Showing papers in "Journal of the American Board of Family Medicine in 2018"

Multimorbidity Trends in United States Adults, 1988-2014.

Abstract: Importance: The simultaneous presence of multiple conditions in one patient (multi-morbidity) is a key challenge facing primary care. Objective: The purpose of this study was to determine the prevalence of multi-morbidity and to document changes in prevalence during the last 25 years. Design/Setting: Cross-sectional study using multiple years (1988–2014) of the National Health and Nutrition Examination Survey (NHANES) were analyzed. Setting: Multiple years (1988 to 2014) of the National Health and Nutrition Examination Survey (NHANES) from the United States were analyzed. Participants: Noninstitutionalized adults. Main Outcomes and Measures: Number of chronic conditions per individual analyzed by age, race, gender, and socioeconomic factors. Results: A total of 57,303 individuals were surveyed regarding the presence of multi-morbidity in separate surveys spanning 1988–2014. The overall current prevalence in 2013–2014 of >2 morbidities was 59.6% (95% CI 58.1%–61.1%), 38.5% had 3 or more, and 22.7% had 4 or more morbidities, which was significantly higher than in 1988 (45.7%, 95% CI 43.5%–47.8%, with >2 morbidities). Among individuals with 2 or more morbidities, 54.1% have obesity compared to 41.9% in 1988. Among adults age >65, prevalence was 91.8% for 2 or more morbidities. Whites and Blacks had significantly higher prevalence (59.2% and 60.1%) than Hispanic or “other” race (45.0%, P 2) than men (55.9%, P = .01). Conclusions and Relevance: Multimorbidity is common and has been increasing over the last 25 years. This finding has implications for public health policy and anticipated health costs for the coming years.

Clinician Experiences with Screening for Social Needs in Primary Care

Abstract: Background: Despite clear evidence demonstrating the influence of social determinants on health, whether and how clinicians should address these determinants remain unclear. We aimed to understand primary care clinicians9 experiences of administering a social needs screening instrument. Methods: Using a prospective, observational design, we identified patients living in communities with lower education and income seen by 17 clinicians from 12 practices in northern Virginia. Before office visits, patients completed social needs surveys, which probed about their quality of life, education, housing, finances, substance use, transportation, social connections, physical activity, and food access. Clinicians then reviewed the completed surveys with patients. Concurrently, clinicians participated in a series of learning collaboratives to consider how to address social needs as part of care and completed diary entries about how knowing the patient9s social needs influenced care after seeing each patient. Results: Out of a total of 123 patients, 106 (86%) reported a social need. Excluding physical activity, 71% reported a social need, although only 3% wanted help. Clinicians reported that knowing the patient had a social need changed care delivery in 23% of patients and helped improve interactions with and knowledge of the patient in 53%. Clinicians reported that assessing social needs is difficult and resource intensive and that there were insufficient resources to help patients with identified needs. Conclusions: Clinicians reported that knowing patients9 social needs changed what they did and improved communication for many patients. However, more evidence is needed regarding the benefit of social needs screening in primary care before widespread implementation.

Socioeconomic Status and Other Factors Associated with Childhood Obesity

Abstract: Background: Childhood obesity in the United States is a critical public health issue. Although multiple child and parental factors are associated with childhood obesity, few models evaluate how socioeconomic status influences these risk factors. We aimed to create a model to examine how socioeconomic status modifies risk factors for child obesity. Methods: We conducted a secondary data analysis of the Early Childhood Longitudinal Birth Cohort. Using logistic regression, we modeled childhood obesity status from known parental and child risk factors for childhood obesity and tested interactions with socioeconomic status. Results: Compared with healthy-weight children, socioeconomic status, race, birth weight, parental smoking, and not eating dinner as a family were associated with kindergarten-aged children being overweight or obese. Parental smoking increased the odds of a child being overweight or obese by 40%, and eating dinner as a family reduced the odds of a child being overweight or obese by 4%. In addition, black or Hispanic children had a 60% increased odds of being overweight or obese when compared with their white counterparts. Native American children had almost double the odds of being overweight or obese compared with white children. Socioeconomic status did not modify any of these associations. Conclusion: Parental smoking, birth weight, and not eating dinner as a family were two modifiable factors associated with overweight and obesity in kindergarten-age children, regardless of socioeconomic status. Changing these life-style factors could reduce the child9s risk for obesity.

Humor During Clinical Practice: Analysis of Recorded Clinical Encounters

Abstract: Objective: Little is known about humor’s use in clinical encounters, despite its many potential benefits. We aimed to describe humor during clinical encounters. Design: We analyzed 112 recorded clinical encounters. Two reviewers working independently identified instances of humor, as well as information surrounding the logistics of its use. Results: Of the 112 encounters, 66 (59%) contained 131 instances of humor. Humor was similarly frequent in primary care (36/61, 59%) and in specialty care (30/51, 59%), was more common in gender-concordant interactions (43/63, 68%), and was most common during counseling (81/112, 62%). Patients and clinicians introduced humor similarly (63 vs 66 instances). Typically, humor was about the patient’s medical condition (40/131, 31%). Discussion and Conclusion: Humor is used commonly during counseling to discuss the patient’s medical condition and to relate to general life events bringing warmth to the medical encounter. The timing and topic of humor and its use by all parties suggests humor plays a role in the social connection between patients and physicians and allows easier discussion of difficult topics. Further research is necessary to establish its impact on clinicians, patients, and outcomes. (J Am Board Fam Med 2018;31: 270–278.) Keywords: Humor, Patient-Centered Care, Primary Health Care, Physician-Patient Relations, Patient-Physician Communication

Greater Occipital Nerve Block for Acute Treatment of Migraine Headache: A Large Retrospective Cohort Study.

