Researchers examined the role of primary care physicians and other clinicians in delivering vaccinations in the United States. They used two main datasets to create an in-depth analysis of services delivered to Medicare patients, followed by analysis of the Agency for Healthcare Research and Quality's 2017 Medical Expenditure Panel Survey (MEPS) to determine where patients are getting vaccinated and by whom. In the 2017 Medicare Part B Fee-For-Service, primary care physicians provided the largest share of services for vaccinations (46%), followed by mass immunizers (45%), then nurse practitioners/physician assistants (5%). The MEPS showed that primary care physicians provided a majority of clinical visits for vaccination (54%). Primary care physicians have played a crucial role in vaccination delivery to the U.S. population, including the elderly. They are well positioned to help with administering COVID-19 vaccinations. They are also equipped to provide clinical guidance to help patients interpret results from COVID-19 testing and immunity determinations and can answer vaccine questions.
Primary Care's Historic Role in Vaccination and Potential Role in COVID-19 Immunization Programs Elizabeth Wilkinson, BA, et al The Robert Graham Center for Policy Studies in Family Medicine and Primary Care, Washington, D.C. https://www.annfammed.org/content/19/4/351
Medication or Exercise? What's Most Effective for Older Adults With Mild to Moderate Depression?
Depression is the most frequently diagnosed psychiatric disorder among older adults, with 8% to 16% of older patients presenting with clinically significant depressive symptoms. Researchers in Spain conducted a randomized clinical trial of 347 older adults with mild to moderate depression, comparing the effectiveness of physical exercise and antidepressants as treatment methods. Study participants were assigned to either a group engaged in supervised physical exercise or a group that received antidepressant treatment by their general practitioners. Depressive symptoms were not significantly different after one month between the two groups. However, after three and six months, the number of people who showed improvement was significantly higher in the antidepressant group. The authors note that the number of participants who withdrew from the study was higher in the physical activity group, while more adverse side-effects were reported in the group treated with antidepressants. Authors felt the advanced age of participants and the health problems and/or functional limitations common to older adults may have negatively influenced adherence to a six-month physical activity program.
Effectiveness of Physical Exercise in Older Adults With Mild to Moderate Depression Jesús López-Torres Hidalgo, MD, et al University of Castile-La Mancha and Albecete Zone VIII Health Center, Albacete, Spain https://www.annfammed.org/content/19/4/302
Community Health Workers Can Play a Role in Identifying Health-Related Social Needs in Patients
Addressing patients' health-related social needs, like housing and food security, is integral to patient care. Federally Qualified Health Centers are leaders in screening for and addressing patients' health-related social needs. However, screening practices vary. This variation is relatively unexplored, particularly with regards to organizational and state policy influences. Study authors conducted in-person, qualitative interviews at Michigan FQHCs to examine how screening approaches vary in the context of statewide social needs screening initiatives and structural factors. They identified four themes: 1) Statewide initiatives and local leadership drove variation in screening practices. 2) Community health workers played an integral role in identifying patients' needs and their roles often shifted from "screener" to "implementer." 3) Social needs screening data was variably integrated into electronic health records and infrequently used for population health management and 4) Sites experienced barriers to social needs screening that limited their perceived impact and sustainability. FQHCs placed value on the role of community health workers, on sustainable initiatives and on funding to support continued social needs screening in primary care settings, according to the study. Determining the optimal approaches to screening is important to advancing community health.
Implementation of Health-Related Social Needs Screening at Michigan Health Centers: A Qualitative Study Margaret Greenwood-Ericksen, MD, MSc, et al Department of Emergency Medicine, University of New Mexico, Albuquerque, New Mexico https://www.annfammed.org/content/19/4/310
Lessons from Primary Care and Behavioral Health Integration Should Inform Health Care Practices to Identify and Address Patients' Social, Economic Needs
Although interest is accelerating around addressing patients' social and economic needs, effective and sustainable strategies for integrating social care practices into health care delivery have not yet been identified. This paper synthesizes learnings from primary care and behavioral health care integration and translates them into organizing principles with the goal of advancing social care integration practices to improve the health of patients and communities.
