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Introduction: Referral rates and patterns to specialists by family physicians have a significant impact on numerous aspects of medical care, including the quality and cost of care provided. The aim of this study was to examine the referral rate and pattern of family physician practices associated with a large academic health center. Methods: We conducted a retrospective chart review of referrals for patients seen in the family medicine clinics associated with a large academic institution. Basic demographic information was collected. The primary outcome was the monthly referral rate, measured as the proportion of patient visits that resulted in a consult to a specialist outside of the referring family medicine clinic. Binomial and γ generalized linear mixed models were fit to determine the associations between high/medium/low referral rate clinics and patient demographics. Results: The average monthly referral rate for all of the clinics was 20.3%, and the rate varied significantly between clinic groups. Patient gender, race, and being in a committed relationship were noted to be associated with lower referral rate. Discussion: Referral rates among family physician practices differ widely and are associated with gender, race, and relationship status of patients. Referrals to several specific specialties are common among family physicians.

Background The study objective was to evaluate the effects of professional continuous glucose monitoring (CGM) as an adjuvant educational tool for improving glycemic control in patients with type 2 diabetes (T2D). Methods We conducted a three-month quasi-experimental study with an intervention (IGr) and control group (CGr) and ex-ante and ex-post evaluations in one family medicine clinic in Mexico City. Participants were T2D patients with HbA1c > 8% attending a comprehensive diabetes care program. In addition to the program, the IGr wore a professional CGM sensor (iPro™2) during the first 7 days of the study. Following this period, IGr participants had a medical consultation for the CGM results and treatment adjustments. Additionally, they received an educational session and personalized diet plan from a dietitian. After 3 months, the IGr again wore the CGM sensor for 1 week. The primary outcome variable was HbA1c level measured at baseline and 3 months after the CGM intervention. We analyzed the effect of the intervention on HbA1c levels by estimating the differences-in-differences treatment effect (Diff-in-Diff). Additionally, baseline and three-month CGM and dietary information were recorded for the IGr and analyzed using the Student’s paired t-test and mixed-effects generalized linear models to control for patients’ baseline characteristics. Results Overall, 302 T2D patients participated in the study (IGr, n = 150; control, n = 152). At the end of the three-month follow-up, we observed 0.439 mean HbA1C difference between groups (p = 0.004), with an additional decrease in HbA1c levels in the IGr compared with the CGr (Diff-in-Diff HbA1c mean of − 0.481% points, p = 0.023). Moreover, compared with the baseline, the three-month CGM patterns showed a significant increase in the percentage of time in glucose range (+ 7.25; p = 0.011); a reduction in the percentage of time above 180 mg/dl (− 6.01; p = 0.045), a decrease in glycemic variability (− 3.94, p = 0.034); and improvements in dietary patterns, shown by a reduction in total caloric intake (− 197.66 Kcal/day; p = 0.0001). Conclusion Professional CGM contributes to reducing HbA1c levels and is an adjuvant educational tool that can improve glycemic control in patients with T2D. Trial registration ClinicalTrials.gov: NCT04667728. Registered 16/12/2020

Introduction: Primary care clinics increasingly hire medical assistants (MAs) to perform a variety of clinical and administrative tasks. Anecdotal reports suggest that MA turnover is high, but no studies to date have calculated the rate or cost of MA turnover. The purpose of this study was to calculate the rate of MA turnover and associated costs in a single, large academic Family Medicine clinic. Methods: Retrospective data were collected from clinic administrators regarding MA turnover, overtime worked, salaries and benefits as well as administrator salaries and benefits and the amount of administrator time spent in MA hiring, training, and termination in 2017. Results: During 2017, MA turnover rate was 59%. The total estimated cost of MA turnover was $213,000. The per-MA cost of turnover was $14,200, or approximately 40% of the average annual salary of MAs. Conclusion: Turnover rate in this practice was similar to other estimates of primary care clinic staff and allied health professionals. The estimated cost of MA turnover relative to annual salary was significantly greater than that in other fields, likely reflecting the costs of training MAs. Establishing a method for calculating the turnover rate and costs can allow other healthcare systems to better describe turnover and evaluate retention strategies.

Objective Residency programs emphasize effective doctor and patient interaction. However, training can be time intensive and logistically challenging. This paper examines a blog providing resident peer feedback and an opportunity to explore how residents think about patient communication. Methods A grounded theory approach examined peer commenting on doctor patient interactions. Between 2012–2015, at a U.S. East Coast Family Medicine Clinic, 35 family medicine residents were recorded interacting with patients, producing a total of 84 videos which were posted to a blog. Residents reflected on these videos resulting in 356 responses, 3162 meaning units and 211 codes. Codes were grouped into 10 themes. Further analysis explored how residents signaled positive and negative doctor communications-related behavior. Results Most common themes identified were Rapport/Relationship building skills, Negotiating the appointment, and Peer interaction. Most common themes discussed in light of both positive and negative behavior were Education, Use of technology, and Negotiating the appointment. Conclusions Residents view their communication with patients as more of a transmission of critical information than an opportunity for dialogue. Practice implications Findings support how online tools can be used for resident reflections. These tools can reveal resident perceptions of salient communication information in a clinical encounter.

While unmet social needs can perpetuate barriers to health equity, health care staff may feel unprepared to address these needs. This article describes a pilot study on implementing a screening process for social determinants of health in a family medicine clinic where there was no prior standard of care. A quality improvement approach was used to frame the implementation and evolution of screening and follow-up strategies for social needs. Social determinant of health screening was successfully implemented during this pilot of 400 encounters, revealing a 26.3% prevalence. Options for addressing social needs grew during the study, although no statistically significant impact was observed on measured short-term health outcomes. Physicians can use quality improvement to counter clinical inertia toward addressing social determinants of health and also to concurrently screen and develop appropriate patient-oriented solutions in their clinics.

Background and Objectives: Despite the importance of breastfeeding, most US women do not meet recommendations for length of any or exclusive breastfeeding. Support in primary care settings is recommended (US Preventive Services Task Force, 2016), but optimal implementation strategies are not established. We evaluated the effect on breastfeeding rates of on-site breastfeeding support within an academic family medicine center with a diverse patient population. Methods: We conducted a retrospective chart review 10 months before and 10 months following the implementation of integrated breastfeeding support provided by an International Board Certified Lactation Consultant (IBCLC) or MD-IBCLC. Two hundred eighty-one infants were identified, 140 before implementation and 141 after. A research assistant extracted data from the electronic medical record. We performed bivariate and multiple logistic regression analyses using STATA. Results: There were no significant demographic differences before and after the intervention. The proportion of infants with any breastfeeding at 2, 4, and 6 months was greater in the postimplementation group (71.7% vs 86.7% at 2 months, P=.05; 61.5% vs 77.1% at 4 months, P=.08; and 50.7% vs 64.4%, P=.09 at 6 months). The proportion of infants exclusively breastfed was also greater in the postimplementation group (58.7% vs 77.8% at 2 months, P=.04; 50.5% vs. 54.2% at 4 months, P=.06; and 44.0% vs 49.3% at 6 months, P=.12). Conclusions: Providing on-site IBCLC breastfeeding support services within an academic family medicine clinic is associated with significant increases in breastfeeding, supporting the provision of lactation services on-site where mothers and children receive primary care.

