Despite Tech Solutions, Physician-to-Physician Engagement for Referrals and Consultations Needs Improvement
Researchers from Mathematica and Weill Cornell Medicine conducted a study to examine communication between primary care physicians and specialist physicians about their common patients, using data collected as part of the evaluation of the Comprehensive Primary Care Plus (CPC+) model. The researchers received survey responses from 4,754 physicians in CPC+ and comparison practices. They then measured the extent to which PCPs reported sending clinical information to specialist physicians at the time of referral and reported receiving information from specialists after consultation.
The researchers found that despite the penetration of electronic health records, the substantial growth in the number and sizes of vertically integrated health systems, and the proliferation of large-scale primary care redesign efforts (such as CPC+), gaps in communication between PCPs and specialist physicians have persisted over the last decade. Twenty-two percent of PCPs in CPC+ and comparison practices in both study tracks reported that they “sometimes” or “seldom or never” sent clinical information to the specialist at the time of referral. Similarly, less than 35% of PCPs in CPC+ and comparison sites reported that they either “sometimes” or “seldom or never” received information back from a specialist after a consultation.
The findings suggest that, despite the availability of communication technologies and recommendations to improve care coordination, physicians do not always intentionally engage in communication for referrals and consultations. The authors argue that this persistent communication gap can impact patients negatively, increasing the likelihood of delayed diagnoses, unnecessary testing, and patient and physician dissatisfaction.
Communication Gaps Persist Between Primary Care and Specialist Physicians
Lori Timmins, PhD, et al
Mathematica, Chicago, Illinois
https://doi.org/10.1370/afm.2781
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How Family Doctors Can Help Patients Navigate Racism’s Painful Legacy
In a moving reflection, Khaliah Johnson, MD, speaks from her experiences as a Black mother, survivor of sibling loss, and pediatric palliative care doctor to suggest how the medical community can stand with their Black patients in their grief experiences. She describes her personal experiences navigating intergenerational grief, suffering and pain brought on by the legacy of racism against Black U.S. Americans over the last 400 years.
While the country continues to grapple with the effects of racism on the Black community, Johnson argues that the medical community has a special role to play in helping Black patients navigate feelings of pain, loss and grief brought on by these shared experiences. “Family clinicians have the undeniable opportunity to tend to the grief of their Black patients by bearing witness to their lived experience,” she added, noting that those in the medical community can respectfully take what they learn from patients’ stories to advocate for improvements in how health systems address their grief and loss in a patient-centered manner.
A Mother’s Tears: Contemplating Black Grief
Khaliah Johnson, MD
Children’s Healthcare of Atlanta and Department of Pediatrics, Emory University, Atlanta, Georgia
https://www.annfammed.org/content/early/2022/05/27/afm.2822
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New EHR-Embedded Survey Tool May Increase Research Efficiency, Decrease Costs of Gathering Data
A new study reports on the development and implementation of digital survey methods that could replace a form of paper-based surveys, known as card studies, in clinic-based research. While card studies are useful for collecting data at the point of care, traditional paper-based methods can be costly and complicated. Additionally, clinical workflows require that card studies be brief, making it challenging to obtain the rich demographic and contextual data required for meaningful analyses using paper-based methods.
Researchers developed and tested a digital parallel to these paper card studies, embedding the tool into the clinic’s electronic health record and thus reducing the complexity for participants. In addition, data collection became more meaningful as each participant’s responses were linked to clinic and patient data.
Each survey took less than one minute to complete. When data collection was finalized, survey responses were removed from the EHR and did not become part of the patient’s legal medical record. At the end of implementation, participating clinicians had completed 79% of all card requests. The authors posit that future EHR-embedded surveys could replicate and automate much of the time-intensive development, which may increase research efficiency and substantially decrease survey-related labor costs.