Applying Lessons From Behavioral Health Integration to Social Care Integration in Primary Care Theresa J. Hoeft, PhD, et al Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle https://www.annfammed.org/content/19/4/356
Researchers, Policy Makers, Health Care Systems and Payers All Play a Part in Meeting Patient Social Care Needs
Drs. Alicia Cohen and Emilia De Marchis provide commentary on three articles in this issue of Annals of Family Medicine, specifically Greenwood-Ericksen et al's research on Michigan's Federally Qualified Health Centers; Hoeft et al's special report about translating lessons learned from behavioral health integration into the social care realm; and Fessler et al's narrative about how they as medical students stepped away from their medical clerkships to act as community volunteers for people experiencing homelessness during the COVID-19 pandemic. All three articles serve as a timely call to action, reminding those in health care that work remains to meet the needs of patients, particularly in screening for and intervening on identified social risks. The urgency of this work has only been heightened by the pandemic as patients face new or intensified socio-economic hardships. Cohen and De Marchis write that collaboration is needed among researchers, policy makers, payers and health care systems to assist in identifying evidence-based practices for social needs integration. This includes improved training and education for all clinical care team members about social risk and social care activities, best practice guidelines, evidence-based interventions, and sustainable funding streams. Social risk data can also more broadly aid advocacy and policy efforts to expand community-based resources, efforts to address health inequities, and population health-level interventions. Cohen and De Marchis note that greater flexibility in using Center for Medicare & Medicaid dollars and the new 2021 Evaluation and Management coding guidelines for social determinants may help with more consistent funding for social care activities. "The path ahead requires working together and sharing learnings to advance our common goal of achieving health equity and wellness--for patients and the health care workforce alike," they write.
Building an Evidence Base for Integration of Social Care Into Health Care: Our Collective Path Ahead Alicia J. Cohen, MD, MSc, FAAFP, Center of Innovation in Long Term Services and Supports, VA Providence Healthcare System; Departments of Family Medicine and Health Services, Policy, and Practice, Brown University, Providence, Rhode Island. Department of Family Medicine, University of Michigan, Ann Arbor, Michigan.
Emilia H. De Marchis, MD, MAS, Department of Family & Community Medicine, University of California, San Francisco https://www.annfammed.org/content/19/4/290
Medical Students Hang Up White Coats, Stethoscopes to Serve Unhoused Communities During COVID-19 Pandemic
Four University of Michigan Medical School students write about being removed from their clinical clerkships and returning to the community to support their neighbors experiencing homelessness during the COVID-19 pandemic. The students made brown bag lunches for people experiencing homelesness and also worked as community volunteers for temporary shelters. "Though formal education was stalled, we reconnected with the initial desire that led us to pursue medical education in the first place and developed key skills in communication, relating to others, and compassion that we believe will enable us to become better physicians in the future," they write.
Sandwiches, 6 Feet Apart: Reflections on Community (and Medical School) During COVID-19 M. Margaret Fessler, BA, et al University of Michigan Medical School, Ann Arbor, Michigan https://www.annfammed.org/content/19/4/368
Today's Health Care Requires Understanding of Social Determinants to Address Increasingly Complex Patient Needs
The authors use a patient story to illustrate their experiences as family physicians who care for patients with complex health care needs that go beyond just physical symptoms or a single morbidity. Justesen et al write that they care for patients with increased medical complexity, which may include both medical and mental health diagnoses and are often combined with substance abuse disorders and low socioeconomic status. Their experiences highlight the importance of addressing social determinants of health, which permeate the context of health and health care. Factors such as financial challenges, limited transportation, food insecurity and low health literacy have a profound influence on health. Family physicians are in a unique position to treat patients appropriately and efficiently by embracing the complexities of the patients they encounter. By doing so, family physicians can help improve health outcomes and manage health care costs in patient populations that increasingly present with complex health needs.