Abstract: Introduction Greater occipital nerve (GON) blocks are frequently used to treat migraine headaches, although a paucity of supporting clinical evidence exists. The objective of this study was to assess the efficacy of GON block in acute treatment of migraine headache, with a focus on pain relief. Methods This retrospective cohort study was undertaken between January 2009 and August 2014 and included patients who underwent at least 1 GON block and attended at least 1 follow-up appointment. Change in the 11-point numeric pain rating scale (NPRS) was used to assess the response to GON block. Response was defined as "minimal" ( 50% NPRS point reduction). Results A total of 562 patients met inclusion criteria; 423 were women (75%). Mean age was 58.6 ± 16.7 years. Of these 562, 459 patients (82%) rated their response to GON block as moderate or significant. No statistically significant relationship existed between previous treatment regimens and response to GON block. GON block was equally effective across the different age and sex groups. Conclusions Greater occipital block seems to be an effective option for acute management of migraine headache, with promising reductions in pain scores.

Advancing Social Prescribing with Implementation Science.

Abstract: A wealth of emerging evidence on the associations between social determinants of health (SDH) (eg, food, housing, transportation, and education) and health outcomes[1][1][⇓][2][⇓][3][⇓][4][⇓][5][⇓][6]–[7][7] has fueled a wave of experimentation around identifying and addressing patients

The Effectiveness of Problem-Solving Therapy for Primary Care Patients' Depressive and/or Anxiety Disorders: A Systematic Review and Meta-Analysis.

Abstract: BACKGROUND There is increasing demand for managing depressive and/or anxiety disorders among primary care patients. Problem-solving therapy (PST) is a brief evidence- and strength-based psychotherapy that has received increasing support for its effectiveness in managing depression and anxiety among primary care patients. METHODS We conducted a systematic review and meta-analysis of clinical trials examining PST for patients with depression and/or anxiety in primary care as identified by searches for published literature across 6 databases and manual searching. A weighted average of treatment effect size estimates per study was used for meta-analysis and moderator analysis. RESULTS From an initial pool of 153 primary studies, 11 studies (with 2072 participants) met inclusion criteria for synthesis. PST reported an overall significant treatment effect for primary care depression and/or anxiety (d = 0.673; P < .001). Participants' age and sex moderated treatment effects. Physician-involved PST in primary care, despite a significantly smaller treatment effect size than mental health provider only PST, reported an overall statistically significant effect (d = 0.35; P = .029). CONCLUSIONS Results from the study supported PST's effectiveness for primary care depression and/or anxiety. Our preliminary results also indicated that physician-involved PST offers meaningful improvements for primary care patients' depression and/or anxiety.

Task Delegation and Burnout Trade-offs Among Primary Care Providers and Nurses in Veterans Affairs Patient Aligned Care Teams (VA PACTs)

Abstract: PURPOSE Appropriate delegation of clinical tasks from primary care providers (PCPs) to other team members may reduce employee burnout in primary care. However, (1) the extent to which delegation occurs within multidisciplinary teams, (2) factors associated with greater delegation, and (3) whether delegation is associated with burnout are all unknown. METHODS We performed a national cross-sectional survey of Veterans Affairs (VA) PCP-nurse dyads in Department of VA primary care clinics, 4 years into the VA's patient-centered medical home initiative. PCPs reported the extent to which they relied on other team members to complete 15 common primary care tasks; paired nurses reported how much they were relied on to complete the same tasks. A composite score of task delegation/reliance was developed by taking the average of the responses to the 15 questions. We performed multivariable regression to explore predictors of task delegation and burnout. RESULTS Among 777 PCP-nurse dyads, PCPs reported delegating tasks less than nurses reported being relied on (PCP mean ± standard deviation composite delegation score, 2.97± 0.64 [range, 1-4]; nurse composite reliance score, 3.26 ± 0.50 [range, 1-4]). Approximately 48% of PCPs and 35% of nurses reported burnout. PCPs who reported more task delegation reported less burnout (odds ratio [OR], 0.62 per unit of delegation; 95% confidence interval [CI], 0.49-0.78), whereas nurses who reported being relied on more reported more burnout (OR, 1.83 per unit of reliance; 95% CI, 1.33-2.5). CONCLUSIONS Task delegation was associated with less burnout for PCPs, whereas task reliance was associated with greater burnout for nurses. Strategies to improve work life in primary care by increasing PCP task delegation must consider the impact on nurses.

