September/October 2021 Annals of Family Medicine tip sheet

American Academy of Family Physicians

Interprofessional Teams Need Financial and Technological Support to Work Effectively

In this editorial, authors Rodriguez and Zink call for rapid recruitment and upskilling of interprofessional teams to meet future primary care needs across the U.S as called for in the National Academies of Sciences, Engineering, and Medicine’s report on Implementing High-Quality Primary Care. The authors provide a high level overview of articles in this edition of Annals, addressing potential solutions to the problem of burnout and pay equity for all members of the primary care team, including medical assistants (Vilendrer et al; Shaw et al), and a paper exploring how information technology and artificial intelligence can assist with pre-visit planning and the need for rigorous evaluation of these technologies in patient-physician relationship support (Holdsworth et al). Additionally, the authors suggest turning to the approach used in the education of MAs and community health workers, training community members to serve their communities, to meet NASEM’S directive to carefully expand and diversify health care teams. Implementing diverse teams will require further research and may be approached in various ways. Rodriguez and Zink suggest multiple directions, including examining if a diverse team impacts patient care and outcomes to the same degree as provider-patient race concordance, and how diversification can be expanded beyond the lowest paying jobs in health care.

Addressing the Use of Teams in Primary Care

José E. Rodríguez, MD, FAAFP

Department of Family and Preventive Medicine, University of Utah, Salt Lake City, Utah

Therese Zink, MD, MPH, FAAFP

Department of Family Medicine and the School of Public Health, Brown University, Providence, Rhode Island

Primary Care Can Shape the ‘New Normal’ to Patient-Centered Health Care Reform in America

The COVID-19 pandemic has forced health care organizations in the United States to transform themselves at an unprecedented rate, with a marked shift to telemedicine. Despite their rapid adoption of patient safety protocols and a shifting insurance landscape, many primary care offices face drastic decreases in revenue. The authors believe that primary care’s adaptations will need to go beyond virtual versions of the traditional office visit and redefine what it means to care for and support patients. Primary care physicians have an opportunity to shape the “new normal” and lead a paradigm shift at a time when our health care system needs it the most. A return to the “old normal” would mean a continuation of existing disparities in health outcomes and health inequities. The authors advocate for payment models that allow primary care to embrace innovations for patients to get the right care from the right team member at the right time, regardless of where the patient is located. “Beyond the chaos of a global pandemic is an opportunity for bold action that our health care system has needed for decades,” they write. “We are well poised to embrace innovative strategies that provide the support and care all patients need where and when they need it.”

Defining the “New Normal” in Primary Care

Kellia J. Hansmann, MD, MPH

University of Wisconsin, School of Medicine and Public Health, Madison, Wisc.

Tammy Chang, MD, MPH, MS

University of Michigan, Department of Family Medicine and National Clinicians Scholar Program, Institute for Healthcare Policy and Innovation, Ann Arbor, Mich.

Researchers Present Clinicians’ Perspectives on Electronic Prompt Implementation to Increase Hearing Loss Referrals

Researchers present clinicians’ perspectives on the implementation process for appropriate referrals for hearing loss (HL) screening. The authors implemented a prompt in the electronic health record to remind clinicians to consider audiology referral for patients 55 and older and then observed clinic processes and conducted semi-structured interviews with family medicine clinicians who interacted with the technology. Data was analyzed using thematic, framework and mixed methods integration strategies. The team interviewed 27 clinicians and conducted 10 field observations. Thematic analyses resulted in six themes including: 1) the prompt was “overwhelmingly” easy to use and was accurate; 2) clinician considered the prompt an effective way to increase awareness of patients about HL; 3) clinician and staff buy-in was vital in implementing the prompt; 4) clinicians prioritized the prompt during annual visits; 5) medical assistant involvement in workflow varied by health system, clinic and clinician; and 6) the prompt resulted in more conversations with patients about HL. Given that integration of the screening prompt varied, further research is needed to understand how to leverage clinician and staff buy-in and whether implementation of a new clinical prompt has a sustained impact on HL screening and patient outcomes.