Michelle's Story: The Complexity of Patient Care in a Family Medicine Residency Clinic Kathryn Justesen, MD, et al Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, Minnesota https://www.annfammed.org/content/19/4/362
Minority Physicians Experience More Diversity, Less Burnout in Family Medicine Practice
More than 40% of physicians in the United States reported at least one symptom of burnout, which is particularly high among family physicians. This study examined a nationally-representative sample of family physicians to determine whether physician race-ethnicity was associated with burnout among a nationally-representative sample of family physicians. Of the 3,0916 physicians studied, 450 (15%) were from racial-ethnic groups underrepresented in medicine (UIM), which include Blacks/African Americans, Hispanics/Latinos, American Indians and Pacific Islanders who together comprise 30-35% of the general population yet account for only 12.4% of family physicians. The study findings support the researchers' hypothesis that UIMs were significantly less likely than their non-UIM counterparts to report emotional exhaustion and depersonalization. This may be attributed to practicing in more racially-diverse counties and being less likely to practice obstetrics, both of which partially mediated the protective effect of UIM status on depersonalization. The mediating effect of working in more racially and ethnically diverse counties is consistent with evidence of the beneficial effect of cultural diversity on health outcomes for minorities and better overall self-rated health among adults. Understanding the attributes of UIMs that may prevent burnout may also provide insights for developing a more resilient physician workforce.
Lower Likelihood of Burnout Among Family Physicians From Underrepresented Racial-Ethnic Groups Montgomery Douglas, MD, et al Department of Family Medicine, University of Connecticut School of Medicine, Farmington, Connecticut https://www.annfammed.org/content/19/4/342 Primary Health Care Practice Characteristics Make Little Impact on Unplanned Hospital Admissions
Given the aging world population, there is international interest in helping older people live longer and healthier lives. Avoiding unplanned hospital admissions is an important aspect of care for older people. Palapar et al focused on the way primary care practice characteristics influence outcomes such as unplanned hospitalizations, function and well-being. They investigated the variability in older people's outcomes by primary care physician and practice characteristics in New Zealand and the Netherlands. Findings revealed that none of the physician or practice characteristics were significantly associated with rates of unplanned admissions in the New Zealand sample. In contrast, in the Netherlands sample, researchers found higher rates of admissions in large practices and practices staffed with a practice nurse who typically works in the primary care setting with general practitioners. Practice nurses are common in primary care practices in New Zealand but are relatively new and only in a portion of practices in the Netherlands, the authors note. It is unclear if these associations are causal or if the increase in hospitalizations represent higher or lower quality care. Considering these findings, the authors conclude that the central focus of international health policies on reducing hospital overuse should approach primary health care structural reform carefully.
Primary Care Variation in Rates of Unplanned Hospitalizations, Functional Ability, and Quality of Life of Older People Leah Palapar, MD, PhD, et al Department of General Practice and Primary Health Care, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand https://www.annfammed.org/content/19/4/318
Chinese Medical Insurance Achieves "Remarkable" Success in Decreasing Diabetes Medication Usage, Costs
Approximately 642 million people are expected to be diagnosed with diabetes by 2040, with Asians representing more than 55% of cases. Researchers conducted the first large-scale study since the implementation of medical insurance in China to evaluate the complexity and cost of drug therapy for Asian people with diabetes. They used available treatment records from Beijing's medical insurance bureau from 2016 to 2018 and looked at five outcomes, including: 1) quantity of outpatient medications, 2) number of co-morbidities diagnosed, 3) estimated annual cost of the outpatient drug regimen, 4) drug therapy strategies for diabetic patients and 5) the most commonly prescribed drug class in the patient cohort. They found that over three years, there was a gradual decrease of almost 9% decrease in the average quantity of diabetes medications. The mean usage of both anti-glycemic and non-antiglycemic drugs decreased by 3.6% and 12.8%, respectively. Researchers found an 18.39% decrease in estimated annual medication costs. The decrease in medical costs could be due to rational use of medications, leading to a decrease in the usage of medications over the three years. This is especially true for what the authors call the needless use of most types of insulin. This could have indirectly led to decreased costs. China's health insurance appears to have achieved "remarkable" success. The study authors advise that therapeutic drugs should be selected with caution according to the diet and lifestyle of each individual.
