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Background: Men who have sex with men (MSM) account for most new HIV diagnoses in the US. Annual HIV testing is recommended for sexually active MSM if HIV status is negative or unknown. Our primary study aim was to determine annual HIV screening rates in primary care across multiple years for HIV-negative MSM to estimate compliance with guidelines. A secondary exploratory endpoint was to document rates for non-MSM in primary care. Methods: We conducted a three-year retrospective cohort study, analyzing data from electronic medical records of HIV-negative men aged 18 to 45 years in primary care at a large academic health system using inferential and logistic regression modeling. Results: Of 17,841 men, 730 (4.1%) indicated that they had a male partner during the study period. MSM were screened at higher rates annually than non-MSM (about 38% vs. 9%, p<0.001). Younger patients (p-value<0.001) and patients with an internal medicine primary care provider (p-value<0.001) were more likely to have an HIV test ordered in both groups. For all categories of race and self-reported illegal drug use, MSM patients had higher odds of HIV test orders than non-MSM patients. Race and drug use did not have a significant effect on HIV orders in the MSM group. Among non-MSM, Black patients had higher odds of being tested than both White and Asian patients regardless of drug use. Conclusions: While MSM are screened for HIV at higher rates than non-MSM, overall screening rates remain lower than desired, particularly for older patients and patients with a family medicine or pediatric PCP. Targeted interventions to improve HIV screening rates for MSM in primary care are discussed. [ABSTRACT FROM AUTHOR]

Purpose: To test whether technology-facilitated self-management support improves depression in primary care settings. Methods: We randomized 204 low-income primary care patients who had at least moderate depressive symptoms to intervention or control. Intervention participants received 12 months of weekly automated interactive voice response telephone calls that assessed their symptom severity and provided self-management strategies. Their patient-nominated supporter (CarePartner) received corresponding guidance on self-management support, and their primary care team received urgent notifications. Those randomized to enhanced usual care received printed generic self-management instructions. Results: One-year attrition rate was 14%. By month 6, symptom severity on the Patient Health Questionnaire-9 (PHQ-9) decreased 2.5 points more in the intervention arm than in the control arm (95% CI −4.2 to −0.8, p = 0.003). This benefit was similar at month 12 (p = 0.004). Intervention was also over twice as likely to lead to ≥50% reduction in symptom severity by month 6 (OR = 2.2 (1.1, 4.7)) and a decrease of ≥5 PHQ-9 points by month 12 (OR = 2.3 (1.2, 4.4)). Conclusions: Technology-facilitated self-management guidance with lay support and clinician notifications improves depression for primary care patients. Subsequent research should examine implementation and generalization to other chronic conditions. clinicaltrials.gov, identifier NCT01834534. [ABSTRACT FROM AUTHOR]

Purpose: Hearing loss (HL) is underdiagnosed and often unaddressed. A recent study of screening for HL using an electronic prompt showed efficacy in increasing appropriate referrals for subsequent testing. We build on the results of this study using a qualitative lens to explore implementation processes through the perspectives of family medicine clinicians.Methods: We collected clinic observations and semistructured interviews of family medicine clinicians and residents who interacted with the HL prompt. All data were analyzed using thematic, framework, and mixed methods integration strategies.Results: We interviewed 27 clinicians and conducted 10 observations. Thematic analysis resulted in 6 themes: (1) the prompt was overwhelmingly viewed as easy, simple to use, accurate; (2) clinicians considered prompt as an effective way to increase awareness and conversations with patients about HL; (3) clinician and staff buy-in played a vital role in implementation; (4) clinicians prioritized prompt during annual visits; (5) medical assistant involvement in prompt workflow varied by health system, clinic, and clinician; (6) prompt resulted in more conversations about HL, but uncertain impact on patient outcomes. Themes are presented alongside constructs of normalization process theory and intervention outcomes.Conclusion: Integration of a HL screening prompt into clinical practice varied by clinician buy-in and beliefs about the impact on patient outcomes, involvement of medical assistants, and prioritization during clinical visits. Further research is needed to understand how to leverage clinician and staff buy-in and whether implementation of a new clinical prompt has sustained impact on HL screening and patient outcomes. [ABSTRACT FROM AUTHOR]

There is a significant interest in improving adolescent access to primary care, yet limited attempts to incorporate youth feedback within these efforts. The purpose of this study was to describe the experiences related to primary care among a large national sample of adolescents to improve patient-centered care. Youth were sent open-ended text message prompts via an ongoing study of 14- to 24-year-olds in the U.S. Text responses were analyzed using qualitative thematic analysis, including descriptive coding, consensus building, and theme development. Secondary quantitative analyses were conducted to determine differences by demographics. Of 1,123 eligible participants, 789 (70.2%) responded to at least one prompt. Four themes were developed: (1) youth recognized the importance of primary care, but barriers exist that limited their utilization; (2) youth felt that improving convenience would increase the use of primary care; (3) youth were unsure how to transition between primary care settings; and (4) feeling respected was essential to youth having positive experiences in a primary care health care setting. Older youth and those identifying as female, nonbinary, or transgender were more likely to report previous bad experiences with primary care. Our findings describe barriers and possible solutions to primary care among youth. Because attitudes toward health and health care are established during adolescence, a transformation is needed to create more patient-centered care that aligns with young people's values and experiences. Thus, primary care providers have the opportunity to positively impact the health of young people today and the adults of the future. [ABSTRACT FROM AUTHOR]