Medication Adherence Improvement Similar for Shared Decision-Making Preference or Longer Patient-Provider Relationship.

Abstract: Background: While increasing evidence supports the beneficial effects of shared decision making (SDM) on patient outcomes, the mechanisms underlying this relationship is unclear. This study evaluated length of the patient-provider relationship as one potential factor that may explain how SDM affects medication adherence in patients with hypertension. Methods: An observational study of 75 hypertensive patients and 27 providers in 3 primary care practices in New York City. A single-item measure assessed patients9 preferences for decision-making style at baseline; medication adherence was collected over the 3-month study with an electronic monitoring device. Length of the relationship was measured as the number of years with the provider, and dichotomized as less than or greater than 1 year with the provider. Two generalized linear mixed models were conducted to determine whether the SDM-adherence association was modified by length of the relationship. Results: Most patients were Black and women, and 64% were seeing the same provider >1 year. Providers were mostly White women and have been at the clinic for 6 years. In the main-effects model, patients were more likely to exhibit better adherence when they preferred shared and active decision-making styles as compared with those who preferred a passive style (B = 15.87 [Standard Error [SE]: 6.62], P = .02; and B = 22.58 [SE:7.62], P = .004, respectively). In Model 2, the relative importance of SDM on adherence decreased as years with the provider increased (t(48) = 2.13; P = .04). Conclusion: The benefits of SDM over passive decision making on medication adherence were reduced with increasing years of the patient-provider relationship. Having an established relationship with the provider may have a positive impact on medication adherence that is comparable to relationships high in SDM.

Dissemination and Implementation Science in Primary Care Research and Practice: Contributions and Opportunities.

Abstract: Dissemination and Implementation Science (DIS) is a growing research field that seeks to inform how evidence-based interventions can be successfully adopted, implemented, and maintained in health care delivery and community settings. In this article, an overview of DIS and how it has contributed to primary care delivery improvement, future opportunities for its use, and DIS resources for learning are described. Case examples are provided to illustrate how DIS can be used to solve the complex implementation and dissemination problems that emerge in primary care. Finally, recommendations are made to guide the use of DIS to inform and drive improvements in primary care delivery.

Living in “Cold Spot” Communities Is Associated with Poor Health and Health Quality

Abstract: Purpose: Little is known about incorporating community data into clinical care. This study sought to understand the clinical associations of cold spots (census tracts with worse income, education, and composite deprivation). Methods: Across 12 practices, we assessed the relationship between cold spots and clinical outcomes (obesity, uncontrolled diabetes, pneumonia vaccination, cancer screening—colon, cervical, and prostate—and aspirin chemoprophylaxis) for 152,962 patients. We geocoded and linked addresses to census tracts and assessed, at the census tract level, the percentage earning less than 200% of the Federal Poverty Level, without high school diplomas, and the social deprivation index (SDI). We labeled those census tracts in the worst quartiles as cold spots and conducted bivariate and logistic regression. Results: There was a 10-fold difference in the proportion of patients in cold spots between the highest (29.1%) and lowest practices (2.6%). Except for aspirin, all outcomes were influenced by cold spots. Fifteen percent of low-education cold-spot patients had uncontrolled diabetes compared with 13% of noncold-spot patients (P Conclusion: Living in cold spots is associated with worse chronic conditions and quality for some screening tests. Practices can use neighborhood data to allocate resources and identify those at risk for poor outcomes.

Delivering Interconception Care During Well-Child Visits: An IMPLICIT Network Study

Abstract: Background Preterm birth, birth defects, and unintended pregnancy are major sources of infant and maternal morbidity, mortality, and associated resource use in American health care. Interconception Care (ICC) is recommended as a strategy to improve birth outcomes by modifying maternal risks between pregnancies, but no established model currently exists. The Interventions to Minimize Preterm and Low Birth Weight Infants through Continuous Improvement Techniques (IMPLICIT) Network developed and implemented a unique approach to ICC by assessing mothers during their baby's well-child visits (WCVs) up to 24 months. Methods Mothers who accompanied their children to WCVs at eleven eastern US family medicine residency programs underwent screening for four risk factors (tobacco use, depression risk, contraception use to avoid unintended pregnancy and prolong interpregnancy interval, and use of a multivitamin with folic acid). Positive screens in women were addressed through brief interventions or referrals to treatment. Results Mothers accompanied their babies to 92.7% of WCVs. At more than half of WCVs (69.1%), mothers were screened for presence of ICC behavioral risks, although significant practice variation existed. Risk factors were identified at significant rates (tobacco use, 16.2%; depression risk, 8.1%; lack of contraception use, 28.2%; lack of multivitamin use, 45.4%). Women screened positive for 1 or more ICC risk factor at 64.6% of WCVs. Rates of documented interventions for women who screened positive were also substantial (tobacco use, 80.0%; depression risk, 92.8%; lack of contraception use, 76.0%; lack of multivitamin use, 58.2%). Conclusion WCVs provide a reliable point of contact with mothers and a unique opportunity to assess and address behavioral risks for future poor birth outcomes.

Impact of Medical Scribes in Primary Care on Productivity, Face-to-Face Time, and Patient Comfort.