Implementation of a Hearing Loss Screening Intervention in Primary Care

Melissa DeJonckheere, PhD, et al

University of Michigan, Department of Family Medicine, Ann Arbor, Michigan

Voice Assistants’ Responses to Cancer Screening Questions Prove Partly Effective, But Reveal Room for Improvement

Researchers compared four widely used voice assistants — Amazon Alexa, Apple Siri, Google Assistant and Microsoft Cortana — to determine the quality and accuracy of responses to questions about cancer screening. The study was conducted using the smartphones of five investigators. Each voice assistant received two independent reviews. The primary outcome was each device’s response to the query, “Should I get screened for (type of) cancer” for 11 cancer types. The researchers assessed the assistants’ ability to 1) understand the queries; 2) provide accurate information through web searches; and 3) provide accurate information verbally. The team compared the assistants’ responses to the U.S. Preventive Services Task Force’s cancer screening guidelines. A response was deemed accurate if it did not directly contradict guideline information and if the response included a starting age for screening consistent with the guidelines. Siri, Google Assistant and Cortana understood 100% of the queries, consistently generating a web search and/or verbal response, while Alexa was unable to understand or respond to any of the queries. Researchers also found that the top three links to additional resources provided by Siri, Google Assistant and Cortana provided information consistent with USPSTF guidelines roughly 70% of the time. However, the authors noted that the voice assistants’ responses to vocal queries were either unavailable or less accurate than text-based web searches, denoting room for improvement across all voice assistants. The study could have implications for users who rely on voice assistants to retrieve important health information and for those who are sight-impaired, less tech-savvy, or have low health literacy.

Voice Assistants and Cancer Screening: A Comparison of Alexa, Siri, Google Assistant, and Cortana

Steven Lin, MD, et al

Stanford Healthcare AI Applied Research Team, Department of Medicine, Stanford University, Stanford, California

Researchers Establish a Practical Safety Protocol for Home Visits in the Era of COVID-19

Researchers describe a protocol for donning and doffing personal protective equipment in home settings for health care professionals who must interact with patients potentially infected with COVID-19. This protocol addresses gaps in COVID-19 related guidelines, specifically the process of donning and doffing PPE during home visits while supplementing PPE guidelines and protocols. To create the protocol, the researchers used an interactive, rapid-prototyping approach. A small workgroup created preliminary drafts, drawing upon hospital-based protocols and modifying them while undertaking simulations. They received wider input by conducting two webinars — one regional in the Hamilton, Ontario, Canada area with palliative clinicians and another that included clinicians from across Canada. Researchers also consulted a group of infectious disease experts. Additionally, the team created a “how to” video to accompany the protocol, which includes guidance on how to prepare for a home visit; entering the home; leaving the home; post-visit and reprocessing. In addition to PPE-related equipment like gloves and surgical masks, the protocol also recommends additional materials including two pails for transporting supplies, plastic bags, hand sanitizer, disinfectant wipes, and printed, easy-to-use checklists. To view the “how to” video, click here.

COVID-19 Personal Protective Equipment in the Home: Navigating the Complexity of Donning and Doffing

José Pereira, MBChB, CCFP (PC), MSc, FCFP

Division of Palliative Care, Department of Family Medicine, McMaster University, Hamilton, and Pallium Canada, Ottawa, Ontario, Canada

New Research Suggests Urine Sampling Shouldn’t Be Restricted to Children With Unexplained Fever to Detect UTI

In a systematic review, researchers assessed the diagnostic value of certain physical symptoms that children may display that could indicate a urinary tract infection. The team performed literature reviews of the most prominent medical research databases from inception until Jan. 20, 2020 for studies reporting specific diagnostic accuracy data for clinical signs and symptoms compared to the use of urine cultures in children 18 and younger. For each clinical feature, the team calculated the likelihood ratios and predictive values for UTI. Researchers conducted several analyses to do this. Of the almost 11,000 studies they accessed, 35 studies of moderate to high quality were included and provided information on 58 clinical symptoms and six prediction rules. They found that only circumcision, diaper rash and stridor (a high-pitched vibrating, breathing sound in the throat, caused by a possible airway obstruction) are useful for ruling out UTI and that body temperature or fever duration have limited diagnostic value. Presence of cloudy urine, malodorous urine, hematuria, no fluid intake, suprapubic tenderness, and loin tenderness increase the probability of UTI. The authors advise that physicians should not restrict urine sampling to children with unexplained fever or specific features suggestive of a urinary tract infection.

Clinical Features for the Diagnosis of Pediatric Urinary Tract Infections: Systematic Review and Meta-Analysis

Hanne A. Boon, MD, et al

Department of Public Health and Primary Care, EPI-Centre, Academic Centre for Primary Care, KU Leuven, Leuven, Belgium.

