to care in underserved communities, researchers from
the University of Ottawa evaluated the implementation of an integrated virtual care
(IVC) model. Their study evaluated the overall experience and satisfaction of patients
receiving care through a combination of virtual and in-person visits. A secondary
aim was to compare the experiences of patients who had been previously seen in person
by a family physician before transitioning to the IVC clinics with those who met their
family physician virtually for the first time in their virtual appointment at participating
clinics.
The IVC model helps alleviate the burden on overwhelmed primary care clinicians by
leveraging telemedicine technology, allowing family doctors located outside the community
to provide care to patients remotely. By utilizing secure messaging, telephone consultations,
and video appointments, the IVC model expands the pool of available family doctors,
ensuring patients can access care even when local clinicians are overburdened. In-person
care is provided by physicians, nurse practitioners and other allied health professionals
including community paramedics within the local family health team.
What This Study Found Using a cross-sectional online survey administered to 121 patients, the researchers determined that across all groups, 90% of patients were very satisfied or satisfied with care from their family physician, and 89% with care from their allied health team. When comparing previous healthcare experiences, 75% of respondents believe that their encounters with IVC were better than or the same as any prior, in-person healthcare encounters.There was no difference in satisfaction or trust between patients who had a previously established in-person relationship with their doctor and those whose first visit was virtual.
Implications
- Findings suggest that a hybrid model of in person and virtual care options to deliver
team-
based, comprehensive primary care with family physician leadership, can provide a high level of patient experience and satisfaction, at least comparable to traditional in-person models of primary care. This can be achieved regardless of whether patients had previously been attached to the same family physician prior to receiving care through the hybrid model.
Raphaëlle Delpech and colleagues
Background French researchers conducted a large, simulated study to examine the relationship
between the presence of primary care physicians (PCPs) and the ability of patients
to register with a PCP. The study aimed to analyze local PCP supply based on various
indicators, including PCP presence, patient registration availability for office visits,
and patient registration availability for home visits. Out of 5,188 census blocks,
55.4% had at least one PCP, with 38.6% of those blocks allowing registration for office
visits and 19.46% allowing registration for home visits.
What This Study Found Geographic inequalities in patient registration were more significant than those related to PCP density, challenging the assumption that patients could easily find and register with a PCP. Doctors were also less likely to accept new patients who required time-consuming procedures including home visits and complicated services. Additionally, they were also less likely to accept new patients if they worked in areas that required them to take on the highest work loads (lowest PCP density in the most disadvantaged areas).
Implications
- Policy decisions mandating patient registration with a PCP to access health care may unintentionally exclude individuals who are unable to register with a PCP, preventing them from benefiting completely from the health care system.
Reimbursement for HPV Vaccine Cost in the Private Sector: A Comparison Across Specialties
Kalyani Sonawane and colleagues
Background Human papillomavirus (HPV) vaccination coverage has improved in the United States,
but privately insured adolescents have lower initiation and completion rates compared
to those under public insurance programs. One of the contributing factors to this
disparity is the higher cost of the HPV vaccine compared to other routinely recommended
adolescent vaccines. While private payers typically reimburse the cost of the HPV
vaccine at or above the CDC list price (i.e., $210.99 in 2017-2018), it remains below
the American Academy of Pediatrics' recommended price (i.e., $263.74). Adequate reimbursement
for vaccine costs by third-party payers plays a critical role in enabling doctors
and other medical staff to offer and continue providing vaccines.
Researchers investigated the reimbursement rates for HPV vaccine costs across various
medical specialties, including pediatricians (as the comparison group), family physicians,
internal medicine specialists, nurse practitioners, and other medical practitioners.
Additionally, they examined whether the reimbursement amounts were associated with
the number of HPV vaccine doses administered by these health care practitioners. The
study analyzed data from over 34,000 unique practitioners.
What This Study Found family physicians had the lowest net returns per dose ($0.34), while pediatricians had the highest returns ($5.08). On average, during 2017-2018, pediatricians received higher reimbursement for HPV vaccine costs ($216.07) compared to family physicians ($211.33; p<0.0001), internists ($212.97; p<0.0001), nurse practitioners ($212.91; p<0.0001), and 'other' practitioners ($213.29; p<0.0001). 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).
Implications
- Although reimbursement for HPV vaccine costs by private payers is considered adequate,
according to the authors, the study highlights that non-pediatric specialties have
a very marginal return on investment, which may be insufficient for covering indirect
expenses for stocking vaccines (storage cost, personnel cost for monitoring inventory,
insurance, waste, and lost opportunity costs). The authors argue that this makes them
more sensitive to changes in cost reimbursement, emphasizing the need for an increase
in reimbursement rates for these practitioners so that they can continue offering
the cancer-preventing HPV vaccine.
C. Nathan Nessle and colleagues
Background Researchers present a methodology for developing joint displays of integrated mixed
data collection. These joint displays provide a framework for supporting integration
of a mixed methodology in research. Drawing upon a convergent mixed methods cohort
study – the Early Discharge of Febrile Neutropenic Children with Cancer Study – the
authors constructed a joint display of integrated mixed data collection from a patient/caregiver
mixed methods survey instrument and manual medical chart abstraction. The paper outlines
the methodological approach, including iterative steps, and explains how the data
display was constructed for the study. It also highlights the features and utility
of the joint display.