Abstract: Background: Medical scribes are a clinical innovation increasingly being used in primary care The impact of scribes in primary care remain unclear We aimed to examine the impact of medical scribes on productivity, time spent facing the patient during the visit, and patient comfort with scribes in primary care Methods: We conducted a prospective observational pre-post study of 5 family and internal medicine-pediatrics physicians and their patients at an urban safety net health clinic Medical scribes accompanied providers in the examination room and documented the clinical encounter After an initial phase-in period, we added an additional 20-minute patient slot per 200-minute session We examined productivity by using electronic medical record data on the number of patients seen and work relative value units (work RVUs) per hour We directly observed clinical encounters to measure the amount of time providers spent facing patients and other visit components We queried patient comfort with scribes by using surveys administered after the visit Results: Work RVUs per hour increased by 105% from 259 prescribe to 286 post-scribe (P Conclusions: Although the full implications of medical scribe implementation remain to be seen, this initial study highlights the promising opportunity of medical scribe implementation in primary care

Using the Quadruple Aim Framework to Measure Impact of Heath Technology Implementation: A Case Study of eConsult

Abstract: Background: Health technology solutions are too often implemented without a true understanding of the system-level problem they seek to address, resulting in excessive costs, poor adoption, ineffectiveness, and ultimately failure. Before implementing or adopting health care innovations, stakeholders should complete a thorough assessment to ensure effectiveness and value. In this article, we describe how to evaluate the impact of a health technology innovation through the 4 dimensions of care outlined by the Quadruple Aim Framework, using our experience with the Champlain Building Access to Specialists through eConsultation (BASE) eConsult service as a case example. Methods: A descriptive overview of data was collected between April 1, 2011, and August 31, 2017, using 4 dimensions of care outlined by the Quadruple Aim Framework: patient experience, provider experience, costs, and population health. Findings were drawn from use data, primary care provider closeout surveys, surveys/interviews with patients and provider, and costing data. Results: Overall, patients have received access to specialist advice within days and find the advice useful in 86% of cases. Provider experience is very positive, with satisfaction ratings of high/very high value in 94% of cases. The service cost a weighted average of $47.35/case, compared with $133.60/case for traditional referrals. In total, 1,299 primary care providers have enrolled in the service, completing 28,838 cases since 2011. Monthly case volumes have grown from an average of 13 cases/month in 2011 to 969 cases/month in 2016. Conclusions: The eConsult service has been widely adopted in our region and is currently expanding to new jurisdictions across Canada. However, although we successfully demonstrated eConsult9s impact on patient experience, provider satisfaction, and reducing costs, we met several challenges in evaluating its impact on population health. More work is needed to evaluate eConsult9s impact on key population health metrics (eg, mortality, morbidity, and system use). Efforts to conduct such evaluations are underway.

Correlates of Burnout in Small Independent Primary Care Practices in an Urban Setting.

Abstract: Background: Little is known about the prevalence and correlates of burnout among providers who work in small independent primary care practices ( Methods: We conducted a cross-sectional analysis by using data collected from 235 providers practicing in 174 small independent primary care practices in New York City. Results: The rate of provider-reported burnout was 13.5%. Using bivariate logistic regression, we found higher adaptive reserve scores were associated with lower odds of burnout (odds ratio, 0.12; 95% CI, 0.02–0.85; P = .034). Conclusion: The burnout rate was relatively low among our sample of providers compared with previous surveys that focused primarily on larger practices. The independence and autonomy providers have in these small practices may provide some protection against symptoms of burnout. In addition, the relationship between adaptive reserve and lower rates of burnout point toward potential interventions for reducing burnout that include strengthening primary care practices9 learning and development capacity.

Ambulatory Antibiotic Stewardship through a Human Factors Engineering Approach: A Systematic Review

Abstract: Introduction: In the United States, most antibiotics are prescribed in ambulatory settings. Human factors engineering, which explores interactions between people and the place where they work, has successfully improved quality of care. However, human factors engineering models have not been explored to frame what is known about ambulatory antibiotic stewardship (AS) interventions and barriers and facilitators to their implementation. Methods: We conducted a systematic review and searched OVID MEDLINE, Embase, Scopus, Web of Science, and CINAHL to identify controlled interventions and qualitative studies of ambulatory AS and determine whether and how they incorporated principles from a human factors engineering model, the Systems Engineering Initiative for Patient Safety 2.0 model. This model describes how a work system (ambulatory clinic) contributes to a process (antibiotic prescribing) that leads to outcomes. The work system consists of 5 components, tools and technology, organization, person, tasks, and environment, within an external environment. Results: Of 1,288 abstracts initially identified, 42 quantitative studies and 17 qualitative studies met inclusion criteria. Effective interventions focused on tools and technology (eg, clinical decision support and point-of-care testing), the person (eg, clinician education), organization (eg, audit and feedback and academic detailing), tasks (eg, delayed antibiotic prescribing), the environment (eg, commitment posters), and the external environment (media campaigns). Studies have not focused on clinic-wide approaches to AS. Conclusions: A human factors engineering approach suggests that investigating the role of the clinic9s processes or physical layout or external pressures9 role in antibiotic prescribing may be a promising way to improve ambulatory AS.