Designing and Implementing an Electronic Health Record–Embedded Card Study in Primary Care: Methods and Considerations
Arwen Bunce, MA, et al
OCHIN Inc., Portland, Oregon
https://doi.org/10.1370/afm.2818
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Psychiatrist Reflects on Internalized Racism and the ‘Model Minority’ as he Builds Awareness of Anti-Asian Racism
In this essay, Jason Eric Cheng, MD, a psychiatry residency program director of Asian descent at a historically Black institution, writes about initially downplaying the effects of anti-Asian racism on himself while, at the same time, providing forums for his majority-Black residents to express and process their feelings about the traumatic effects of racism on our society. This led Cheng to examine the personal impact of anti-Asian racism and how his internalization of the “model minority stereotype” caused him to suppress his own feelings in response to increasing reports of hate crimes targeting those in the Asian community.
“Whether the tendency to keep my head down is personal, familial or cultural, it is something I continue to work on,” he writes. “I discuss with the residents when and how to address racism head-on in psychotherapy and other settings. The people at my program and the increased antiracist activity nationally have helped me find my voice in speaking out against racism against my own group.”
How I Learned to Speak Up About Anti-Asian Racism
Jason Eric Cheng, MD
Meharry Medical College, Nashville, Tennessee
https://doi.org/10.1370/afm.2819
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Tool Uniting Clinical and Home Blood Pressure Readings With EHR Helps with Hypertension Management, Doctor-Patient Shared Decisions
Researchers developed and implemented a new visualization tool that combines clinical and home blood pressure readings, displaying them within the patient’s electronic health record in a single chart for easy navigation and analysis. They then studied how the tool was used during primary care visits and its effect on doctor-patient communication as it relates to shared decision-making for effective blood pressure management.
The tool was tested by a 10-practice primary care network. Researchers found that physicians and patients reviewed the home blood pressure trends over time to determine if the patient’s blood pressure was adequately controlled, regardless of how the blood pressure readings were reviewed (i.e., paper or EHR). When using the visualization tool, however, all readings were presented in the same chart, eliminating time spent navigating between the two data sources. Additionally, researchers observed that medication records embedded in the tool prompted additional conversations about possible adverse effects of medications, dosage adjustments, and the correlation between medication use and reductions in blood pressure. There were missed opportunities for such discussions when the patient’s at-home readings were not integrated with their EHR.
The tool was not found to have a significant impact on visit efficiency and length. However, the authors conclude that reviewing home blood pressure using a visualization tool is useful for clinicians and patients. It promotes shared decision-making in blood pressure management in the primary care setting. Primary care practices and their patients need adequate funding and infrastructure support to realize these benefits.
Impact of Home Blood Pressure Data Visualization on Hypertension Medical Decision Making in Primary Care
Deborah J. Cohen, PhD, et al
Oregon Health and Science University, Portland, Oregon
https://doi.org/10.1370/afm.2820
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Practices Leverage Telehealth to Enhance Access to Abortion Services
The COVID-19 pandemic disrupted the delivery of many health services, including abortion, prompting researchers in Seattle to examine the feasibility of telehealth to improve access to this important care. Researchers conducted 21 interviews with clinical staff from four practice settings: independent primary care practices; specialized family planning clinics; online medical services; and primary care clinics within multispecialty health systems. Across all practice settings, the researchers found similar operational procedures for remote medication abortion services, with each site following five basic steps for care provision: patient engagement, care consultations, payment, medication dispensing and follow-up communication.
Though the overarching structure of services remained consistent across clinics, each site adapted services to their specific setting, local laws and regulations, and the needs of their patient populations. Service sites used multiple methods of medication delivery, including on-site pharmacies, medication dispensing protocols, and partner pharmacies. Family planning and health system clinics mailed medications from clinic stock or internal pharmacies, while independent clinics and online services often used mail-order pharmacies. The authors assert that these findings demonstrate the feasibility of offering abortion services in a variety of medical settings and highlight the potential variations that can be made to adapt the service to patient needs.
Remote Delivery in Reproductive Health Care: Operation of Direct-to-Patient Telehealth Medication Abortion Services in Diverse Settings
Anna E. Fiastro, MPH, MEM, et al
Department of Family Medicine, University of Washington, Seattle, Washington
https://www.annfammed.org/content/early/2022/07/14/afm.2821
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Public Health Researchers Develop Web-Based Guide to Help Family Physicians Address COVID-19 Vaccine Hesitancy
Public health researchers in Canada developed an interactive, web-based guide to help family physicians better address a wide range of patient concerns related to the COVID-19 vaccine. To ensure relevancy, the researchers conducted qualitative interviews with primary care physicians in multiple Canadian provinces. The data was then used to identify commonly held beliefs, attitudes and perceptions that impact a patient’s willingness to receive the vaccine.