Purpose: Hearing loss, the second most common disability in the United States, is under-diagnosed and under-treated. Identifying it in early stages could prevent its known substantial adverse outcomes.Methods: A multiple baseline design was implemented to assess a screening paradigm for identifying and referring patients aged ≥55 years with hearing loss at 10 family medicine clinics in 2 health systems. Patients completed a consent form and the Hearing Handicap Inventory for the Elderly (HHI). An electronic alert prompted clinicians to screen for hearing loss during visits.Results: The 14,877 eligible patients during the study period had 36,701 encounters. Referral rates in the family medicine clinics increased from a baseline rate of 3.2% to 14.4% in 1 health system and from a baseline rate of 0.7% to 4.7% in the other. A general medicine comparison group showed referral rate increase from the 3.0% baseline rate to 3.3%. Of the 5,883 study patients who completed the HHI 25.2% (n=1,484) had HHI scores suggestive of hearing loss; those patients had higher referral rates, 28% vs 9.2% (P <.001). Of 1,660 patients referred for hearing testing, 717 had audiology data available for analysis: 669 (93.3%) were rated appropriately referred and 421 (58.7%) were considered hearing aid candidates. Overall, 71.5% of patients contacted felt their referral was appropriate.Conclusion: An electronic alert used to remind clinicians to ask patients aged ≥55 years about hearing loss significantly increased audiology referrals for at-risk patients. Audiologic and audiogram data support the effectiveness of the prompt. Clinicians should consider adopting this method to identify patients with hearing loss to reduce its known and adverse sequelae. [ABSTRACT FROM AUTHOR]

Purpose: Clinical pharmacists can help primary care physicians (PCPs) manage medications for patients with poorly controlled type 2 diabetes. Studies have shown that clinical pharmacist involvement in care can improve outcomes such as glycosylated hemoglobin (A1C), blood pressure and lipid control, and decrease episodes of hypoglycemia. Despite these findings, some PCPs may be slow or disinclined to refer to clinical pharmacists when available. This study addressed PCP perceptions regarding referral to clinical pharmacists and endocrinologists for patients with poorly controlled type 2 diabetes. Methods: Physicians from five family medicine sites were surveyed. Physicians were queried regarding their patterns for patient referral to endocrinologists and/or clinical pharmacists. Clinical contributions and importance of factors to consider when referring were compared between clinical pharmacists and endocrinologists using paired t tests. Results: Fifty physicians responded to the survey, resulting in a response rate of 73.5%. The majority of PCPs indicated that they have referred to endocrinologists (89.5%) and clinical pharmacists (93.5%) for specialty care. PCPs tended to refer to clinical pharmacists sooner and at lower A1C values than to endocrinologists. PCPs also considered multiple medical comorbidities, history of noncompliance with medical recommendations, low reading ability or math skills, complex psychosocial situations, fear of needles, or difficulty affording medications or supplies to be more important when referring patients to clinical pharmacists than endocrinologists. Conclusion: We hypothesized that referrals to a clinical pharmacist or endocrinologist are made with careful consideration of the patients' needs. PCPs reported increased utilization of clinical pharmacists for patients with nonmedical needs, indicating that extra time, education, and psychosocial support provided by the clinical pharmacist is highly valued. [ABSTRACT FROM AUTHOR]

CONTEXT: Tobacco, alcohol and drug use are among the top 10 causes of preventable death in the United States, but unhealthy substance use is often under-recognized and under-treated. In primary care, screening, brief intervention, and referral to treatment (SBIRT) contributes to improved patient outcomes. While many barriers exist to implementing SBIRT, the annual or new patient visit is often a critical touchpoint for many patients. Objective: The purpose of this study was to assess, at the population level, our department's rates of screening, risk identification and intervention for tobacco, alcohol and other substance use. STUDY DESIGN/SETTING/POPULATION: Monocentric multisite retrospective chart review over the calendar year 2019. We conducted secondary data analysis of 18,420 patients (Mean age = 43 years, SD = 13; range: 18-65 years old), with a health maintenance exam in this 12 month period who received care at six Family Medicine clinics. PROCESS AND OUTCOME MEASURES: The primary process measures examined screening rates for tobacco, alcohol, and other substance use. The primary outcome measures examined evidence of intervention (dx, medication prescription, referral) among those with and without positive screen. RESULTS: The percent of patients identified at risk for unhealthy use: 9.4% tobacco, 7.3% alcohol, and 6.15% other substance use. Of those who screened positive for tobacco use, 54.7% with evidence of intervention (50% associated diagnosis code; 17% CPT code cessation counseling; less than 2%, with a referral; 14% medication prescription). Of those who screened positive for unhealthy alcohol use, 7.2% with evidence of intervention (7% associated diagnosis code; 1% referral; 0.3% medication prescription). Of those who screened positive for substance use, 7.4% with evidence of intervention (7.4% associated diagnosis code; 0.1% referral). Few statistically significant differences identified by patient or provider demographics or care site. Conclusions: Overall, patients who were screened and were positive were more likely to have evidence of intervention, supporting efforts to complete at least annual screens. The department is strongest at identifying and intervening on tobacco use. Brief assessment and intervention with alcohol and substance use are areas in need of additional focus. The use of validated tools, systematic survey implementation, and population level data storage provide avenues for improvement. [ABSTRACT FROM AUTHOR]