What This Study Found The integration of qualitative and quantitative information in clinical, prospective, mixed methods cohort studies presents challenges due to the large volume of data and the need for logical organization to enable integrated data analysis.
Implications
- While tailoring joint displays to specific studies can be complex, the authors emphasize that embracing flexible methods allows mixed methods researchers to develop effective joint displays that demonstrate connections between mixed data collection and provide an initial structure for organizing findings.
Chien-Chang Lee and colleagues
Background In their comprehensive meta-analysis (comprising 221 randomized controlled trials involving 65,601 patients), researchers investigated the effectiveness of various pharmacological therapies for acne vulgaris across diverse age groups and genders. The articles described 37 interventions, with a median patient age of 20 years old and median duration of treatment of 12 weeks. The median total, inflammatory and non-inflammatory lesion counts were 71.5, 27 and 44, respectively.
What This Study Found oral isotretinoin was the most effective treatment (mean difference 48.41; p-score 1.00), followed in efficacy by a triple therapy containing a topical antibiotic, a topical retinoid and benzoyl peroxide (BPO) (MD 38.15; p-score 0.95) and another triple therapy containing an oral antibiotic, a topical retinoid and BPO (MD 34.83; p-score 0.90). For monotherapies besides isotretinoin, antibiotics or topical retinoids have comparable efficacy for inflammatory lesions, while antibiotics have less effect on non-inflammatory lesions. Additionally, the authors present a comprehensive comparison of each intervention, providing a valuable resource for clinical decision-making.
Implications
- The authors note that their study provided the most comprehensive evidence to date
regarding the common pharmacological interventions for acne vulgaris, with analyses
of both
percentage and absolute reduction in lesion counts and detailed comparisons for each
intervention.
Old Books, Warm Cookies, and Death With Dignity
Eric Ardman
Background Family physician Eric Ardman, MD, shares his transformative experience as a first-year Family Medicine resident encountering a patient seeking to end her life under Oregon's "Death with Dignity Act."
What This Study Found The patient's comfortable home became the backdrop for a profound journey that expanded Ardman's understanding of the patient-doctor relationship.
Implications
- From routine interactions with her family to assisting in her decision to die, Ardman
realized the importance of being present for patients in whatever capacity they need.
The encounter reinforced his ongoing exploration of his role as a physician, emphasizing
the need to adapt and remain open to unexpected opportunities for growth, beauty and
love throughout his career.
The Warmest of Handoffs: A Neighborhood Physician's Transfer of Care
Ann B. Reichsman and Corey Meador
Background Drs. Ann Reichsman and Corey Meador write a reflection about the care transition of a patient from an outgoing physician (Reichsman) to one who is incoming (Meador). They discovered that a handoff of care is the intergenerational transfer of the culture of the organization, a process that involves worrying, watching and then relaxing into hopefulness.
>
What This Study Found They found that the experience provided a precious opportunity to transfer knowledge and trust. In the essay, the authors explore this process from both their perspectives – Meador as a physician who recently completed training and Reichsman as a retiring physician leaving her beloved patients and practice of 40 years.
Implications
- The authors express that the method they arrived at for this transfer provided the space for collaboration on what the essence of caring for a unique individual would entail.
The Limits of Professional Identity: A Lesson From My Grandfather
Norman Hearst
Background Norman Hearst, MD, MPH, reflects on the life of his grandfather, Caesar Hirsch, a prominent Jewish doctor who escaped the Holocaust but ultimately died by suicide after being unable to reestablish his career in the United States.
What This Study Found After an emotional trip to the hospital in Stuttgart, Germany, where his grandfather
had served as the founding chief of the Otolaryngology Department, Hearst is reminded
that professional status can be lost or taken away and warns others against solely
defining oneself through a career.
Implications
- “Uncovering the truth about my grandfather has not changed the world, but it has changed me,” Hearst writes. “As physicians, we know that health and life are fleeting, but we imagine that our position and status are earned rights that are inalienable. We are wrong. Careers can be derailed in many ways, and heaven help us if this is all we have.”
Meeting Adolescents Where They Are: Hybrid Virtual-in-Person Visits for Routine Preventive Care
Brian P. Jenssen and colleagues
Background Researchers in Philadelphia conducted a pilot program to test a hybrid well-visit telehealth model aimed at reaching adolescents who were difficult to reach and had been lost to follow-up. The program involved an initial virtual visit followed by an in-person visit, if necessary. The program focused on a group of 50 patients age 18 with Medicaid insurance who hadn't attended a well visit in over two years and had a history of no-shows. The researchers contacted patients or their caregivers to gauge interest in virtual well visits and initially aimed to fill five telehealth slots over three evenings. However, due to high demand, they expanded the slots to 15.
What This Study Found Of the 15 patients scheduled for a telehealth visit, 11 attended the visit (a show rate of 73%), five successfully completed the virtual follow-up, with nine requiring in-person follow-up. The intervention demonstrated a significant impact, resulting in a 40% increase in show rates for well visits compared to the previous average show rate of 33% within this specific patient cohort. For participants who came in for in-person visits, doctors were able to counsel them on substance use and safe sex practices; screen for sexually transmitted infection; write needed medication prescriptions and administer vaccinations.
Implications