Changes in Direct Medical Cost and Medications for Managing Diabetes in Beijing, China, from 2016 to 2018: Electronic Insurance Data Analysis Lixin Guo, MD, et al Department of Endocrinology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, PR China https://www.annfammed.org/content/19/4/332
Early Perceptions of COVID-19 in Pennsylvania
A survey conducted in March 2020 reports that early concern for COVID-19 outmatched concern for influenza, but respondents may have been less focused on their perceived likelihood of contracting COVID-19 and more concerned with its severe impact on their health. Additionally, when the Centers for Disease Control and Prevention began advising social distancing recommendations in the early months of the pandemic, a majority of adults surveyed believed in the effectiveness of social distancing and intended to follow CDC guidelines. Health agency websites like the CDC were the most frequently identified as "trusted sources" for COVID-19 information, as opposed to substantial distrust in COVID-19 information from mass media and politicians. The study, conducted by researchers at Penn State University, was completed by almost 6,000 adults enrolled in a central Pennsylvania health care system in late March 2020. It suggests that knowledge about COVID-19 and adherence to behavioral recommendations was generally high.
Knowledge, Perceptions, and Preferred Information Sources Related to COVID-19 Among Central Pennsylvania Adults Early in the Pandemic: A Mixed Methods Cross-Sectional Survey Lauren Jodi Van Scoy, MD, Department of Medicine, Pennsylvania State University. Robert P. Lennon, MD, JD, et al Departments of Medicine, Humanities, Public Health Sciences and Qualitative and Mixed Methods Core, Pennsylvania State University, State College, Pennsylvania https://www.annfammed.org/content/19/4/293
Choosing the Right Communication Tool at the Right Time Ensures Patients Have Full Access to Health Care
Kumara Raja Sundar, MD, a family physician at Kaiser Permanente of Washington, uses two media synchronicity theory principles - conveyance and convergence - as a framework for choosing the right medium of care for his patients. In this essay, Sundar discusses how operating within this framework changed his own practice and decision making during the COVID-19 pandemic, particularly with the use of telemedicine versus in-person clinic visits. The theory of conveyance focuses on transmitting and processing diverse information to understand a situation. It requires time to analyze data, create patterns and make conclusions. Convergence focuses on discussing pre-processed information to achieve a mutual understanding of it. It often requires a rapid exchange of information to allow immediate feedback to test and verify each person's knowledge. Sundar writes that patients benefit from telehealth's convenience when they have access to the right technology but that they must have access to all care options. "We must guide patients towards the right care medium for them and in the correct order and use all of our tools efficiently and effectively," he adds. "It is the only way we will be able to achieve our mission of healing."
Virtual Care: Choosing the Right Tool, At the Right Time Kumara Raja Sundar, MD Kaiser Permanente of Washington, Burien, Washington https://www.annfammed.org/content/19/4/365
Innovations in Primary Care
Innovations in Primary Care are brief one-page articles that describe novel innovations from health care's front lines. In this issue:
A Novel Adaptation to the Extension for Community Healthcare Outcomes (ECHO) Model--To better meet the need for up-to-date information about COVID-19, ECHO Colorado connects experts in academic medicine with community primary care counterparts. The addition of a research team primarily composed of medical students and family medicine residents allowed for a dynamic, experiential learning opportunity.
Allison Costello, MD, MBA, et al University of Colorado Family Medicine Residency, Denver, Colorado https://www.annfammed.org/content/19/4/371
Annals of Family Medicine is a peer-reviewed, indexed research journal that provides a cross-disciplinary forum for new, evidence-based information affecting the primary care disciplines. Launched in May 2003, Annals is sponsored by seven family medical organizations, including the American Academy of Family Physicians, the American Board of Family Medicine, the Society of Teachers of Family Medicine, the Association of Departments of Family Medicine, the Association of Family Medicine Residency Directors, the North American Primary Care Research Group, and The College of Family Physicians of Canada. Annals is published six times each year and contains original research from the clinical, biomedical, social and health services areas, as well as contributions on methodology and theory, selected reviews, essays and editorials. Complete editorial content and interactive discussion groups for each published article can be accessed free of charge on the journal's website, http://www.AnnFamMed.org.
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