Purpose: Lifestyle change programs are an effective but underutilized approach to prevent or delay type 2 diabetes in people with prediabetes. Understanding clinician prediabetes knowledge, attitudes, and practices can inform implementation efforts to increase lifestyle change program referrals. Methods: We surveyed clinicians at an academic family medicine clinic about their prediabetes knowledge, attitudes, and practices. From the same clinic, we reviewed electronic health records to assess prediabetes screening, diagnosis, and treatment coverage in the cohort of adults seen from 2015 to 2017. Results: Thirty-one clinicians (69.6%) completed the survey. Clinicians believed prediabetes was an important health issue (n = 29; 93.7%) and that prediabetes screening (n = 20, 64.5%) and diagnosis (n = 31, 100%) were important for prediabetes management. About half of the respondents (n = 14; 45.2%) reported familiarity with the National Diabetes Prevention Program (DPP). Electronic chart review included 15,520 adult patients. Most of the 5360 nondiabetic patients meeting US Preventive Services Task Force diabetes screening guidelines (n = 4068; 75.9%) received a hemoglobin A1c test. Of the 1437 patients with an A1c result diagnostic of prediabetes, 729 (50.7%) had the diagnosis in their chart. Prediabetes patients receiving point-of-care A1c testing instead of laboratory testing had 4.7 increased odds (95% CI, 3.5 to 6.4) of metformin prescription. No patients were referred to a DPP. Conclusions: Clinicians9 positive attitudes toward prediabetes screening, moderate knowledge of prediabetes management, and low awareness of DPPs were reflected by high diabetes screening coverage, limited prediabetes diagnosis, and no DPP referrals. We will tailor our implementation strategy to overcome these prediabetes care barriers.

Background and Objectives: Patients with severe mental illness often lack care coordination between primary care and mental health providers which can negatively impact patient outcomes. Team-based care is integral in the effective management of patients with multiple comorbidities, with the family physician central in coordinating holistic care. Family medicine residency programs must provide models of effective interprofessional collaboration and mental health treatment to prepare residents to navigate an evolving health care landscape. The objective of this study was to evaluate family medicine residents’ learning about providing holistic care with an interprofessional team and medication safety monitoring from the interprofessional cross-organizational care conference experience. Methods: To bridge care and cultivate the necessary skills, a family medicine clinic and mental health clinic implemented monthly interprofessional care conferences to coordinate care for their shared patients during 2019. Residents who participated in the care conference each (n=11) completed a retrospective pre/postsurvey (11/11=100% response rate) to gather perceptions of what they learned from the interprofessional care conference experience. Results: After participating in the care conference, all residents agreed they understood the elements that must be considered to provide holistic patient care, were confident conducting medication safety monitoring for their patients taking second-generation antipsychotics (eg, lipids, A1C, ECG), and agreed the care conference helped them develop a more comprehensive patient-centered care plan. Additionally, they all intend to work collaboratively across professions in the future. Conclusions: Interprofessional and cross-organizational care conferences create an authentic learning environment that enhances family medicine residents’ understanding and confidence in providing collaborative and holistic care for patients with severe and persistent mental illness.

BACKGROUND AND OBJECTIVES Rates of chlamydia and gonorrhea among adolescents continue to rise. We aimed to evaluate if a universal testing program for chlamydia and gonorrhea improved testing rates in an urban general pediatric clinic and an urban family medicine clinic within a system of federally qualified health care centers and evaluated the feasibility, cost, and logistic challenges of expanding implementation across 28 primary care clinics within a federally qualified health care centers system. METHODS A universal testing quality improvement program for male and female patient 14 to 18 years old was implemented in a general pediatrics and family medicine clinic in Denver, Colorado. The intervention was evaluated by using a controlled pre-post quasi-experimental design. The difference in testing rates due to the intervention was assessed by using a difference-in-differences regression model weighted with the inverse probability of treatment. RESULTS In total, 15 541 pediatric encounters and 5420 family medicine encounters were included in the analyses. In pediatrics, the unadjusted testing rates increased from 32.0% to 66.7% in the intervention group and from 20.9% to 28.9% in the comparison group. For family medicine, the rates increased from 38.5% to 49.9% in the intervention group and decreased from 26.3% to 24.8% in the comparison group. The intervention resulted in an adjusted increase in screening rates of 25.2% (P < .01) in pediatrics and 11.8% (P < .01) in family medicine. The intervention was well received and cost neutral to the clinic. CONCLUSIONS Universal testing for chlamydia and gonorrhea in primary care pediatrics and family medicine is a feasible approach to improving testing rates .

To the Editor: Stack et al[1][1] describe a comprehensive opioid reduction protocol in patients with chronic noncancer pain conducted by Family Medicine providers in a rural community. Although the authors describe a multifaceted approach with medical and psychoeducational components, 1 key element

Background Recommendations on clinic-administered medications to stock in an urban family medicine clinic and how to manage an outpatient formulary are not well defined in the literature. Although there are numerous hypothesized incentives for a standardized medication inventory, the financial impact at the level of a single clinic is unknown. Objectives The purpose of this project was to develop clinic-administered medication inventory recommendations for urban family medicine clinics and to determine the financial impact of standardization at a single clinic. Methods The current clinic-administered medication inventory was assessed using the following prespecified criteria: (1) clinic administration is required for successful patient outcomes, (2) use of the medication for intended indication is evidence-based, (3) appropriately trained staff and equipment are available to administer and monitor the medication, (4) most cost-effective dosage form of the medication is stocked in the clinic, and (5) quantity and location of medication stocked in the clinic match need. Changes to the medication inventory were made effective on August 1, 2018, based on physician group consensus. Monthly clinic medication cost during the study period was analyzed before and after intervention. Results A total of 80 medications were identified; 45 medications remained after changes according to the prespecified criteria. The monthly cost of maintaining the inventory during the study period was $1947 preintervention compared with $1048 postintervention. The estimated average monthly cost savings of a standardized inventory in a single, urban family medicine clinic is $900, or $10,800 annually. Conclusion Standardizing a clinic-administered medication inventory in an urban family medicine clinic can help reduce unnecessary cost.

Collaborative practice models that use an advanced practice pharmacist (APP) have been shown to improve outcomes for patients with chronic diseases. Few studies have evaluated the effects of team-based practice models involving an APP for time needed to attain glycated hemoglobin A1c (HbA1c) goals in patients with diabetes mellitus (type 2 diabetes). Ours is a retrospective cohort study, involving patients with type 2 diabetes who worked with a pharmacist in an academic family medicine clinic. These patients experienced a shorter time to achieve an HbA1c of less than 7%, as compared with patients who did not work with a pharmacist. Future studies should evaluate the length of time patients can sustain an HbA1c of less than 7% with team-based care involving an APP and the influence of such care on diabetes-related complications.

Type 2 diabetes (T2D) incurs tremendous health costs associated with various complications due to poor diabetes control. Medication adherence, which is correlated with patients' health literacy, should be consistently practiced achieving optimal diabetes control. A deeper understanding of the specific communication and psychosocial factors related to medication-taking behaviors across different levels of health literacy among people with T2D will guide the development of effective interventions and strategies to enhance medication adherence.This cross-sectional study aimed to identify salient patient factors associated with diabetes medication adherence across different levels of health literacy.A questionnaire was administered via a face-to-face approach with 205 participants at a family medicine clinic. Study participants were all above 20 years of age with T2D, were prescribed at least one oral diabetes medication, and understood English. The questionnaire assessed participants' health literacy, self-efficacy for medication use, beliefs in medicines, patient-provider communication, perceived barriers to medication adherence, and self-reported medication adherence. Separate analysis of covariance was used to compare the mean scores of patient factors related to medication adherence across people with different health literacy levels.The mean age of participants was 61 years old, and the majority of the participants were female (57%), White (75%), and college educated (62%). Thirty-three percent of the participants had adequate health literacy, but only 43% of them reported high adherence to their diabetes medications. Analysis of covariance showed that having stronger self-efficacy (P 0.001), lower concern beliefs about medication (P = 0.047), and fewer perceived barriers to medication-taking (P 0.001), are necessary for better medication adherence.Findings suggest that practitioners should address concern beliefs among low-adherent patients with low health literacy, help improve self-efficacy, and address perceived barriers to medication adherence among all low-adherent patients to optimally support patients' diabetes care.