The research team found that physicians frequently encountered many of the same reasons for COVID-19 vaccine hesitancy, including concerns around safety; interactions with co-morbidities; conspiracy theories; religious or moral restrictions; and past traumas experienced in the medical setting. Using this information, researchers created several physician resources to help better counsel vaccine-hesitant patients, in direct response to each potential concern.
Additionally, the free guide outlines four steps to help physicians have better conversations with vaccine-hesitant patients, emphasizing the physician’s role as an ally on the patient’s health journey. Steps include engaging with patients; affirming patient concerns; asking permission before sharing information; and evoking future risks to motivate patients to reconsider vaccine hesitancy. The guide is available at www.vhguide.ca.
Improving Conversations With COVID-19 Vaccine Hesitant Patients: Action Research to Support Family Physicians
Myles Leslie, PhD, et al
School of Public Policy and Department of Community Health Sciences,
Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
https://www.annfammed.org/content/early/2022/07/18/afm.2816
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Special Report Outlines Actionable Steps to Address Racial/Ethnic, Linguistic and Socioeconomic Disparities in Telehealth Models of Care
Researchers in San Francisco and New York have proposed a health equity framework to address growing disparities in the uptake of telehealth services across the United States during and after the COVID pandemic. Using the Institute for Healthcare Improvement as a benchmark, the authors present strategies to advance equity within a healthcare organization across the domains of: 1) making health and racial/ethnic equity in telemedicine a strategic priority, including having committed leaders across the organization and using robust data to identify disparities; 2) building structures and processes to support telemedicine equity, including ensuring more direct input from marginalized patients; 3) deploying telemedicine strategies to address social determinants of health and access barriers to telemedicine; 4) eliminating institutional racism in telemedicine provision, such as hiring and retaining a health care workforce that reflects the diversity of the patients served and; 5) partnering with patients and community organizations to implement telemedicine.
Most importantly, the researchers call for the integration of equity and innovation efforts to ensure all people have access to telemedicine and other digitally enabled health tools.
Centering Health Equity in Telemedicine
Courtney R. Lyles, PhD, et al
UCSF Center for Vulnerable Populations and Division of General Internal Medicine, Zuckerberg San Francisco General Hospital, as well as Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, California
https://doi.org/10.1370/afm.2823
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Family Physicians Advocate to Eliminate Barriers to Medical School for Students With Disabilities
A group of family doctors at the University of Michigan call attention to the many barriers that students with disabilities encounter when they enter medical school and how this adversely impacts the health care system. In addition to barriers, medical students with disabilities encounter ableism (i.e., discrimination in favor of people without disabilities). These barriers have negative repercussions for the health system as a whole and particularly for patients with disabilities who may not receive optimal care. The authors argue that physicians who have personal experiences with disability are better able to build empathy with patients, combat ableist biases, and address attitudinal barriers in health care.
The authors charge the American Medical Association and American Association of Medical Colleges to 1) adjust technical standards for medical school admissions; 2) create a culture that supports universal design in hiring practices and physical workspaces; 3) provide clear and accessible instruction for how to submit accommodations requests; 4) foster a culture that normalizes help-seeking behaviors and facilitates access to wellness services; and 5) incorporate training about people with disabilities into medical school curriculum.
Call to Action: Eliminate Barriers Faced by Medical Students With Disabilities
Brianna A. Marzolf, DO, et al
Department of Family Medicine, University of Michigan, Ann Arbor, Michigan
https://doi.org/10.1370/afm.2824
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Veterans Health Administration Aims to Reduce Benzodiazepine Prescriptions for People 75 and Older
A new study within the Veterans Health Administration system aimed to identify strategies to reduce benzodiazepine prescriptions for older adults. This is important because benzodiazepines have been known to impair cognition, mobility and driving skills in older people, as well as increase the risk of falls. Unlike many community-based health care clinic settings, the VA system has successfully decreased its rate of benzodiazepine prescriptions in older veterans since 2013.
