Routine Vaccination Rates Must Recover to Reduce Secondary Health Consequences of the COVID-19 Pandemic
Editor’s note: The authors of this paper are employed by or are contract employed by Merck Sharp & Dohme Corp, a subsidiary of Merck & Co, Inc, Kenilworth, New Jersey.
Authors of this special report note that, although ending the COVID-19 pandemic is of utmost importance, it is critical to recover from what they describe as a “severe” disruption to routine vaccination services, which has resulted in “considerable deficits'' of vaccination rates across all age groups. Vaccinations that have seen drops include measles-mumps-rubella (MMR), diphtheria, tetanus and acellular pertussis (DTaP) and polio, as well as HPV vaccination rates for children 9-12. This drop in routine vaccinations may have dire consequences to future population health and a potential to strain an already overtaxed health system. The authors conclude, “Recovering from the decline in routine vaccination rates caused by the pandemic will take years. This recovery requires all stakeholders to drive awareness of the importance of routinely recommended vaccines; facilitate access to vaccination; and build vaccine confidence.”
Silent Consequences of COVID-19: Why It’s Critical to Recover Routine Vaccination Rates Through Equitable Vaccine Policies and Practices
Ava Skolnik, MPH et al
Merck, North Wales, Pennsylvania
https://www.annfammed.org/content/19/6/527
Person-Centered Primary Care Measure Shows Validity Across 35 Countries
Researchers administered the Person-Centered Primary Care Measure (PCPCM) in 28 languages to 35 Organisation for Economic Cooperation and Development countries to examine the reliability and validity of the measure and to explore the differences in primary care across 35 OECD countries. The PCPCM is an 11-item, patient-reported measure developed in 2017 to assess primary care qualities such as health care accessibility, advocacy, community context, family context, goal-oriented care, health promotion, integration and relationship. Survey constructs are based on what patients, clinicians and, to a lesser extent, payers say is most important to them in primary care.
The PCPCM showed solid psychometric properties across all languages and countries, according to the study. The results are important as they provide evidence to primary care researchers that the PCPCM is able to collect data with high comparability, despite differences in geography, culture, or language. The authors encourage further ecological and individual data analyses of the PCPCM to learn about different approaches to health care across different countries.
Measuring Primary Care Across 35 OECD Countries
Rebecca S. Etz, PhD, et al
Virginia Commonwealth University Department of Family Medicine and Population Health, Richmond, Virginia
https://www.annfammed.org/content/19/6/547
Researchers Identify Four Factors That Promote High Clinician and Patient Trust, Which May Improve Patient Care
Trust in the medical profession has dropped from a high of 75 percent in a 1966 survey to a low of 33 percent in 2018. Researchers sought to determine the characteristics of health organizations that promoted clinician trust. They further hypothesized that clinician trust may be correlated with patients’ trust in their clinician.
“High clinician-high patient” trust occurred when clinicians perceived their organizational culture as having: 1) an emphasis on quality; 2) an emphasis on communication and information; 3) cohesiveness among clinicians; and 4) values aligned between clinicians and their leaders.
The researchers concluded that addressing organizational culture may improve trust at the organizational and patient levels. Lack of trust in the medical profession has implications for patient care since research from past epidemics has shown that lack of trust decreases the likelihood of patients adhering to public health recommendations. Linzer et al write that it is critical to identify factors that will assist health systems to better understand how to create the most trust within their work environments.
Where Trust Flourishes: Perceptions of Clinicians Who Trust Their Organizations and Are Trusted by Their Patients
Mark Linzer, MD, et al
Hennepin Healthcare Research Institute, Hennepin Healthcare and the University of Minnesota, Minneapolis, Minnesota
https://www.annfammed.org/content/19/6/521
Supplementing Patient Health Questionnaire With Suicide Cognition Scale Questions Improves Identification of Individuals at Highest Risk of Suicide
Researchers from academia and the U.S. military sought to determine if suicide risk screening can be improved to better identify highest-risk patients. Patients eligible to receive medical treatment from the U.S. Department of Defense medical system were recruited from six military primary care clinics in five military installations across the country. Adding one of three Suicide Cognitions Scale (SCS) items to the Patient Questionaarie (PHQ-9) self report measure during routine primary care clinical visits improved the accuracy of identifying those patients who were at the highest risk of suicidal behavior within a month of screening positive.
One byproduct of augmenting the PHQ-9 is a potential reduction in unnecessary treatment and/or misallocated resources — a benefit to both patients and physicians, considering a majority of patients who screen positively on the PHQ-9 suicide risk item do not attempt or die by suicide.