Transgender and gender nonconforming (TGNC) patients have a wide array of often negative experiences when accessing health care, and may encounter insensitive or subcompetent care; thus, the authors conducted a qualitative study with patients at one family medicine residency clinic to assess how primary care clinics can improve care for TGNC patients.In 2015, the authors held three separate focus groups at Smiley's Family Medicine Clinic in Minneapolis, Minnesota. They invited diverse TGNC participants who have accessed TGNC-related and/or primary care at Smiley's. The authors analyzed and coded data using a grounded theory approach with NVivo10 (QSR). The authors also administered short demographic questionnaires and analyzed the results with REDCap.Twenty-three patients participated in the focus groups, and 22 completed the survey. Gender identities among the participants were diverse. Four main themes emerged: (1) shared negative experiences with health care, (2) the need for sensitive and inclusive primary care, (3) defining TGNC-sensitive care, and (4) the challenges of mainstreaming TGNC-competent care into primary care settings.Providing sensitive and competent primary care to TGNC patients involves allowing patients to self-identify, respecting the gender identities of every patient, and focusing on the whole person-not the trans status of the patient. Education and training on TGNC care at a clinic-wide level is needed.

There is a movement in the United States to transform family medicine practices from single physician–based patient care to team-based care. These teams are usually composed of multiple disciplines, including social workers, pharmacists, registered nurses, physician assistants, nurse practitioners, and physicians. The teams support patients and their families, provide holistic care to patients of all ages, and allow their members to work to the highest level of their training in an integrated fashion. Grouping care team members together within visual and auditory distance of each other is likely to enhance communication and teamwork, resulting in more efficient care for patients. This grouping is termed colocation. The authors describe how the use of colocation can lead to clearer, faster communication between care team members. This practice style has the potential to be expanded into various clinical settings in any given health system and to almost all clinical specialties and practices.

Revision of laboratory test requisitions is a simple utilisation strategy that can reduce unnecessary testing.1 2 The goal of this study was to improve test utilisation via a collaborative team-based evaluation and revision of a standardised lab requisition used by six large family medicine units. ### Revising the family requisition form A historical laboratory requisition used by the Family Medicine Department at Unity Health, St. Michael’s Hospital site, Unity Health Toronto, Toronto, Canada, was reviewed and modified by a steering committee comprised of family medicine clinicians (physicians and a nurse practitioner), lab medicine specialists and a quality improvement specialist. Decisions were made by consensus, and input was sought from the entire Department of Family Medicine via departmental rounds before changes were finalised. Laboratory tests were removed from the requisition if there was evidence in the literature of overuse (eg, Aspartate Aminotransferase (AST), folate, urea, Erythrocyte Sedimentation Rate (ESR),3 4 if they were outdated (eg, amylase, Creatine Kinase (CK)),3 or if there was consensus that they were infrequently needed in a family practice (eg, rheumatoid factor, direct bilirubin). The requisition was also revised to improve readability, and education was imbedded regarding some special tests such as urine toxicology screening and coagulation testing (changes in online supplemental table 1). Tests that were removed from the requisition remained orderable with longhand. ### Supplementary data [bmjoq-2020-001219supp001.pdf] ### Data analyses The primary outcome was the monthly volume of targeted tests ordered by the family medicine clinic 6 months pre- and 6 months post-requisition changes (September …

The American Diabetes Association recommends insulin initiation when A1c ≥10%. The aim of this study was to determine adherence to insulin initiation in patients with an A1c ≥10% at an outpatient family medicine clinic. The secondary objectives were to determine whether initiation of insulin within 3 weeks of an A1c ≥10% increased the rate or decreased the time to achieve an A1c7% and to determine whether pharmacist involvement increased the rate of reaching an A1c7%. This institutional review board-approved, retrospective, observational, cohort study identified 120 patients with type 2 diabetes mellitus and an A1c ≥10% in 2014. Patients already receiving insulin or those without a follow-up A1c were excluded. Study outcomes included proportion of patients receiving insulin therapy within 3 weeks of A1c/=10%, rate of meeting A1c7%, time to reach A1c7%, and proportion of patients meeting with a pharmacist. Fifty-five patients with a mean age of 55 years, a mean duration of diabetes of 6.4 years, and a mean baseline A1c of 11.7% met the inclusion criteria. Most patients were receiving no therapy (29%), monotherapy (27%), or dual therapy (29%) at baseline. Insulin was initiated in 5 patients (9.1%, P0.05) within 3 weeks of the qualifying A1c. Another 5 patients (P0.05) received insulin at some point during the study. An A1c7% was achieved in 35.6% of patients not receiving insulin, 20% of patients receiving early insulin, and no patients who received insulin after 3 weeks. The mean time to A1c7% was 6 months for patients not on insulin and 3 months for those receiving early insulin. Thirty-three percent of patients who met with a pharmacist reached an A1c7% compared with 30% of patients who did not. Adherence to insulin initiation guidelines and rate of achieving A1c7% in patients with A1c ≥10% is low. Increasing pharmacy involvement may increase the rate of reaching goal A1c.

Family medicine is officially a specialty, but is often not regarded as a specialty by the general public. Past studies have usually investigated the opinions of medical students and resident physicians regarding family medicine, whereas few have focused on practicing family physicians themselves, especially in terms of analyzing how they represent themselves. This study aimed to investigate the patterns of clinic names to better apprehend whether general practitioners see themselves as being on an equal footing with other medical specialists. The registered names, medical specialties, and levels of urbanization of all clinics of Western medicine in Taiwan were collected. For clinics of each specialty, we examined whether their names contained the corresponding specialty designation. For example, a family medicine clinic was checked to determine whether its name contained the term &ldquo, family medicine&rdquo, or its abbreviation. The naming of family medicine clinics was then compared with that of clinics with other specialties. Of the 9867 Western medicine clinics included in this study, two-thirds (n = 6592) were single-specialty clinics. In contrast to the high percentages of single-specialty clinics of other specialties with specialty-containing names (97.5% for ophthalmology, 94.8% for dermatology, and 94.7% for otolaryngology), only 13.3% (132/989) of the family medicine clinics had such names. In addition, the urban family medicine clinics had a higher proportion (15.2%, 74/487) of specialty-containing names than the suburban (12.6%, 44/349) and rural family medicine clinics (9.2%, 14/153). Overall, a low percentage of family medicine clinics in Taiwan included &ldquo, in their names. This issue of professional identity deserves further qualitative investigation.

Objectives Oral case presentations following resident-patient interactions provide the primary mechanism by which faculty supervisors assess resident competence. However, the extent to which these presentations capture the content and quality of resident-patient communication during the encounter remains unknown. We aimed to determine whether: (i) the resident-patient encounter content matched information conveyed in the case presentation; (ii) the quality of resident-patient communication was accurately conveyed, and (iii) supervisors addressed effective and ineffective communication processes. Methods A total of 22 pairs of resident-patient encounters and family medicine resident case presentations were video- or audiorecorded, transcribed and compared for content. Resident-patient communication was assessed using adapted versions of the Calgary-Cambridge Guide to the Medical Interview and Explanation and Planning Scale. Results Interviews and presentations contained largely congruent content, but social history and the patient's perspective were consistently excluded from case presentations. Although six of 19 specific communication skills were used in over 80% of resident encounters, the effective use of communication skills was widely variable. In most presentations, the quality of resident-patient communication was not explicitly conveyed to the supervisor. Although resident presentations provided 'cues' about communication issues, supervisors rarely responded. Conclusions This study lends support to direct observation in workplace-based learning of communication skills. When content areas such as the patient's perspective and education are excluded, supervisors cannot address them. In addition, presentations provided minimal insight about the quality of resident-patient encounters and limited the ability to address communication skills. These skills could be enhanced by attending to communication cues during case presentations, making increased use of direct observation and feedback, and promoting faculty development to address these missed teaching opportunities.