Impact of Pharmacist Previsit Input to Providers on Chronic Opioid Prescribing Safety.

Abstract: INTRODUCTION Primary care providers (PCPs) account for half of opioid prescriptions, often feel chronic pain patients are challenging to manage, and there is wide variability in practice patterns. The purpose of this pilot study was to evaluate the impact of a previsit pharmacist review of high-risk patients treated with opioids for chronic pain on compliance to guideline recommendations at a family medicine residency clinic. METHODS All adult patients with an appointment for chronic pain who were prescribed >50 morphine milligram equivalents (MMEs)/day had charts reviewed by a pharmacist before each appointment; recommendations were sent electronically to the provider before the appointment. After 4 months of implementation, each patient's chart was manually reviewed to gather outcome variables. The primary outcomes were the mean MMEs/day and pain scores. RESULTS Pharmacist previsit recommendations were provided for 45 patients. When comparing outcomes before and after intervention, the mean MMEs/day decreased by 14% (P < .001), with no change in pain scores (P = .783). Statistically significant improvements were noted in multiple other secondary opioid safety outcomes. CONCLUSION Clinical pharmacists providing previsit recommendations was associated with decreased opioid utilization with no corresponding increase in pain scores and increased compliance to guideline recommendations.

Practice facilitator strategies for addressing electronic health record data challenges for quality improvement: EvidenceNOW

Abstract: Purpose: Practice facilitators (“facilitators”) can play an important role in supporting primary care practices in performing quality improvement (QI), but they need complete and accurate clinical performance data from practices9 electronic health records (EHR) to help them set improvement priorities, guide clinical change, and monitor progress. Here, we describe the strategies facilitators use to help practices perform QI when complete or accurate performance data are not available. Methods: Seven regional cooperatives enrolled approximately 1500 small-to-medium-sized primary care practices and 136 facilitators in EvidenceNOW, the Agency for Healthcare Research and Quality9s initiative to improve cardiovascular preventive services. The national evaluation team analyzed qualitative data from online diaries, site visit field notes, and interviews to discover how facilitators worked with practices on EHR data challenges to obtain and use data for QI. Results: We found facilitators faced practice-level EHR data challenges, such as a lack of clinical performance data, partial or incomplete clinical performance data, and inaccurate clinical performance data. We found that facilitators responded to these challenges, respectively, by using other data sources or tools to fill in for missing data, approximating performance reports and generating patient lists, and teaching practices how to document care and confirm performance measures. In addition, facilitators helped practices communicate with EHR vendors or health systems in requesting data they needed. Overall, facilitators tailored strategies to fit the individual practice and helped build data skills and trust. Conclusion: Facilitators can use a range of strategies to help practices perform data-driven QI when performance data are inaccurate, incomplete, or missing. Support is necessary to help practices, particularly those with EHR data challenges, build their capacity for conducting data-driven QI that is required of them for participating in practice transformation and performance-based payment programs. It is questionable how practices with data challenges will perform in programs without this kind of support.

Implementation of the Geriatric Patient-Aligned Care Team Model in the Veterans Health Administration (VA)

Abstract: Background: Here, we describe the implementation of a specialty primary care medical home (PCMH) model called Geriatric Patient-Aligned Care Teams (GeriPACT) in the Veterans9 Health Administration (VA) that is focused on serving older complex patients. In particular, our aims in this article are to describe how the GeriPACT model was developed and implemented in VA sites, provide a closer look at how GeriPACT functions by presenting a case study, and highlight data showing national variation in the implementation of GeriPACT staffing models and PCMH practices. Methods: Stakeholder feedback regarding the GeriPACT model was obtained from a GeriPACT team and the director of GeriPACT in VA. Here, we present national data regarding variations in GeriPACT staffing and PCMH practices. Results: Following the adoption and implementation of the GeriPACT model and release of the GeriPACT handbook, sites were able to adopt the model9s principles. The VA9s adoption of PCMH reinforced the mission of patient-centered primary care by integrating psychosocial and environmental determinants of health. This was accomplished with enhancements to staff support through new full-time employment equivalents, but also by optimizing staff productivity through improved team function and interpersonal care. The GeriPACT model was implemented in a bottom-up fashion that has led to variation in how GeriPACTs are structured and staffed, as well as how they conform to various PCMH principles. Conclusions: GeriPACT is one approach for bringing an interdisciplinary, patient-centric perspective to primary care in a manner that can likely support the higher staffing costs with economies realized from diminished reliance on institutional placement and highly technologic health care. It is a model which can provide training for the next generation of providers and clinicians.

Primary Care Physicians' Struggle with Current Adult Pneumococcal Vaccine Recommendations.