At the time of this study, there were 24,512 veterans, 75 years old and older, who were receiving long-term benzodiazepine treatment. All facilities that were interviewed, regardless of performance, employed passive strategies primarily consisting of education about appropriate prescribing, alternatives to prescribing benzodiazepines, and identifying potential patients for discontinuation. However, high-performing facilities described leveraging one or more active strategies including providing prescribing guidance for clinicians, administrative restrictions on benzodiazepine prescriptions, and performance measures to incentivize clinicians to lower prescriptions rates for benzodiazepines.
The researchers concluded that initiatives that are primarily limited to passive strategies, such as education and patient identification, may have limited success in lower prescription rates for older adults. They also suggest clinicians might benefit from additional recommendations, support, and incentives to modify prescribing practices.
Strategies Associated With Reducing Benzodiazepine Prescribing to Older Adults: A Mixed Methods Study
Donovan T. Maust, MD, MS, et al
Department of Psychiatry and Institute for Healthcare Policy and Innovation, University of Michigan and Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
https://doi.org/10.1370/afm.2825
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Clinicians Perceive Electronic Health Records as a Barrier to Patient Engagement; Patients Feel Otherwise
Researchers report the results of a survey to assess the impact of electronic health record use during face-to-face visits in the primary care setting. Fifty-nine clinicians (including physicians, physician assistants and nurse practitioners) and 1,000 adult patients were surveyed. Clinicians reported that when they used an EHR system during a patient visit, they felt that they maintained less eye contact (79.1%); listened less carefully (53.5%); focused less on patients (65.1%); and that the visit felt less personal overall (62.8%). Only one-third of providers felt that patients perceived EHR use as a positive experience.
However, most surveyed patients felt that use of the EHR was a positive experience (91.7%). Additionally, patients reported that clinicians using EHR technology during their visit provided sufficient eye contact (96.8%) and listened carefully (97.0%). They also disagreed that practitioners focused less on them (86.7%) and visits felt less personal when the technology was used (87.2%).
Rather than focusing on the patient experience, the authors argue that perceptions of care involving EHR use demonstrate the need for organizations to address increasing rates of clinician stress and burnout related to patient data documentation.
Use of the Electronic Health Record During Clinical Encounters: An Experience Survey
Ellen C. Meltzer, MD, MSc, et al
Division of General Internal Medicine, Mayo Clinic, Scottsdale, Arizona
https://doi.org/10.1370/afm.2826
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Primary Care and Family Physicians Argue for New, Person-Centered Focus in Patient-Centered Medical Homes
As those in health care increasingly consider patient-centered medical homes an improvement for health care, two professors from the University of Oklahoma Health Sciences Center, Drs. James W. Mold and F. Daniel Duffy, argue that patient-centered medical homes do not address the underlying problem facing our health system: a disease-oriented health model. They argue that for medical homes to deliver true person-centered care, physicians and their teams must fundamentally change the way they think about care by focusing more directly on the outcomes important to each patient, rather than on disease management alone.
The authors recommend two complementary approaches to encourage this paradigm shift: narrative medicine and goal-oriented care. Narrative medicine emphasizes the importance of patients’ personal stories, encouraging clinicians to absorb, interpret and respond to them throughout the care journey. Simultaneously, a goal-oriented care approach encourages clinicians to co-create plans of care that allow each individual patient to live a meaningful life, optimize personal growth, and experience a good death. While transitioning primary care practices into patient-centered medical homes has been an important step forward, Mold and Duffy argue that the next step is to transform patient-centered medical homes into truly person-centered models of care.