Shared Language Is Important for Shared Work in Population, Community and Public Health

A large group of family medicine researchers, educators and clinicians propose a framework of definitions to clarify the similarities, differences and relationships between common terms used by those involved in population health, community health and public health. They write that shared language must be clear enough to help and not hinder people working together as they come to a mutual understanding of roles, responsibilities and actions in their joint work. A diagram of common population and community health terms for navigating the territory includes goals such as health, population health, and community health; realities such as social determinants, disparities and equity; and ways to get the job done such as care delivery, primary care, and public health, along with a broad zone of collaboration. This is designed to enable people to move forward in collaboration for health with less confusion, ambiguity and conflict. They add that shared language for shared work is important not only for division of labor, but for teaching clinicians, public health students and others to work effectively and collaboratively in different settings and to make the subject more intelligible for researchers, policymakers and funders.

Shared Language for Shared Work in Population Health

C.J. Peek, PhD, et al

University of Minnesota Medical School, Department of Family Medicine and Community Health, Minneapolis, Minnesota

Israel’s Quality Indicators Show Increase In Breast and Colorectal Cancer Screening, Lag in Cervical Screenings

Researchers from Hebrew University-Hadassah in Jerusalem and Cardioinfantil Foundation, Cardiology Institute in Bogota, Colombia, conducted a repeated, cross-sectional study to examine whether breast, colorectal and cervical cancer screening rates in women differed by age and socioeconomic position , and whether screening rates and socioeconomic disparities changed following the introduction of a primary care-based national quality indicator program. The study included all female Israeli residents in age ranges appropriate for each screening assessed, in 2002-2017, with a cohort of more than 1.5 million records. Screening rates were highest for breast cancer (70.5%), followed by colorectal (64.3%) and cervical cancer (49.6%). Following the introduction of relevant quality indicators, breast and colorectal cancer screening rates increased, with greater reductions in disparities for breast cancer. In contrast, the rates for cervical cancer screening showed no change because this cancer was not included in the initial quality indicators. The authors note that the recent introduction of a cervical cancer screening indicator may increase participation and reduce disparities, as was seen in breast and colorectal cancer screenings.

Socioeconomic Disparity Trends in Cancer Screening Among Women After Introduction of National Quality Indicators

Yiska Loewenberg Weisband, MPH, PhD, et al

Hebrew University-Hadassah, Braun School of Public Health, Jerusalem, Israel

An Enhanced Primary Care Model Is A Path to Team Development, Which Is Linked To Professional Development

The authors assessed the effectiveness of Primary Care 2.0, a team-based model that includes an increase in the medical assistant-to-primary care physician ratio; advanced practice provider integration; expanded medical assistants’ roles; and utilization of an extended interprofessional team to support medical assistants. Researchers conducted a prospective, quasi-experimental evaluation of staff and clinician team development and wellness survey data, comparing the program to conventional clinics within Stanford Healthcare. They surveyed staff and clinicians prior to model launch and again at nine, 15- and 24-month intervals post-launch. The team also assessed secondary data, including cost, quality metrics and patient satisfaction via routinely collected operational data. Results indicated that team development significantly increased in the Primary Care 2.0 clinic and was sustained across all three post-implementation intervals. Among the wellness domains, only “control of work” approached significant gains but was not sustained. Burnout showed early trends towards improvement post-implementation but never reached statistical significance and the trend was not sustained over 24 months. Adjusted models confirmed an inverse relationship between team development and burnout. Secondary outcomes, which included cost, quality and patient satisfaction, generally remained stable between intervention and comparison clinics, with labor costs decreasing over the four fiscal years post-launch. The Primary Care 2.0 model of enhanced team-based primary care demonstrates a path to increased team development, which could play a role in protecting health care professionals against burnout, but is not sufficient in preventing it.

Primary Care 2.0: A Prospective Evaluation of a Novel Model of Advanced Team Care With Expanded Medical Assistant Support

Jonathan G. Shaw, MD, MS, et al

Stanford University School of Medicine, Evaluation Sciences Unit, Division of Primary Care & Population Health, Stanford, California

Technology, Both AI and Non-AI, Can Help With Pre-Visit Planning, but Tools Need Rigorous, Independent Evaluation

A Stanford-based group of authors explored barriers to implementation, evidence of impact and potential use of artificial intelligence and non-AI tools to support pre-visit planning. Based on previous research, AI and non-AI tools may improve the effectiveness, efficiency and experience of care. The team used an environmental scanning approach involving a literature review; key informant interviews with pre-visit planning experts in ambulatory care; and a public domain search for technology-enabled and AI solutions that support pre-visit planning. They synthesized findings using a qualitative matrix analysis. The authors found 26 unique pre-visit planning implementations in the literature and conducted 16 key informant interviews. Key informants reported that many pre-visit planning barriers are human effort-related and see the potential for non-AI and AI technologies to support certain aspects of pre-visit planning. They also identified eight examples of commercially-available technology-enabled tools supporting pre-visit planning, some with AI capabilities. However, few of these technologies have been independently evaluated. The study concluded that pre-visit planning activities, driven by humans and modifiable by technology, may become more important and powerful, and should be rigorously evaluated.