Abstract: INTRODUCTION In 2012, the Advisory Committee on Immunization Practices recommended 13-valent pneumococcal conjugate vaccine (PCV13) in series with 23-valent pneumococcal polysaccharide vaccine (PPSV23) for at-risk adults ≥19; in 2014, it expanded this recommendation to adults ≥65. Primary care physicians' practice, knowledge, attitudes, and beliefs regarding these recommendations are unknown. METHODS Primary care physicians throughout the U.S. were surveyed by E-mail and post from December 2015 to January 2016. RESULTS Response rate was 66% (617 of 935). Over 95% of respondents reported routinely assessing adults' vaccination status and recommending both vaccines. A majority found the current recommendations to be clear (50% "very clear," 38% "somewhat clear"). Twenty percent found the upfront cost of purchasing PCV13, lack of insurance coverage, inadequate reimbursement, and difficulty determining vaccination history to be "major barriers" to giving these vaccines. Knowledge of recommendations varied, with 83% identifying the PCV13 recommendation for adults ≥65 and only 21% identifying the recommended interval between PCV13 and PPSV23 in an individual <65 at increased risk. CONCLUSIONS Almost all surveyed physicians reported recommending both pneumococcal vaccines, but a disconnect seems to exist between perceived clarity and knowledge of the recommendations. Optimal implementation of these recommendations will require addressing knowledge gaps and reported barriers.

The Impact of the Affordable Care Act (ACA) Medicaid Expansion on Visit Rates for Diabetes in Safety Net Health Centers.

Abstract: Objective: To (1) compare clinic-level uninsured, Medicaid-insured, and privately insured visit rates within and between expansion and nonexpansion states before and after the Affordable Care Act (ACA) Medicaid expansion among the 3 cohorts of patient populations; and (2) assess whether there was a change in clinic-level overall, primary care visits, preventive care visits, and diabetes screening rates in expansion versus nonexpansion states from pre-ACA to post-ACA Medicaid expansion. Methods: Electronic health record data on nonpregnant patients aged 19 to 64 years, with ≥1 ambulatory visit between 01/01/2012 and 12/31/2015 (n = 483,912 in expansion states; n = 388,466 in nonexpansion states) from 198 primary care community health centers were analyzed. Using a difference-in-difference methodology, we assessed changes in visit rates pre-ACA versus post-ACA among a cohort of patients with diabetes, prediabetes, and no diabetes. Results: Rates of uninsured visits decreased for all cohorts in expansion and nonexpansion states. For all cohorts, Medicaid-insured visit rates increased significantly more in expansion compared with nonexpansion states, especially among prediabetic patients (+71%). In nonexpansion states, privately insured visit rates more than tripled for the prediabetes cohort and doubled for the diabetes and no diabetes cohorts. Rates for glycosylated hemoglobin screenings increased in all groups, with the largest changes among no diabetes (rate ratio, 2.26; 95% CI, 1.97–2.56) and prediabetes cohorts (rate ratio, 2.00; 95% CI, 1.80–2.19) in expansion states. Conclusion: The ACA reduced uninsurance and increased access to preventive care for vulnerable patients, especially those with prediabetes. These findings are important to consider when making decisions regarding altering the ACA.

Changing Patterns of Mental Health Care Use: The Role of Integrated Mental Health Services in Veteran Affairs Primary Care

Abstract: Objective Aiming to foster timely, high-quality mental health care for Veterans, VA's Primary Care-Mental Health Integration (PC-MHI) embeds mental health specialists in primary care and promotes care management for depression. PC-MHI and patient-centered medical home providers work together to provide the bulk of mental health care for primary care patients with low-to-moderate-complexity mental health conditions. This study examines whether increasing primary care clinic engagement in PC-MHI services is associated with changes in patient health care utilization and costs. Methods We performed a retrospective longitudinal cohort study of primary care patients with identified mental health needs in 29 Southern California VA clinics from October 1, 2008 to September 30, 2013, using electronic administrative data (n = 66,638). We calculated clinic PC-MHI engagement as the proportion of patients receiving PC-MHI services among all primary care clinic patients in each year. Capitalizing on variation in PC-MHI engagement across clinics, our multivariable regression models predicted annual patient use of 1) non-primary care based mental health specialty (MHS) visits, 2) total mental health visits (ie, the sum of MHS and PC-MHI visits), and 3) health care utilization and costs. We controlled for year- and clinic-fixed effects, other clinic interventions, and patient characteristics. Results Median clinic PC-MHI engagement increased by 8.2 percentage points over 5 years. At any given year, patients treated at a clinic with 1 percentage-point higher PC-MHI engagement was associated with 0.5% more total mental health visits (CI, 0.18% to 0.90%; P = .003) and 1.0% fewer MHS visits (CI, -1.6% to -0.3%; P = .002); this is a substitution rate, at the mean, of 1.5 PC-MHI visits for each MHS visit. There was no PC-MHI effect on other health care utilization and costs. Conclusions As intended, greater clinic engagement in PC-MHI services seems to increase realized accessibility to mental health care for primary care patients, substituting PC-MHI for MHS visits, without increasing acute care use or total costs. Thus, PC-MHI services within primary care clinics may improve mental health care value at the patient population level. More research is needed to understand the relationship between clinic PC-MHI engagement and clinical quality of mental health care.

Missed Opportunities for Depression Screening and Treatment in the United States.