Improving Suicide Risk Screening to Identify the Highest Risk Patients: Results From the PRImary Care Screening Methods (PRISM) Study
Craig J. Bryan, PsyD, ABPP, et al
The Ohio State University Wexner Medical Center, Columbus, Ohio
https://www.annfammed.org/content/19/6/492
Child & Adolescent Psychiatrist Describes Her Experience as a Mother of a Transgender Child, Strives to Teach Physicians to be Supportive of Gender Creative Children
Child and adolescent psychologist, Justine Larson, MD, writes about her child, Neo, who, at age 11, informed her that he was a boy and not a girl, as assigned at birth. Despite Dr. Larson’s training, she struggled to accept her child’s decision and had to learn how to best support Neo. She writes about how she and her husband had to navigate the adjustments to Neo’s new pronouns, name change, transition at school, and informing friends and family about the changes. “Seeing Neo’s sadness and despondency when he was not accepted sparked me to educate myself about medical options for transgender individuals and other ways to be gender affirming,” Larson writes. “Neo taught me to challenge societal dichotomies and taught me about how physicians, in particular, can support families with gender creative children.”
Parenting My Transgender Child: From Loss to Acceptance
Justine Larson, MD
Sheppard Pratt, Takoma Park, Maryland.
https://www.annfammed.org/content/19/6/556
Insurance Type, Gender, Disability and Race of Persons With Disabilities Account for Gaps in Annual Wellness Visits
Researchers documented the use of Annual Wellness Visits (AWV) by persons with physical disabilities during the Affordable Care Act rollout. They extracted data from an administrative claims database including both Medicare Advantage and commercial insurance payers from 2008-2016, and looked specifically at unique yearly wellness visits for adults with physical disabilities. They used interrupted time series analysis to compare AWV use by insurance type, gender, disability type and race over time. Results showed that by 2016, AWV reached 47.6 percent (44.7, 50.8) among commercial insurance–covered white women with congenital disabilities (spina bifida and cerebral palsy). In contrast, the rate among commercially insured Hispanic men with acquired disabilities (spinal cord injuries, hemi-, para- and quadriplegia) was lower at 21.6 percent (18.4, 25.2). Medicare Advantage-insured Black and Hispanic men with acquired disabilities had a similarly low level of AWV use. The ACA mandated zero copays, allowing persons with physical disabilities the option for screening without cost. Insurance and gender significantly influenced AWV use, followed by disability type and race. Overall, the highest AWV use for persons with disabilities is nearly 15 percent less than the 62 percent AWV use threshold seen in the general population. Addressing use gaps and increasing AWV use may be one way to increase overall improved health of persons with disabilities.
Annual Wellness Visits for Persons With Physical Disabilities Before and After ACA Implementation
Diane M. Harper, MD, MPH, MS, et al
University of Michigan, Department of Family Medicine, Obstetrics and Gynecology, Ann Arbor, Michigan
https://www.annfammed.org/content/19/6/484
Researchers Explore Participatory Approaches to Case Studies of Complex Primary Care Innovation
Engaging stakeholders in case study development may enhance implementation of complex health care interventions in primary care. Researchers defined several levels of stakeholder engagement of varying intensity, from full involvement in all stages of the research to involvement in certain stages. They then provide twelve steps for conducting case studies with a participatory approach, illustrated by a practical example of how one primary care research team used the case study approach to assess the implementation of a complex health care innovation.
Researchers clarify the methods, validity and scope of conducting case studies with a participatory approach. They believe this can be used in health services research and to potentially assist in the implementation analysis of complex primary care interventions.
Case Study With a Participatory Approach: Rethinking Pragmatics of Stakeholder Engagement for Implementation Research
Catherine Hudon, MD, PhD, et al
University of Sherbrooke, Quebec, Canada
https://www.annfammed.org/content/19/6/540
Peer Coaching Focused on Building Patient Autonomy Associated with Higher Levels of Patient Engagement in Diabetes Self Management
A new study on diabetes self-management found that autonomy-supportive peer coaching is associated with higher levels of patient engagement. The study assessed the characteristics of low-income, Black veteran men who participated in a peer coaching program called Technologically Enhanced Coaching: A Program to Improve Diabetes Outcomes (VA-TEC) at the John D. Dingell VA Medical Center in Detroit and analyzed their levels of program engagement and health outcomes at six and 12 months.
At the six-month follow-up, participants who evaluated their peer coaches as highly autonomy-supportive were more likely to have engaged in the program than participants who rated their coaches lower on autonomy supportiveness. Additionally, the authors highlight characteristics of peer coaches who contributed to increased patient engagement including shared background and lived experiences with participants; sharing information on resources and self-management strategies that were helpful in their own lives; being encouraging, supportive and authentic during sessions; and being reliable and consistent.
The study provides important insights for self-management support programs tailored to promote positive health outcomes for low-income Black veteran men.