PURPOSE We compared the transformation experience of 2 family medicine practices that implemented the Primary Care Redesign (PCR) team-based model to improve access, quality, and experience without increasing cost. The University of Colorado’s A.F. Williams Family Medicine clinic (pilot practice) implemented the model in February 2015, and a smaller, community-based practice (wave 2 practice) did so 2 years later, in February 2017. METHODS The PCR model increased the ratio of medical assistants to clinicians from about 1:2 to 2.5:1 while expanding the role of the medical assistants, through enhanced rooming procedures, in-room support (eg, scribing), postclinician wrap-up, and in-basket assistance. We assessed access, clinical quality metrics, staffing costs, and clinician and staff experience and burnout for at least 7 months before and 42 months after the intervention. RESULTS In the pilot practice, compared with preimplementation, there were improvements in total appointments and rates of hypertension control, colorectal cancer screening, and most diabetic quality metrics. In the wave 2 practice, total appointments increased slightly when clinicians were added pre-PCR and then increased substantially after implementation; initially variable hypertension control improved rapidly after implementation. The wave 2 practice’s colorectal cancer screening improved gradually, then accelerated postimplementation, while diabetic metrics initially remained stable or declined, then improved postimplementation. New patient appointments began to increase for both practices in late 2015, but grew faster in the pilot practice under PCR. Over time, all experiential domains improved for clinicians; most remained stable for staff. Clinician burnout was reduced by at least one-half in both practices except during low staffing periods, which also adversely affected staff. After a ramp-up period, the number of staff hours per visit remained stable. CONCLUSIONS The PCR model is associated with simultaneous improvements in quality, access, and clinician experience, as well as reductions in burnout, while maintaining staffing costs.

Background: Sugar-sweetened beverages (SSBs) are a major source of calories, and are associated with adverse health outcomes. Because the majority of studies are undertaken in urban areas, the rural intake of SSB presents a significant gap in current knowledge. The objective of our study was to assess SSB intake in a rural primary care clinic. Methods: The Beverage Intake Questionnaire is a 15-item self-reported questionnaire and has been extensively validated to assess habitual SSB consumption. The survey was administered to adult primary care clinic patients presenting for routine care over a 6-week period at a clinic in a rural central Nebraska community (population Results: Survey participants (n = 121) were primarily white with an average age of 61 years (SD = 18.0) and an average body mass index (BMI) of 29.9 kg/m2 (SD = 7.5). Participants consumed an average of 1.05 SSBs per day (SD = 1.3), and 33.5% of respondents consumed one or more SSBs per day. The average daily caloric intake from SSBs was 153 Kilocalories (Kcals) compared the national average intake of 145 Kcals. The most commonly consumed caloric beverages, based on Kilocalories consumed, were 100% juice and regular soda. SSB consumption was not related to with BMI. Discussion: In a rural primary care clinic, the daily consumption of SSB by patients was found to be a noteworthy source of calories, with no significant difference in consumption across BMI categories. Mitigation of SSB consumption by rural primary care clinicians is imperative for optimizing health.

PurposeThe purpose of this study is to evaluate the impact of a collaborative diabetes shared medical appointment on patient outcomes in an urban family medicine practice.MethodsFifty-nine patients were enrolled to participate in multiple shared medical appointments (SMAs) over 12 months. Baseline data included hemoglobin (A1C), lipids, systolic blood pressure (SBP), weight, adherence to American Diabetes Association (ADA) guidelines, and surveys, including the Problem Areas in Diabetes (PAID-2) scale and the Spoken Knowledge in Low Literacy in Diabetes Scale (SKILLD). A1C and SBP were evaluated at each visit. Lipid control was assessed at baseline and at 6 and 12 months. Adherence to ADA guidelines, SKILLD and PAID-2 survey scores, and number of antihyperglycemic and antihypertensive medications were also evaluated at 12 months.ResultsThirty-eight patients completed the study. Compared with baseline, A1C and low-density lipoprotein cholesterol (LDL-C) levels decreased significantly over 12 months ( P < .001 and P = .004, respectively). More patients became compliant with the ADA guidelines throughout the course of the study. Specifically, more patients achieved the LDL-C goal of ≤100 mg/dL (2.59 mmol/L; P < .001), were prescribed appropriate antihypertensive medications ( P < .001) and aspirin ( P < .001), and received the pneumonia vaccine ( P < .001). PAID-2 and SKILLD survey scores also significantly improved over the course of the study ( P ≤ .001 and P = .003, respectively).ConclusionShort-term interdisciplinary SMAs decreased A1C and LDL-C, improved patient adherence to ADA guidelines, improved emotional distress related to diabetes, and increased knowledge of diabetes.

Introduction The purpose of this study was to determine whether heat waves are associated with increased frequency of clinic visits for ICD-9 codes of illnesses traditionally associated with heat waves. Methods During 4 years of family medicine clinic data between 2012 and 2016, we identified six heat wave events in San Diego County. For each heat wave event, we selected a control period in the same season that was twice as long. Scheduling a visit on a heat wave day (versus a non-heat wave day) was the primary predictor, and receiving a primary ICD-9 disease code related to heat waves was the outcome. Analyses were adjusted for age, gender, race/ethnicity and marital status. Results Of the 5448 visits across the heat wave and control periods, 6.4% of visits (n = 346) were for heat wave-related diagnoses. Scheduling a visit on heat wave day was not associated with receiving a heat wave-related ICD code as compared with the control period (adjusted odds ratio: 1.35; 95% confidence interval: 0.86-1.36; P = 0.51). Discussion We show that in a relatively large and demographically diverse population, patients who schedule appointments during heat waves are not being more frequently seen for diagnoses typically associated with heat waves in the acute setting. Given that heat waves are increasing in frequency due to climate change, there is an opportunity to increase utilization of primary care clinics during heat waves.

Background: Diabetes self-management education (DSME) is a key component of diabetes care aimed at delaying complications. Unlike usual care, DSME is a more structured educational approach provided by trained, certified diabetes educators (CDE). In Kenya, many diabetic patients are yet to receive this integral component of care. At the family medicine clinic of the Aga Khan University Hospital (AKUH), Nairobi, the case is no different; most patients lack education by CDE. Aim: This study sought to assess effects of DSME in comparison to usual diabetes care by family physicians. Setting: Family Medicine Clinic, AKUH, Nairobi. Methods: Non-blinded randomised clinical trial among sub-optimally controlled (glycated haemoglobin (HbA1c) ≥ 8%) type 2 diabetes patients. The intervention was DSME by CDE plus usual care versus usual care from family physicians. Primary outcome was mean difference in HbA1c after six months of follow-up. Secondary outcomes included blood pressure and body mass index. Results: A total of 220 diabetes patients were screened out of which 140 met the eligibility criteria and were randomised. Around 96 patients (69%) completed the study; 55 (79%) in the DSME group and 41 (59%) in the usual care group. The baseline mean age and HbA1c of all patients were 48.8 (standard deviation [SD]: 9.8) years and 9.9% (SD: 1.76%), respectively. After a 6-month follow-up, no significant difference was noted in the primary outcome (HbA1c) between the two groups, with a mean difference of 0.37 (95% confidence interval: -0.45 to 1.19; p = 0.37). DSME also made no remarkable change in any of the secondary outcome measures. Conclusion: From this study, short-term biomedical benefits of a structured educational approach seemed to be limited. This suggested that offering a short, intensified education programme might have limited additional benefit above and beyond the family physicians’ comprehensive approach in managing chronic conditions like diabetes.