Abstract: Purpose: This study estimates the prevalence of depression assessment in adults age 35 and older and how prevalence varies by sociodemographic characteristics and depressive symptoms. Methods: We used a nationally representative survey, the Agency for Healthcare Research and Quality9s Medical Expenditure Panel Survey, to evaluate if adults 35+ were being assessed for depression by their health care providers in 2014 and 2015. Using multivariate logistic regression, we examined the health and sociodemographic characteristics of patients associated with depression assessment. Results: Approximately 50% of US adults aged 35+ were being assessed for depression (48.6%; 95% CI, 45.5%–51.6%). The following were less likely to be assessed: men compared with women (OR, 0.58; 95% CI, 0.46–0.72), adults 75+ compared with adults 50 to 64 years old (OR, 0.47; 95% CI, 0.32–0.69), the uninsured compared with those with private insurance (OR, 0.30; 95% CI, 0.18–0.51), and adults without recognized depressive symptoms compared with those with recognized symptoms (OR, 0.39; 95% CI, 0.24–0.63). Compared with non-Hispanic whites, the following were less likely to be assessed: Asian (OR, 0.35; 95% CI, 0.19–0.67), Hispanic (OR, 0.47; 95% CI, 0.29–0.75), and African American (OR, 0.42; 95% CI, 0.27–0.67). Conclusions: Many Americans are not having their depression needs assessed. Certain populations are more likely to be missed, including men, people over 75 years old, minorities, and the uninsured. Additional efforts are needed to determine methods to increase screening recommended by the United States Preventive Services Task Force and to ensure that all Americans have their mental health needs met.

Wide Gap between Preparation and Scope of Practice of Early Career Family Physicians.

Abstract: We found substantial gaps between preparation for, and practice of, early career family physicians in nearly all clinical practice areas. With reported intentions of graduates for a broad scope of practice, gaps between practice and preparation suggest family physicians early in their careers may not be finding opportunities to provide comprehensive care.

'The Hand on the Doorknob': Visit Agenda Setting by Complex Patients and Their Primary Care Physicians.

Abstract: Background Choosing which issues to discuss in the limited time available during primary care visits is an important task for complex patients with chronic conditions. Design, setting, and participants We conducted sequential interviews with complex patients (n = 40) and their primary care physicians (n = 17) from 3 different health systems to investigate how patients and physicians prepare for visits, how visit agendas are determined, and how discussion priorities are established during time-limited visits. Key results Visit flow and alignment were enhanced when both patients and physicians were effectively prepared before the visit, when the patient brought up highest-priority items first, the physician and patient worked together at the beginning of the visit to establish the visit agenda, and other team members contributed to agenda setting. A range of factors were identified that undermined the ability of patient and physicians to establish an efficient working agenda: the most prominent were time pressure and short visit lengths, but also included differing visit expectations, patient hesitancy to bring up embarrassing concerns, electronic medical record/documentation requirements, differences balancing current symptoms versus future medical risk, nonactionable items, differing philosophies about medications and lifestyle interventions, and difficulty by patients in prioritizing their top concerns. Conclusions Primary care patients and their physicians adopt a range of different strategies to address the time constraints during visits. The primary factor that supported well-aligned visits was the ability for patients and physicians to proactively negotiate the visit agenda at the beginning of the visit. Efforts to optimize care within time-constrained systems should focus on helping patients more effectively prepare for visits. Physicians should ask for the patient's agenda early, explain visit parameters, establish a reasonable number of concerns that can be discussed, and collaborate on a plan to deal with concerns that cannot be addressed during the visit.

If We Don't Ask, They Won't Tell: Screening for Urinary and Fecal Incontinence by Primary Care Providers.

Abstract: Background: More than half of older adults experience urinary (UI) or fecal incontinence (FI), but the majority have never discussed symptoms with health care providers. Little is known about primary care providers9 (PCPs9) screening for UI and FI. Methods: We conducted a cross-sectional electronic survey of PCPs within a Midwest academic institution to ascertain and compare PCPs9 beliefs, attitudes, and behaviors regarding screening and treatment for UI and FI; determine factors associated with screening for FI; and identify potential barriers to and facilitators of FI screening and treatment. Results: Among 154 PCPs, the screening rate for UI (75%) was more than double that for FI (35%; P Conclusions: Most PCPs screen for UI but not FI. High reported interest in educational materials, coupled with high reported rates of perceived importance of screening for UI and FI, suggests that PCPs welcome informative interventions to streamline diagnosis and treatment.

Understanding Implementation of Complex Interventions in Primary Care Teams.