Peer Coaching to Improve Diabetes Self-Management Among Low-Income Black Veteran Men: A Mixed Methods Assessment of Enrollment and Engagement
Cassie D. Turner, MSW, et al
University of Michigan and Ann Arbor Veterans’ Affairs (VA) Healthcare System, Ann Arbor, Michigan
https://www.annfammed.org/content/19/6/532
Health Practitioners Rely on Case Management Programs to Address Patients’ Social Care Needs
Health professionals recognize that social factors such as food, housing and economic insecurity, affect health outcomes. Researchers conducted a qualitative study to gain practical insights into strategies used by clinicians, leaders and policymakers to address patients’ social needs in the United States. They selected sites to ensure diversity in ownership, structure, geography and urbanicity, ranging from small primary care practices to multi-state health systems. Interviews focused on how organizations develop and implement case management-style programs to assist patients with social needs including staffing, assistance intensity and use of referrals to community-based organizations. The authors identified four barriers to addressing patients’ social needs including: 1) effectively engaging CBOs; 2) obtaining buy-in from clinical staff; 3) considering patients’ perspectives; and 4) ensuring program sustainability. Researchers conclude that many health care organizations will likely develop or rely on case management approaches to address patients’ social challenges and may require support to address the key operational challenges.
Resource Brokering: Efforts to Assist Patients With Housing, Transportation, and Economic Needs in Primary Care Settings
Taressa K. Fraze, PhD, et al
University of California, San Francisco, San Francisco, California
https://www.annfammed.org/content/19/6/507
Clinicians Response to Patients’ Emotions is Associated with Visit Length
Beach et al evaluated the association of clinician responses to patient emotions during a clinic visit. Researchers audio-recorded 41 clinicians with 342 unique patients as part of the maRIPOHSA (Maximizing Respect and Improving Patient Outcomes in HIV and Substance Abuse) Study. They classified physicians’ responses to patient emotions as either providing space or reducing space for patients to elaborate on their emotions. Within these categories, they identified these responses as either explicit or non-explicit, meaning that the physician either named the emotion in their response or did not. They found that patients repeated their emotions when physicians provided space. When physicians explicitly addressed emotions, visit length was shorter. Finally, they noticed that as the clinic visit progressed, the physician was less likely to respond by providing space.
The study took place in an HIV ambulatory care center, where patients received both specialty HIV care and primary care. The mean visit length was 30.4 minutes with 1,028 emotional expressions total. Most clinician responses provided space (81 percent) and most were non-explicit (56 percent). Beach and her colleagues concluded that if saving time is a goal, clinicians should consider their responses that explicitly address patient emotions.
Clinician Response to Patient Emotion: Impact on Subsequent Communication and Visit Length
Mary Catherine Beach, MD, MPH, et al
Johns Hopkins School of Medicine, Baltimore, Maryland
https://www.annfammed.org/content/19/6/515
A Doctor Reflects on the Meaning of ‘Continuity Of Care,’ A Core Value of Family Medicine, in his Professional Practice and Personal Life
David Loxterkamp, MD looks back at his career as a practicing physician in rural Maine. He reflects on how family medicine’s emphasis on continuity of care has shaped his sense of identity and purpose, and is dismayed by the erosion of this value in primary care. Despite research that establishes the benefits of relational continuity in the lives of patients and their physicians, the author sees a marked shift in family medicine practices toward the “transactional,” episodic care of mainstream medicine. The loss of continuity makes it increasingly difficult to win the patient's trust, enter deeply into their day-to-day lives, and establish the deep bonds that make any long-term relationship mutually meaningful.
The Lost Pillar: Does Continuity of Care Still Matter?
David Loxterkamp, MD
Northern Light Family Medicine Residency Program and Director, Seminar on the Arts & Humanities in Medicine, Bangor, Maine
https://www.annfammed.org/content/19/6/553
Institutional Trust and Communication Practices Can Help Doctors Build Patient Rapport, Sustain Continuity of Care
Family physician and blogger Kenneth W. Lin, MD, MPH, writes about the theme of trust and relationships in primary care. “As I continue promoting COVID-19 vaccines for patients with low levels of trust in the medical system, it helps to know that my practice team and health care organization have my back,” he writes. Linzer et al’s research, published in this edition of Annals, identified four features of organizational culture that correlate with high clinician trust in the organization and high patient trust in the clinicians: quality; communication and information; clinician cohesion; and clinician-leader value alignment. Organizations that build trust among physicians may have happier clinicians and more satisfied patients, according to Lin.
Lin also responds to Beach et al’s findings that clinicians were less likely to give patients opportunities to elaborate on emotions as clinic time elapsed. “Readers can judge if saving about two minutes per visit is worth what was potentially lost in these encounters,” Lin writes.
Other papers in this edition of Annals discuss the tension of competing priorities between independent physicians and clinicians who work in larger health care organizations, Lin suggests that patients and doctors alike will benefit from promoting doctor-patient relationships and trust, while also providing physicians and other health professionals with the support of a larger medical system.