Technology-Enabled and Artificial Intelligence Support for Pre-Visit Planning in Ambulatory Care: Findings From an Environmental Scan

Laura M. Holdsworth, PhD, et al

Stanford School of Medicine, Division of Primary Care and Population Health, Stanford, California

Financial Incentives for Medical Assistants May Increase Work Quality, But Workflow Processes Must be Considered

Medical assistants have seen their roles expand as a result of team-based primary care models. Unlike their health care provider colleagues, however, financial incentives are rarely a part of MA compensation. Researchers conducted an exploratory evaluation to understand MAs’ attitudes toward financial incentives and their perceived control over common population health measures. The study team conducted semi-structured focus groups across 10 clinics based in three institutions in California and Utah. They analyzed MA perceptions of experienced and hypothetical financial incentives, their potential influence on workflow processes, and the level of control related to population health measures to identify emerging themes. MAs reported little direct experience with financial incentives. A hypothetical bonus representing 2-3% of average annual base pay was reported as acceptable and influential in improving consistent performance during patient rooming workflow. MAs also indicated that relatively small financial incentives would increase their motivation and quality of care. The data suggest target measures should focus on MA work processes completed in the same day as the patient encounter, particularly vaccinations, since MAs report higher control over vaccinations and same-day measures as compared to multiday measures. Future investigation is needed to understand the effectiveness of MA financial incentives in practice.

Financial Incentives for Medical Assistants: A Mixed-Methods Exploration of Bonus Structures, Motivation, and Population Health Quality Measures

Stacie Vilendrer, MD, MBA, MS, et al

Stanford University School of Medicine, Division of Primary Care and Population Health, Stanford, California

Family Medicine Doctor Contemplates Meaning of Emotional Connections She Shared With Terminal Patient

Ruth Kannai, MD, of the Department of Family Medicine at Ben-Gurion University of the Negev, Israel, writes an essay about her interactions and 20-year relationship with an elderly Holocaust survivor who, towards the end of his life, made repeated requests for her assistance in ending his life as he experienced worsening COPD and metastasized pancreatic cancer. She also describes her interactions with her patient’s family members who had different opinions about how she should administer end-of-life care. Her narrative shares the emotions she experienced when her patient, Mr. Schwartz refused treatment for his medical conditions. She describes being moved by his honesty; feeling frustrated at her inability to offer him relief or a sense of meaning; and pensive as she reflects on existential issues regarding her role as a doctor and her relationships with her own loved ones. Kannai writes, “I came to accept that even if I felt unable to help, the mere act of my showing up consistently for Mr. Schwartz was in fact a gift I could give him, for he was able to at least express his despair and anger and not remain alone with it. I allowed him to have an impact on my willingness to remain open to such personal connections, for this is the heart and soul of family medicine.”

Mourning My Patient, Mr Schwartz

Ruth Kannai, MD

Ben-Gurion University of the Negev, Department of Family Medicine, Beersheba, Israel

Doctor Raises Alarm About Health Care Crisis Among Asylum Seekers at U.S.-Mexico Border

Elena Hill, MD, MPH, a recent graduate of Boston Medical Center’s Family Medicine Residency Program, is a volunteer physician with the not-for-profit Refugee Health Alliance in Tijuana, Mexico. She writes about the “hard” lessons she learned about the asylum process, or lack thereof, at the U.S.-Mexico border. She mentions a modern-day list of more than 15,000 asylum seekers who want a chance at a new life in the U.S. and tells the stories of three individuals who are seeking asylum. Due to a lack of transparency about how the asylum system works, thousands of families are stranded in Mexico without basic rights, including health care, she notes. “Health care professionals should be aware of this largely fabricated ‘asylum system’ and be an active faction in the fight for its reform,” she writes.

“I Need to Keep Me and My Mother Safe”: The Asylum Crisis at the US-Mexico Border

Elena Hill, MD, MPH

Boston Medical Center, Boston, Massachusetts

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:

Moving From In-Person to Telehealth Group Visits for a Mindful-Eating Healthy Nutrition Program—When COVID-19 required a transition from in-person to virtual team meetings, a mindful-eating and nutrition program experienced benefits and challenges of adapting technologies, interpersonal communications, accessibility, staffing and time for patients, staff and clinicians.

Jennifer K. Carroll, MD, MPH, et al

University of Colorado Department of Family Medicine and UCHealth Integrative Medicine Center, Aurora, Colo.

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