Objective To evaluate the ability of electronic health record (EHR) data extracted into a data-sharing system to accurately identify contraceptive use. Study design We compared rates of contraceptive use from electronic extraction of EHR data via a data-sharing system and manual abstraction of the EHR among 142 female patients ages 15–49 years from a family medicine clinic within a primary care practice-based research network (PBRN). Cohen's kappa coefficient measured agreement between electronic extraction and manual abstraction. Results Manual abstraction identified 62% of women as contraceptive users, whereas electronic extraction identified only 27%. Long acting reversible (LARC) methods had 96% agreement (Cohen's kappa 0.78; confidence interval, 0.57–0.99) between electronic extraction and manual abstraction. EHR data extracted via a data-sharing system was unable to identify barrier or over-the-counter contraceptives. Conclusions Electronic extraction found substantially lower overall rates of contraceptive method use, but produced more comparable LARC method use rates when compared to manual abstraction among women in this study's primary care clinic. Implications Quality metrics related to contraceptive use that rely on EHR data in this study's data-sharing system likely under-estimated true contraceptive use.

This study examined the point prevalence of neurodevelopmental disorders among predominantly low-income, African-American psychiatric patients at Jackson Park Hospital's Family Medicine Clinic on Chicago's South Side.Using active case ascertainment methodology, the authors assessed the records of 611 psychiatric patients visiting the clinic between May 23, 2013, and January 14, 2014, to identify those with DSM-5 neurodevelopmental disorders.A total of 297 patients (49%) met criteria for a neurodevelopmental disorder during childhood. Moreover, 237 (39%) had clinical profiles consistent with neurobehavioral disorder associated with prenatal alcohol exposure, and 53 (9%) had other neurodevelopmental disorders. The authors disagreed on the specific type of neurodevelopmental disorder of seven (1% of 611) of the 297 patients with neurodevelopmental disorders.A high prevalence of neurodevelopmental disorders was found among low-income predominantly African-American psychiatric patients on Chicago's South Side. If replicated, these findings should bring about substantial changes in medical practice with African-American patients.

Objectives To determine the rate of prescribing errors in a family medicine clinic and the subsequent impact of pharmacist-led educational and error notification interventions on prescribing errors. Design Single site, pre–post study design. Setting An outpatient academic family medicine clinic serving pediatric and adult populations in Oklahoma from March 1, 2011, through April 30, 2012. Participants 24 resident physicians who prescribed medications during routine outpatient visits. Intervention A prescribing educational program, audit and feedback methods, and weekly newsletter. Main outcomes measure Percentage of prescription errors and physician error rate before and after intervention among pediatric and adult populations. Results During the two assessment periods, 24 resident physicians wrote 2,753 prescriptions for 394 pediatric and 899 adult patients. The overall percentage of prescription errors decreased from 18.6% during March 2011 to 14.5% during April 2012 ( P = 0.004). Errors were more commonly seen with prescriptions written for pediatric patients (24.9%) than for adult patients (13.9%) ( P = 0.001). Individual physician error rates ranged from 5% to 36% (mean ± SD 16.5% ± 8.1). Physicians committed significantly fewer prescribing errors during the postintervention assessment period (14.9%) than during the preintervention assessment period (20.9%) ( P = 0.002). Controlling for time, pediatric prescription error rates among physicians who participated in the educational intervention were 36% lower than the error rates among physicians who did not participate (rate ratio 0.64 [95% CI 0.45, 0.91], P = 0.01). Conclusion The pharmacist-led educational program was effective in reducing pediatric prescribing errors among resident physicians in a family medicine clinic.

Purpose: While the potential benefit of a chronic disease registry for tobacco use is great, outcome reports have not been generated. We examined the effect of implementing a tobacco use registry, including a decision support tool, on treatment outcomes within an academic family medicine clinic. Methods: A chart review of 200 patients who smoked and attended the clinic before and after registry implementation assessed the number of patients with clinic notes documenting (1) counseling for tobacco use, (2) recommendations for cessation medication, (3) a set quit date, (4) referrals to the on-site Nicotine Dependence Program (NDP) and/or QuitlineNC, and (5) pneumococcal vaccine. Data from the NDP, QuitlineNC, and clinic billing records before and after implementation compared the number of clinic-generated QuitlineNC fax referrals, new scheduled appointments for the NDP, and visits coded for tobacco counseling reimbursement. Results: Significant increases in documentation occurred across most chart review variables. Significant increases in the number of clinic-generated fax referrals to QuitlineNC (from 27 to 96), initial scheduled appointments for the NDP (from 84 to 148), and coding for tobacco counseling (from 101 to 287) also occurred when compared with total patient visits during the same time periods. Patient attendance at the NDP (52%) and acceptance of QuitlineNC services (31%) remained constant. Conclusions: The tobacco use registry9s decision support tool increased evidenced-based tobacco use treatment (referrals, medications, and counseling) for patients at an academic family medicine clinic. This novel tool offers standardized care for all patients who use tobacco, ensuring improved access to effective tobacco use counseling and medication treatments.

Objective To describe the number of medication discrepancies associated with subsequent medication reconciliations by a clinical pharmacist in an ambulatory family medicine clinic and the proportion of subsequent medication reconciliation visits that were associated with hospital discharge, long-term anticoagulation management, or both. Methods Data on medication reconciliations were collected over a 2-year time period in an ambulatory family medicine clinic for patients taking 10 or more medications. Results Medication reconciliation was performed 752 times for 500 patients. A total of 5,046 discrepancies were identified, with more than one-half deemed clinically important. A mean (± SD) of 6.7 ± discrepancies per visit (3.5 ± clinically important) were identified. The findings showed that the distribution of total discrepancies identified by pharmacist-performed medication reconciliation was significantly different over the course of subsequent medication reconciliations. However, the distribution of clinically important discrepancies was not significantly different; important discrepancies were as likely to be found in later reconciliations as in earlier ones. As subsequent medication reconciliation visits were performed, an increasing proportion consisted of post-hospital discharge visits, long-term anticoagulation managed by a clinical pharmacist, or both. Conclusion Patients with a recent hospital discharge, on long-term anticoagulation management, or both, were more likely to have multiple sessions with a clinical pharmacist for medication reconciliation. These findings can help identify patients for whom medication reconciliation is warranted.

Background: Pneumococcal vaccination rates among high-risk patients (eg, diabetes, asthma, smoking) seen in 2 family medicine clinics are unknown. Objectives: To assess differences in pneumococcal polysaccharide vaccination rates and reasons for nonvaccination among patients with diabetes and asthma and patients who smoke. Methods: A chart review at 2 family medicine residency training clinics showed 425 patients with a medical indication for PPSV23 were seen between April 1, 2015, and April 30, 2015. One reviewer searched the electronic health records to assess reasons for nonvaccination. Results: Rates of nonvaccination were 29.8% in patients with diabetes, 58.7% in patients with asthma, and 62.5% in patients who smoke cigarettes. Patients were classified into 3 groups based on the reasons for nonvaccination: documented patient refusal, not being addressed by a provider, and being documented as low risk despite the presence of a medical indication. Conclusion: The 3 reasons for nonvaccination were vaccination not being addressed, misclassification of high-risk patients as low-risk patients for infection, and documented patient refusal. Providers overlooked vaccination more often in patients with asthma and cigarette use than in patients with diabetes. Patients seeing pharmacists were most likely to be vaccinated, whereas patients seeing physician assistants were least likely to be vaccinated. Pharmacists see patients to provide medication management and preventive care, whereas other providers treat more urgent conditions. Because indications are often overlooked and not addressed, pharmacists can play a larger role in identifying and vaccinating high-risk patients.