How Patient-Centered Medical Homes Can Bring Meaning to Health Care: A Call for Person-Centered Care
James W. Mold, MD, MPH
University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
F. Daniel Duffy, MD, MACP
University of Oklahoma- Tulsa School of Community Medicine, Tulsa, Oklahoma
https://doi.org/10.1370/afm.2827
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Physician-Pharmacist Team Says Primary Care Management of Anticoagulant Therapy is Best for Patients
A family medicine clinic in Minnesota was recently notified by its health system that it would no longer be allowed to provide anticoagulation treatment for patients in the primary care setting. Instead, anticoagulation services were transitioned to a centralized anticoagulation clinic within the health system. Co-authors Montag Schafer and Keenan argue that removing anticoagulation services from the primary care setting is detrimental to patients and opens the door to other possible restrictions on family medicine’s scope of practice. They contend that siloing anticoagulation management into a specialty setting risks increasing the cost of patient care, the likelihood of patient hospitalization, burden to patients who must coordinate their own care, and loss of irreplaceable relationships that serve the patient and care team outside of just the anticoagulation visit.
The authors advocate for holding true to what defines family medicine: comprehensive and person-centered, relationship-based health care over the patient’s lifespan.
Why Warfarin Should Be Managed in Primary Care
Katherine Montag Schafer, PharmD and Anne Keenan, MD
Department of Family Medicine and Community Health, University of Minnesota Medical School, St. Paul, Minnesota
https://doi.org/10.1370/afm.2828
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Primary Care Physicians Need Optimized Treatments and Better Support for Patients With COPD
Researchers conducted a study to describe the demographic and clinical characteristics of patients receiving care for chronic obstructive pulmonary disease in the U.S. primary care setting. More than 17,000 electronic patient records were included in their analysis, drawn from the Chronic Obstructive Pulmonary Disease Optimum Patient Care DARTNet Research Database. (COPD-RD). The group also used an additional source of data for a subset of these patients called the Advancing the Patient Experience Chronic Obstructive Pulmonary Disease (APEX-COPD) registry, which includes patient-reported descriptive and longitudinal data of patients managing COPD in the primary care setting. One thousand, three hundred and fifty-four patients were included in this sub-sample.
Almost 50% (49.9%) of patients in the APEX registry self-reported experiencing more than one exacerbation episode in the past year. This exacerbation burden was surprising to the researchers, considering that 87.9% of these patients were on some form of maintenance therapy. Despite treatment, APEX patients continued to report high or very high levels of COPD symptoms, as measured by the COPD Assessment Test. They experienced significant levels of breathlessness, indicating that they may not be treated properly or may be poorly compliant with medication regimes. Additionally, the authors recommend a greater focus on non-pharmacologic treatment options to reduce symptom burden (37.4% of APEX patients also reported continuing to smoke) and additional physician education to improve early diagnosis and treatment.
The authors argue that their findings indicate further opportunity for medication optimization in the primary care setting for COPD management and call for more real-life effectiveness trials to better support treatment decisions at the primary care level.
COPD Population in US Primary Care: Data From the Optimum Patient Care DARTNet Research Database and the Advancing the Patient Experience in COPD Registry
David B. Price, FRCGP, et al
University of Aberdeen, Division of Applied Health Sciences, Foresterhill, Aberdeen, United Kingdom
https://doi.org/10.1370/afm.2829
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Recently Updated ICPC Guide Provides Health Professionals Greater Understanding of Patient Functioning, Promotes Person-Centered Care
Through a series of patient visit episodes, members of the World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians demonstrate how the recently updated International Classification of Primary Care (ICPC-3) can allow primary care physicians to better document patient encounters with care providers and to understand trends in patient outcomes over time. The International Classification of Primary Care (ICPC) is the most widely used international classification for capturing and organizing clinical information in primary care. The third edition of the classification system, released in 2020, allows clinicians to record the reason for the encounter, patient functioning (activities and participation), and personal preferences linked to morbidity. The ICPC-3 has also added a new chapter on visits related to immunization; special screenings; public health promotion; classes for programs related to specific health conditions; and nationally and regionally relevant classes.
The authors assert that implementation of the ICPC-3 in an electronic health record yields improved health information to primary care professionals and supports better information exchange within medical teams and between primary and secondary care staff. It also provides policymakers and funders with insight into what is occurring in primary care and has the potential to improve care. Authors advocate the use of ICPC-3 in all primary care health care settings, considering that it supports interoperability between classification systems such as ICD-10, ICD-11, ICF and the clinical terminology system known as SNOMED CT. They assert that it can also help health care professionals understand how patients do or do not experience improving health.