Trust and Relationships Remain at the Heart of Primary Care
Kenneth W. Lin, MD, MPH
Georgetown University Medical Center, Washington, DC
https://www.annfammed.org/content/19/6/482
Small Primary Care Practices That Received Training in Creating and Using Quality Measures to Enhance Care Improved Patient Outcomes
A team of family medicine researchers conducted an assessment to determine if the implementation of policies and workflows designed to improve quality of care in smaller primary care practices was associated with improved health outcomes for patients with cardiovascular disease. The study also examined whether enhancements in quality improvement capacity are associated with a change in clinic performance.
During the15-month intervention, study participants received training on how to extract clinical quality measures from patient data and implement QI innovations using plan-do-study-act cycles of improvement. Performance on three cardiovascular quality measures —appropriate aspirin use, blood pressure (BP) control, and tobacco screening/cessation counseling—were reported by clinics at baseline and follow-up.
Within 15 months of the intervention, practices were able to make improvements in all areas, with most improvements occurring in the domains related to QI where facilitators focused their efforts. Additionally, the researchers observed that for each one-point increase in the QICA score, practices were 24 percent more likely to reach the Million Hearts campaign goal of 70 percent of patients with well-controlled blood pressure. With these findings, the authors suggest that relatively light QI support provided by an external facilitator can support important QI changes within small primary care practices.
Improving Quality Improvement Capacity and Clinical Performance in Small Primary Care Practices
Katie F. Coleman, MSPH
MacColl Center for Health Care Innovation, Kaiser Permanente of Washington Health Research Institute, Seattle, Washington
https://www.annfammed.org/content/19/6/499
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:
Community Paramedic Mobile COVID-19 Unit Serving People Experiencing Homelessness — Members of the Mayo Clinic Ambulance Service partnered with the Olmsted County Housing Stability Team to provide timely, person-centered care to COVID-19 positive individuals experiencing homelessness. The unit, which cared for 13 people in its first two weeks, is currently working toward expansion to all shelters and encampments, not limited to individuals with confirmed COVID-19 infection.
Zachary Stickler, NRP, AAS, et al
Mayo Clinic Ambulance Service, Rochester, Minnesota
https://www.annfammed.org/content/19/6/562
The Implementation of a Clinic-Based Opioid Review Board to Address High-Risk Opioid Prescribing in Primary Care —The internal medicine clinic at Oregon Health & Science University formed an opioid review board (ORB) to set clinic policy for safe opioid prescribing aligned with state and federal guidelines and evidence-based practices. The ORB has updated the patient-physician opioid agreement and now conducts formal case reviews of two to four patients each month. The ORB focuses on the process of case reviews and has improved clinical alignment with state and federal guidelines. Increasingly, providers actively seek ORB assistance for difficult cases.
Jonathan Robbins, MD, MS
Division of General Internal Medicine & Geriatrics, Oregon Health & Science University, Portland, Oregon
https://www.annfammed.org/content/19/6/563
Implementation of a “Cases and Conundrums” Conference Among Early Career Internal Medicine Clinicians — Authors John C. Matulis and Suzette Barakat, two early career internal medicine physicians at the Mayo Clinic in Rochester, Minn., created a forum for themselves and their health care colleagues to review challenging cases and seek input on difficult clinician decision-making scenarios, but also to provide an informal setting for networking. The conference improved a sense of belonging among participants by 25 points and enthusiasm by 18 points on a 100-point scale, although there were non-significant improvements in overall quality of life scores, burnout scores and meaning in work scores. The authors believe a conference similar to the Mayo Clinic’s ‘Cases and Conundrums’ may be an effective intervention for building community among early career clinicians while improving patient care.
John C. Matulis III, DO, MPH and Suzette Barakat, MD, MPH
Division of Community Internal Medicine, Mayo Clinic, Rochester, Minnesota
https://www.annfammed.org/content/19/6/560
Fulfilling a Need: A Residency-Based Program to Preserve a Suboxone Treatment Program in a Rural Community — Members of the Mayo Clinic Family Medicine Residency-Eau Claire created a medication-assisted treatment program for opioid disorders within its practice. They did this by taking over care for a large group of established patients from a single family physician who was leaving the community. Part of this entailed the development of didactic sessions and documentation templates, which facilitated treatment and seamless patient scheduling with residency providers. The new program helped patients and their original physician to avoid the challenges of identifying other providers and possibly being unable to access care. Program coordinators felt this significantly decreased the risk of patient relapse with its associated costs to individuals and the community.
Meredith C. Buck, MD, et al
Mayo Clinic Family Medicine Residency-Eau Claire, Eau Claire, Wisconsin
https://www.annfammed.org/content/19/6/560
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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, www.AnnFamMed.org.
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