Symptoms account for more than 400 million clinic visits annually in the USA. The SPADE symptoms (sleep, pain, anxiety, depression, and low energy/fatigue) are particularly prevalent and undertreated. To assess the effectiveness of providing PROMIS (Patient-Reported Outcome Measure Information System) symptom scores to clinicians on symptom outcomes. Randomized clinical trial conducted from March 2015 through May 2016 in general internal medicine and family practice clinics in an academic healthcare system. Primary care patients who screened positive for at least one SPADE symptom. After completing the PROMIS symptom measures electronically immediately prior to their visit, the 300 study participants were randomized to a feedback group in which their clinician received a visual display of symptom scores or a control group in which scores were not provided to clinicians. The primary outcome was the 3-month change in composite SPADE score. Secondary outcomes were individual symptom scores, symptom documentation in the clinic note, symptom-specific clinician actions, and patient satisfaction. Most patients (84%) had multiple clinically significant (T-score ≥ 55) SPADE symptoms. Both groups demonstrated moderate symptom improvement with a non-significant trend favoring the feedback compared to control group (between-group difference in composite T-score improvement, 1.1; P = 0.17). Symptoms present at baseline resolved at 3-month follow-up only one third of the time, and patients frequently still desired treatment. Except for pain, clinically significant symptoms were documented less than half the time. Neither symptom documentation, symptom-specific clinician actions, nor patient satisfaction differed between treatment arms. Predictors of greater symptom improvement included female sex, black race, fewer medical conditions, and receiving care in a family medicine clinic. Simple feedback of symptom scores to primary care clinicians in the absence of additional systems support or incentives is not superior to usual care in improving symptom outcomes. clinicaltrials.gov identifier: NCT02383862.

Introduction Although an increasing number of physicians are completing medical acupuncture training, only half of those physicians are able to successfully incorporate acupuncture into practice. We conducted a qualitative study to identify the factors and barriers that can enhance and impede physicians' delivery of and patients' engagement in medical acupuncture within the family medicine clinic. Methods We conducted interviews with 15 family physicians and 17 patients in a US family medicine clinic that has integrated medical acupuncture into its practice. Audio recordings were transcribed and analyzed by 2 members of the study team in ATLAS.ti, using the constant comparative method. Results We identified 3 physician themes of factors/barriers that impact delivery/engagement: 1) patients' aversion to needles, 2) time challenges, and 3) access to resources. We identified 3 additional themes from patient interviews: 1) appointment access; 2) wanting noninvasive, no side effects alternative; and 3) openness to anything. Discussion The factors and barriers reported by physicians/patients help illustrate conditions needed to enhance physicians' ability to provide acupuncture and patients' willingness to engage and sustain it. Participants' experiences help to illustrate strategic approaches to managing these barriers-strategies that can be used by other individuals/institutions to enhance care delivery and patient engagement.

Purpose Patient preferences regarding the role of the primary care provider (PCP) in discussing electronic cigarette (e-cigarette) use are unknown. Methods We administered a cross-sectional survey to 568 adult patients in a family medicine clinic to explore e-cigarette use, sources of information on e-cigarettes, perceived knowledge about e-cigarette health effects, views regarding PCP knowledge of e-cigarettes, interest in discussing e-cigarettes with PCPs and preferred format for e-cigarette information. We performed χ2 testing with a 2-tailed P Results The prevalence of e-cigarette use was 10% for recent (≤30 days) use and 29% for nonrecent (>30 days) use. Prevalence was significantly higher among those who were younger, less educated, or smoked cigarettes, but did not vary by sex or self-reported health status. Roughly one quarter of participants believed they were knowledgeable about the health effects of e-cigarettes, secondhand smoke, and quitting cigarettes. Sources of e-cigarette information included television advertisements (56.6%), friends and family (49.9%), or e-cigarette shops (25.5%), but included physician offices much less frequently (6.0%). Although 30.2% disagreed that their PCP knew a lot about e-cigarettes, 62.0% were comfortable discussing e-cigarettes with their PCP. However, only 25% of all patients wanted their PCP to discuss e-cigarettes with them, but 62.0% of recent e-cigarette users wanted such a discussion. Most preferred a brief discussion or handout to a lengthy discussion. Conclusion PCPs were infrequent sources of information for patients regarding e-cigarette use. PCPs need evidence-based strategies to help them address e-cigarettes in primary care.

Background/aim: The aim of this study was to examine the reasons constituting the definition of 'difficult patient' and to evaluate attitudes and behaviors of physicians in coping with these patients and their relatives. Materials and methods: This cross-sectional study was conducted in May and June 2013 with 400 randomly selected physicians from different specialties working in two training and research hospitals in Ankara. A questionnaire was created by reviewing the relevant literature, by family medicine clinic, and delivered to the physicians following a pilot study. Results: In our study 92.8% of the physicians participating had experienced a negative contact with patients and/or their relatives, previously; 46.8% of the participants stated that they used their own experiences in coping with those situations. The frequency of negative communications was higher in surgical departments, increasing with average daily working hours and number of patients and decreasing with the experience of the physicians. The ways of coping with a difficult patient were nonjudgmental listening, patience, tolerance, and empathy, in declining order of importance. Conclusion: Physicians frequently experience negative communications with patients and/or relatives. Awareness of physicians about the concept of difficult patients and the causes and solutions should be enhanced.

OBJECTIVES To evaluate the incidence of medication discrepancies in electronic health record (EHR) medication lists in an outpatient family medicine clinic where clinical pharmacists perform medication reconciliation, to classify and resolve the discrepancies, to identify the most common medication classes involved, and to assess the clinical importance of the discrepancies. METHODS This research was conducted at Bethesda Family Medicine Clinic in St. Paul, MN, with data collected from February 2009 to February 2010. To be included, patients had to be 18 years or older and have at least 10 medications listed in the EHR. The clinical pharmacist saw each patient before the physician, reviewed the medication list with the patient, and made corrections to the EHR medication list. When possible, comprehensive medication management (CMM) also was conducted. RESULTS During 1 year, 327 patients were seen for medication reconciliation. A total of 2,167 discrepancies were identified and resolved, with a mean (±SD) of 6.6 ± 4.5 total discrepancies and 3.4 ± 3.2 clinically important discrepancies per patient. The range of total discrepancies per patient was 0 to 26. The most common discrepancy category was "patient not taking medication on list" (54.1%). Overall, the source of the discrepancy usually was the patient, but it varied according to discrepancy category. The most common medication classes involved were pain medications, gastrointestinal medications, and topical medications. Of the 2,167 discrepancies, 51.1% were determined to be clinically important by the pharmacist. The pharmacist conducted CMM in 48% of patients. CONCLUSION Outpatient medication reconciliation by a pharmacist identified and resolved a large number of medication discrepancies and improved the accuracy of EHR medication lists. Because more than 50% of the discrepancies were thought to be clinically important, improving the accuracy of medication lists could affect patient care.

OBJECTIVES The aim of this study was to estimate the validity of self-reported blood pressure control and medication use in people with hypertension, with and without diabetes. METHODS In a sample of 161 patients with hypertension in a family health team in Ontario, we applied questions from the 2009 Survey on Living with Chronic Disease in Canada Hypertension Component and compared responses against objectively measured and chart-abstracted clinical indicators. Objective blood pressure control was defined as a blood pressure of less than 130/80 mmHg and less than 140/90 mmHg for individuals with and without diabetes, respectively. RESULTS Self-reported blood pressure control showed reasonable sensitivity (83±11 and 78±10%) but low specificity (30±19 and 58±21%) in people with and those without diabetes, respectively. In the subgroup with diabetes, specificity improved to 88±11% when blood pressure control was defined on the basis of a 140/90 mmHg target. Self-reported and chart-abstracted numbers of prescribed antihypertensive medications showed fair agreement (κ=0.7); 9 and 14% of patients overestimated and underestimated the number of prescribed medications, respectively. CONCLUSION Although most individuals with controlled hypertension reported having controlled blood pressure, a large proportion of individuals with uncontrolled hypertension also reported that their blood pressure was controlled. This level of misclassification suggests that in a family medicine clinic population and in health survey contexts, a self-reported measure of blood pressure control may not be useful for assessing hypertension control.