Improving Primary Health Care Data With ICPC-3: From a Medical to a Person-Centered Perspective.
Huib Ten Napel, MSc, et al
Radboud University Medical Center, The Netherlands
https://doi.org/10.1370/afm.2831
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EHRs May Improve Research Data and Health Care Outcomes, but Best Practices Must be Established First
Anthony Paulo Sunjaya, MD, SM, writes Annals’ July/August editorial in which he highlights four newly published papers about the electronic health record and its role in facilitating high-quality health care. The four papers (Meltzer et al, Ghosh et al, Cohen et al, and Bunce et al) examine the use, functionality and effectiveness of EHRs, as well as physicians’ and patients’ perspectives of the EHR on clinical effectiveness. Meltzer et al’s unique study assesses patients’ experience with EHR use during clinic visits, with patients regarding the experience more positively than physicians in terms of perceptions of listening quality. Ghosh et al’s paper found that a substantial number of practices — both primary and secondary care — continued to operate in siloes despite the presence of EHRs and the ability to share patient clinical information. Sunjaya says this symbolizes a “forgetful health care system” and causes inefficiencies, safety reductions and increased physician burnout. He proposes developing a single national EHR system or mandating interoperability.
Two additional research papers highlight EHR utility, including the usability of an EHR-integrated home blood pressure visualization tool that can promote beneficial out-of-office health monitoring, with data linked to EHR systems (Cohen et al). This study, Sunjaya notes, suggests that capturing reliable patient data remotely has become more possible than ever. Bunce et al’s research suggests that the EHR can be used to effectively collect more research data in primary care through the articulation of practical steps to develop an EHR-embedded care study. This has the potential to improve response rates and data quality while reducing the burden of users to participate in research and facilitating higher quality primary care research at scale.
Sunjaya argues that future research must focus on developing and utilizing metrics that measure EHR’s benefits and harms. They should include measurement of any possible unintended consequences on health equity, user wellbeing, and those with lower tech literacy and socioeconomic status. Best practice goals for these EHR metrics can then be developed and their achievement linked to reimbursement and other rewards to realize benefits to clinicians, patients and health systems faster.
Uplifting Primary Care Through the Electronic Health Record
Anthony Paulo Sunjaya, MD, SM
The George Institute for Global Health, University of New South Wales Sydney, Sydney, Australia
https://doi.org/10.1370/afm.2860
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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:
Long COVID Shared Medical Appointments: Lifestyle and Mind-Body Medicine With Peer
Support - Members of the Wellness and Preventive Medicine Department at the Cleveland Clinical Community Care Institute created a novel shared medical appointment program to provide healthy lifestyle education, mindfulness training, and group peer support for patients experiencing long COVID symptoms. An interdisciplinary team of physicians, nurse practitioners and psychotherapists led the virtual SMA sessions. Each SMA group met for two hours weekly for six weeks with a maximum of 10 participants. Since May 2021, eight SMA cohorts have been conducted, and more than 80% of participants attended at least four of the six sessions. Patients felt educated, connected and supported through the SMAs, and providers could educate multiple patients longitudinally, while patients benefited from education and peer support.
Yufang Lin, MD, FACP, FAAP, ABOIM, IFMCP et al
Wellness and Preventive Medicine Department, Cleveland Clinic Community Care Institute, Cleveland, Ohio
https://www.annfammed.org/content/early/2022/04/22/afm.2817
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Adapting Primary Care Workflows to Promote Advance Care Planning - The University of Southern Indiana embedded a multi-modal Advanced Care Planning initiative in a primary care clinic, anchored by the Medicare Annual Wellness Visit. Prior to the AWV, patients are reminded about the importance of advanced care planning and are given multiple opportunities to learn more about the planning process. After the AWV visit, patients are able to meet with a dedicated ACP facilitator to complete the ACP process. The multi-modal and team-based approach offers an alternative for patients to create advanced care plans.
Kevin J. Valadares, PhD, et al
University of Southern Indiana, Evansville, Indiana
https://doi.org/10.1370/afm.2831
# # #
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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Annals of Family Medicine
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