Abstract: Background: The implementation of interventions to support practice change in primary care settings is complex. Pragmatic strategies, grounded in empiric data, are needed to navigate real-world challenges and unanticipated interactions with context that can impact implementation and outcomes. Objective: This article uses the example of the “5As Team” randomized control trial to explore implementation strategies to promote knowledge transfer, capacity building, and practice integration, and their interaction within the context of an interdisciplinary primary care team. Methods: We performed a qualitative evaluation of the implementation process of the 5As Team intervention study, a randomized control trial of a complex intervention in primary care. We conducted thematic analysis of field notes of intervention sessions, log books of the practice facilitation team members, and semistructured interviews with 29 interdisciplinary clinician participants. We used and further developed the Interactive Systems Framework for dissemination and implementation to interpret and structure findings. Results: Three themes emerged that illuminate interactions between implementation processes, context, and outcomes: (1) facilitating team communication supported collective and individual sense-making and adoption of the innovation, (2) iterative evaluation of the implementation process and real-time feedback-driven adaptions of the intervention proved crucial for sustainable, context-appropriate intervention impact, (3) stakeholder engagement led to both knowledge exchange that contributes to local problem solving and to shaping a clinical context that is supportive to practice change. Conclusion: Our findings contribute pragmatic strategies that can help practitioners and researchers to navigate interactions between context, intervention, and implementation factors to increase implementation success. We further developed an implementation framework that includes sustained engagement with stakeholders, facilitation of team sense-making, and dynamic evaluation and intervention design as integral parts of complex intervention implementation. Trial registration: NCT01967797. 18 October 2013

One Year of Family Physicians' Observations on Working with Medical Scribes

Abstract: PURPOSE The immense clerical burden felt by physicians is one of the leading causes of burnout. Scribes are increasingly being used to help alleviate this burden, yet few published studies investigate how scribes affect physicians' daily work, attitudes and behaviors, and relationships with patients and the workplace. METHODS Using a longitudinal observational design, data were collected, over 1 year, from 4 physicians working with 2 scribes at a single academic family medicine practice. Physician experience was measured by open-ended written reflections requested after each 4-hour clinic session. A data-driven codebook was generated using a constant comparative method with grounded theory approach. RESULTS A total of 361 physician reflections were completed, yielding 150 distinct excerpts; 289 codes were assigned. The 11 themes that emerged were further categorized under 4 domains. The most frequently recurring domain was clinic operations, which comprised 51.6% of the codes. Joy of practice, quality of care, and patient experience comprised 22.1%, 16.3%, and 10.0% of the codes, respectively. CONCLUSIONS Our study suggests that integrating scribes into a primary care clinic can produce positive outcomes that go beyond reducing clerical burden for physicians. Scribes may benefit patient experience, quality of care, clinic operations, and joy of practice.

Primary Care Physician Perspectives about Antipsychotics and Other Medications for Symptoms of Dementia.

Abstract: Background Guidelines, policies, and warnings have been applied to reduce the use of medications for behavioral and psychological symptoms of dementia (BPSD). Because of rare dangerous side effects, antipsychotics have been singled out in these efforts. However, antipsychotics are still prescribed "off label" to hundreds of thousands of seniors residing in nursing homes and communities. Our objective was to evaluate how and why primary-care physicians (PCPs) employ nonpharmacologic strategies and drugs for BPSD. Methods Semi-structured interviews analyzed via template, immersion and crystallization, and thematic development of 26 PCPs (16 family practice, 10 general internal medicine) in full time primary-care practice for at least 3 years in Northwestern Virginia. Results PCPs described 4 major themes regarding BPSD management: (1) nonpharmacologic methods have substantial barriers; (2) medication use is not constrained by those barriers and is perceived as easy, efficacious, reasonably safe, and appropriate; (3) pharmacologic policies decrease the use of targeted medications, including antipsychotics, but also have unintended consequences such as increased use of alternative risky medications; and (4) PCPs need practical evidence-based guidelines for all aspects of BPSD management. Conclusions PCPs continue to prescribe medications because they meet patient-oriented goals and because PCPs perceive drugs, including antipsychotics and their alternatives, to be more effective and less dangerous than evidence suggests. To optimally treat BPSD, PCPs need supportive verified prescribing guidelines and access to nonpharmacologic modalities that are as affordable, available, and efficacious as drugs; these require and deserve significant additional research and payer support. Community PCPs should be included in BPSD policy and guideline development.

The Association of Patient Satisfaction-Based Incentives with Primary Care Physician Opioid Prescribing

Abstract: Purpose: The opioid epidemic in the United States is an ongoing public health concern. Health care institutions use standardized patient satisfaction surveys to assess the patient experience and some offer incentives to their providers based on the results. We hypothesized that providers who report being incentivized based on patient satisfaction surveys are more likely to report an impact of such surveys on their opioid prescribing practices. Methods: We developed a 23-item survey instrument to assess the self-perceived impact of patient satisfaction surveys on opioid prescribing practices in primary care and the potential impact of institutional incentives. The survey was emailed to all 1404 members of the Colorado Academy of Family Physicians. Results: The response rate to the online survey was 10.4% (n = 146). Clinical indications for which responders prescribe opioids included acute pain (93%), cancer pain (85%), and chronic nonmalignant pain (72%). Among physicians using patient satisfaction surveys, incentivized physicians reported at least a slight impact on opioid prescribing 3 times more often than physicians who were not incentivized (36% vs 12%, P = .004). Conclusions: Efforts to improve patient satisfaction may have potentially untoward effects on providers9 opioid prescribing behaviors. Our results suggest a need to further study the impact of provider incentive plans that are based on patient satisfaction scores.