The management of schizophrenia typically involves the use of antipsychotics (neuroleptics). Use of such medications, however, can result in tardive dyskinesia, or the involuntary contracture of muscles, and associated symptomatic somatic dysfunction. The authors present a case of a 29-year-old woman who presented to a family medicine clinic for ongoing management of schizophrenia with noticeable tardive dyskinesia and complaints of neck and upper back pain. Conventional management of tardive dyskinesia involves either a change in or reduction of the offending antipsychotic. In the present case, the patient received osteopathic manipulative treatment in addition to conventional care for the management of her neck and upper back pain. Although not curative, osteopathic manipulative treatment can provide palliative relief for patients with tardive dyskinesia.

Background: Using a self-service kiosk to measure blood pressure (BP) has the potential to increase patients9 awareness of their BP control and free up medical assistant (MA) time. The objective of this study was to evaluate BP kiosk acceptability and usability, as well as its effects on the workflow of patient BP self-measurement in a primary care clinic. Methods: We used qualitative and quantitative assessments of kiosk implementation via meetings with clinic leaders, focus groups with clinic providers and staff, observations of kiosk users, and surveys of kiosk users at 2 and 8 months. Results: Most patients were comfortable using the kiosk (82% at 2 months, 87% at 8 months). Initial provider concerns included accuracy, but most gained confidence after comparing it with other monitors and reviewing the literature supporting its accuracy. Patients and providers saw many benefits: easier BP checks, increased patient engagement, and saved MA time for other tasks. The clinic addressed early concerns (eg, infection control, confusing instructions, perceived loss of personal touch). Most patients (86%) supported the clinic continuing to use the kiosks. Conclusions Providers, staff, and patients adapted to the use of BP kiosks, providing value by engaging patients in their own care and saving MA time. The clinic decided to keep the self-service kiosk after the pilot period.

Objective. To examine knowledge of and self-treatment with antibiotics among medically-insured adults in Mexico. Materials and methods. We conducted a cross-sectional, interviewer-administered survey among 101 adult patients seeking care for acute respiratory tract infections in a family medicine clinic in Mexico. Knowledge scores were calculated as a composite of correct, incorrect and don’t know responses. Factors associated with antibiotic knowledge and antibiotic self-treatment were explored with bivariate analyses. Results. 47% of participants were taking antibiotics prior to the visit, 20% were self-treating. Antibiotic knowledge was highly variable. Many participants believed common nonantibiotic treatments for colds and coughs were antibiotics, such as ambroxol (45%), Desenfriol (45%) and paracetamol (44%). Older participants (>40 years) had better knowledge scores. Discussion. Self-treatment with and misperceptions about antibiotics are common among medically insured adults seeking medical attention in Mexico.

Purpose: The purpose of this study was to compare prescriber monitoring for safety and efficacy of medication classes used to treat benign prostatic hyperplasia (BPH). Methods: This was a retrospective chart review of patients diagnosed with BPH who were prescribed medications within a family medicine clinic between January 2008 and August 2010. Patients were divided into those receiving nonselective and uroselective alpha-blockers, 5-alpha reductase inhibitors (5-ARIs), and combination therapy. A chart review was performed with regard to predetermined criteria to monitor how efficacy and adverse effects were assessed by providers in the clinic. Results: A general genitourinary assessment was documented most frequently for patients receiving 5-ARIs and least frequently in patients receiving nonselective alpha-blockers. A digital rectal examination was documented in 11% of patients. Prostate-specific antigen concentrations were assessed evenly across all medication classes and documented in 47% of eligible patients. However, the American Urological Association Symptom Index and quality-of-life questions were not performed on any patients, and assessments of adverse effects were not documented. Conclusion: Although prescribers in a family medicine clinic recorded a general genitourinary assessment for patients receiving BPH medications, a more standardized approach is needed.

Medical-legal partnerships (MLPs) bring legal services into health care settings to address patients' unmet legal needs. This pilot project examined whether MLP services impact patients' perceptions of stress and wellbeing. methods. Providers referred patients with legal concerns to the Tucson Family Advocacy Program (TFAP), an MLP within a family medicine clinic. Stress levels and wellbeing were assessed before and after legal ser - vices using self-administered 10-item Perceived Stress Scale (PSS-10) and Measure Yourself Concerns and Wellbeing (MYCaW) instruments. results. Sixty-seven participants completed pre- and post-service questionnaires. Within this group, the mean PSS-10 score decreased 8.1 points. Wellbeing scores improved by 1.8 points. Individual changes in perceived stress were strongly related to participants' level of concern regarding the particular legal issues addressed. conclusions. Services in patient-centered medical homes to address unmet legal needs have the potential to reduce perceived stress and improve overall wellbeing. Additional studies concerning MLPs and patient outcomes are needed.

Our study explored the attitudes of patients toward complementary and alternative medicine (CAM) use, their family physicians' role regarding CAM, and models for CAM referral and treatment. We compared patients' perspectives regarding integration of CAM into primary care with attitudes of primary care physicians (PCPs) and CAM practitioners.We conducted a comprehensive literature review and focus group discussions to develop a questionnaire, which we gave to three groups: a random sample of patients receiving care at an academic family medicine clinic and PCPs and CAM practitioners employed in the largest health maintenance organization in Israel.A total of 1150 patients, 333 PCPs, and 241 CAM practitioners responded to our questionnaire. Compared with PCPs, patients expected their family physician to refer them to CAM, to have updated knowledge about CAM, and to offer CAM treatment in the clinic based on appropriate training. When asked about CAM integration into medical care, more patients expected to receive CAM in a primary care setting compared to PCPs' expectations of prescribing CAM (62% vs. 30%; p=0.0001). Patients, CAM practitioners, and PCPs expected family practitioners to generate CAM referrals in an integrative primary care setting (85.6% vs. 82.4% vs. 62.6%; p0.0001). Patients supported CAM practitioners providing CAM treatments in the primary care setting, regardless of whether the practitioner held a medical degree (MD). Also, more patients than PCPs or CAM practitioners expected their family physician to provide CAM (28.2% vs. 14.5% vs. 3.8%; p0.0001).Patients, PCPs, and CAM practitioners suggested that family physicians play a central role in CAM referral and, to a lesser extent, that they actually provide CAM treatment themselves.PCPs need to be aware of their present and future role in informed referral to CAM and, to a lesser degree, in providing CAM in integrative primary care clinics. With the increasing use of CAM, patients may expect their family physician to be more knowledgeable, skillful, and have a balanced approach regarding CAM use. In addition, practitioners should learn how to communicate effectively and better collaborate with CAM practitioners to the benefit of their patients.

Background A pharmacist managed anticoagulation service was initiated in a multi-physician family medicine clinic in December 2006. In order to determine the patient and physician satisfaction with the service, a study was designed to describe the patients’ satisfaction with the warfarin education and management they received from the pharmacist, and to describe the physicians’ satisfaction with the level of care provided by the pharmacist for patients taking warfarin. A self-administered survey was completed by both eligible patients receiving warfarin and physicians prescribing warfarin between December 2006 and May 2008. The patient survey collected information on patient demographics, satisfaction with warfarin education and daily warfarin management. The physician survey collected data about the satisfaction with patient education and daily anticoagulation management by the pharmacist. Results Seventy-six of 94 (81%) patients completed the survey. Fifty-nine percent were male with a mean age of 65 years (range 24–90). Ninety-six percent agreed/strongly agreed the pharmacist did a good job teaching the importance of warfarin adherence, the necessity of INR testing and the risks of bleeding. Eighty-five percent agreed/strongly agreed the risk of blood clots was well explained, 79% felt the pharmacist did a good job teaching about dietary considerations and 77% agreed/strongly agreed the pharmacist explained when to see a doctor. All patients felt the pharmacist gave clear instructions on warfarin dosing and INR testing. Four of nine physicians (44%) completed the survey. All agreed/strongly agreed the pharmacist was competent in the care provided, were confident in the care their patients received, would like the pharmacist to continue the service, and would recommend this program to other clinics. Conclusions Patients and family physicians were satisfied with the pharmacist managed anticoagulation program and recommended continuation of the program. These results support the role of the pharmacist in the management of anticoagulation in a multi-physician family medicine clinic.

Because of their frequent encounters with sedentary patients, family physicians are poised to be on the forefront of the medical community's response to physical inactivity. The purpose of this pilot study was to examine whether the addition of a pedometer to brief physician counseling could help patients increase their ambulatory activity. Ninety four participants recruited from a family medicine clinic were randomly assigned to 2 groups. Both groups received a brief physician endorsement of regular physical activity, a handout on the benefits of an active lifestyle, and 3 follow-up phone calls from a health educator. In addition, the intervention group received a pedometer and was instructed to record their steps daily over the 9-week study period. Measurements were taken for self-reported walking, walking stage-of-change, walking self-efficacy, and pedometer steps (intervention group only). Among completers, mean daily step counts in the pedometer group rose from 6779 at baseline to 8855 at study end. Average individual improvement was 41% over the study period. Both groups significantly increased blocks walked per day, stair climbing versus using the elevator, days per week walking > or = 30 minutes, and walking for fun/leisure. The frequency of walking short trips improved significantly more in the pedometer group relative to the comparison group. The results of this pilot study highlight the need for further research on the use of pedometers as a motivational tool in the context of medical encounters with inactive patients.

Purpose: The prevalence of bipolar disorder in patients being treated for depression with antidepressants in a family medicine clinic was investigated in this study. Methods: Adult patients with depression who were treated with an antidepressant in a general outpatient family medicine clinic at the University of Texas were screened for bipolar disorder using the Mood Disorder Questionnaire (MDQ), a brief self-report inventory. A subsample of subjects received the Structured Clinical Interview based on the DSM-IV (SCID) to test the operating characteristics of the MDQ in this population. Results: of the patients taking an antidepressant for depression, 21.3% screened positive for bipolar disorder on the MDQ. These patients were somewhat younger, more likely to be white, more likely to be living alone, much less likely to be married, and less likely to be employed than those who screen negative. Nearly two thirds of those screened positive had never received diagnosis of bipolar disorder. The sensitivity and specificity of the MDQ in this population, after adjusting for the sampling protocol, were 0.580 (0.454 to 0.706, 95% CI) and 0.930 (0.878 to 0.981, 95% CI) respectively. Conclusion: Bipolar disorder frequently occurs in patients being treated with antidepressants in primary care settings. Most are unrecognized and undiagnosed. Screening for bipolar disorder in such patients may improve recognition, identification, and appropriate treatment.

Adverse drug events (ADEs) occur in approximately 27% of outpatients, with approximately 1.5 million preventable ADEs occurring each year in the United States, mostly in the outpatient setting.[1][1],[2][2] The Food and Drug Administration (FDA) responds to new clinically significant ADEs and risks

Objectives. To determine the number of interventions made by pharmacy students at an urban family medicine clinic and the acceptance rate of these recommendations by the healthcare providers. The secondary objective was to investigate the cost avoidance value of the interventions. Methods. A prospective, unblinded study was conducted to determine the number and cost avoidance value of clinical interventions made by pharmacy students completing advanced pharmacy practice experiences (APPEs) in an urban family medicine clinic. Results. Eighteen students completed this experience in the 8 months studied. Of the 718 interventions performed, 77% were accepted by physicians, including 58% of the 200 interventions that required immediate action. Projected avoidance was estimated at $61,855. Conclusion. The clinical interventions by pharmacy students were generally well received by healthcare providers and resulted in significant cost savings. Pharmacy students can play an important role in a family medicine clinic.

Purpose: To examine urban, inner-city female patients9 acceptability of the provision of early abortion services by their family physician in the family medicine clinic (FMC). Methods: We administered a survey with open- and closed-ended questions to a convenience sample of English- or Spanish-speaking female patients aged 18 to 45 recruited from a FMC in the Bronx, New York. Responses were analyzed using quantitative and qualitative methods. Results: One hundred forty-eight women completed the survey. The majority of respondents stated the FMC should offer abortion services. Seventy percent agreed their clinic should provide medication abortion, and 47% agreed their clinic should provide suction abortion. Of those who would personally consider an abortion, 73% responded that they would prefer to have it done by their family physician in the FMC, whereas 22% would prefer it at a freestanding, high-volume abortion clinic, and 5% had no preference. Conclusions: The majority of patients surveyed accepted the integration of abortion services into our FMC setting, and would choose to have an early abortion at their FMC. Increasing options for abortion provision within our FMC was acceptable to the majority of our sample.

The distribution of drug product samples by pharmaceutical companies to a family medicine clinic was studied. Data on all deliveries of drug samples to the clinic site of a university-affiliated family medicine residency program from November 1992 through December 1993 were collected. In addition, the 11 faculty family physicians were surveyed about their experiences with the deliveries of samples. Forty-three manufacturers delivered samples of 331 drugs during the 14-month study period. There were 366 visits by the drug company representatives, who made 1117 separate deliveries. The total value of the samples, based on the average whole-sale price, was $240,782. Twenty-nine percent of the drugs were nonformulary, and only 49% were stocked by the pharmacy. The physicians surveyed indicated that they were either usually or always asked to sign for samples they did not in fact request, that they usually did not know what was recorded on the receipts for samples that they signed, and that they seldom verified what was actually delivered. Pharmaceutical manufactures delivered large quantities of drug samples during the study period, and many of the drugs were nonformulary or not stocked by the pharmacy. The physicians indicated that they were not well informed about delivered samples for which they signed receipts.

OBJECTIVES: To determine the prevalence of herpes simplex virus (HSV) antibody in a general medical practice setting and to assess the frequency of subclinical infection. DESIGN: Prevalence study. SETTING: A family practice clinic at the University of Washington Medical Center, Seattle. PARTICIPANTS: Five hundred randomly selected patients between the ages of 18 and 45 years. MAIN OUTCOME MEASURES: Serum samples were tested by Western blot assay to detect the presence of antibody to HSV type 1 (HSV-1) and HSV-2. Demographic information and clinical history of oral and genital herpes were obtained. RESULTS: One hundred fourteen patients (23%) were seropositive for HSV-2 antibody, 277 patients (56%) were seropositive for HSV-1 antibody, 59 patients (12%) were seropositive for both HSV-2 and HSV-1 antibodies, and 163 patients (33%) were seronegative for both. Women were almost twice as likely as men to be seropositive for HSV-2 antibody (28% vs 15%, P < .001). Blacks had the highest rates of HSV-2 antibody seropositivity (60%) compared with whites (20%) and Asians (6%) (P < .001). Other demographic correlates of seropositivity included being older, having fewer years of education, and having public insurance. The specificity of a clinical history of genital herpes or sores for HSV-2 infection was high (99%), but the sensitivity was low (27%). CONCLUSIONS: Herpes simplex virus infection is common among patients seeking primary care. Women, blacks, and patients of lower socioeconomic status are most likely to be seropositive for HSV-2 antibody. The high frequency of unrecognized HSV infection has implications for primary care physicians in counseling patients regarding HSV infection and transmission.