Objectives. We examined how family medicine clinic physicians and staff worked in collaborative teams to implement an automated clinical reminder to improve tetanus, diphtheria, and acellular pertussis (Tdap) booster vaccine administration and documentation. Methods. A clinical reminder was developed at 5 University of Michigan family medicine clinics to identify patients 11 to 64 years old who were in need of the Tdap booster vaccine. Quality improvement cycles were used to improve clinic care processes. Immunization rates from 2008 to 2011 were compared with rates at 4 primary care control clinics. Results. Vaccination rates among eligible patients increased from 15.5% to 47.3% within the family medicine clinics and from 14.1% to 30.2% within the control clinics. After adjustment for covariates, family medicine patients had a higher probability of vaccination than control patients during each measurement period (0.17 vs 0.15 at baseline, 0.53 vs 0.22 during year 1, and 0.50 vs 0.30 during year 2). Conclusions. Automated clinical reminders, when designed and implemented via a consensus-based framework that addresses the process of care, can dramatically improve provision of preventive health care. [ABSTRACT FROM AUTHOR]

Background: There is growing interest in the use of complementary and alternative medicine (CAM) throughout the world, however previous research done in Japan has focused primarily on CAM use in major cities. The purpose of this study was to develop and distribute a Japanese version of the International Complementary and Alternative Medicine Questionnaire (I-CAM-Q) to assess the use of CAM among people who visit rural Japanese family medicine clinics. Methods: Using a Japanese version of the International Complementary and Alternative Medicine Questionnaire (I-CAM-Q), a cross-sectional survey was conducted in three rural family medicine clinics. All patients and those accompanying patients who met inclusion criteria were eligible to participate. Data were entered into SPSS Statistics and analyzed for use by age, gender, and location. Results: Of the 519 respondents who participated in the project, 415 participants reported CAM use in the past 12 months (80.0%). When prayer is excluded, the prevalence of CAM use drops to 77.3% in the past year, or 403 respondents. The most common forms of CAM used by respondents were pain relief pads (n = 170, 32.8%), herbal medicines/supplements (n = 167, 32.2%), and massage by self or family (n = 166, 32.0%). Female respondents, individuals with higher levels of education, and those with poorer overall health status were more likely to use CAM than respondents without these characteristics. Only 22.8% of CAM therapies used were reported to physicians by survey participants. Conclusions: These data indicate that CAM use in rural Japan is common. The results are consistent with previous studies that show that Japanese individuals are more interested in forms of CAM such as pain relief pads and massage, than in mind-body forms of CAM like relaxation and meditation. Due to the high utilization of certain CAM practices, and given that most CAM users do not disclose their CAM use to their doctors, we conclude that physicians in rural Japan would benefit by asking about CAM use during patient interviews, and by familiarizing themselves with the potential benefits and risks of commonly used CAM modalities. [ABSTRACT FROM AUTHOR]

Background: Antidepressants are used by primary care providers to treat a variety of conditions, including (but not limited to) depression and anxiety. A trial-and-error approach is typically used to identify effective therapy, as treatment efficacy and safety can vary based on the response, which is affected by certain gene types. Pharmacokinetic pharmacogenomic (PGx) testing provides phenotypic classification of individuals as poor, intermediate, extensive, and ultrarapid CYP450 metabolizers, providing information for optimal drug selection. Objective: The objective of this pilot study is to examine the feasibility, acceptability, and preliminary effectiveness of PGx testing when used after starting a new antidepressant medication. Methods: We are conducting a pilot study with physicians from 6 Department of Family Medicine clinics at the University of Michigan who are willing to use PGx test results to manage antidepressant medication use. From enrolled physicians, patients were recruited to participate in a 6-month randomized, wait-list controlled trial in which patient participants newly prescribed an antidepressant had PGx testing and were randomized equally to have the results released to their primary care physician as soon as results were available or after 3 months. Patients were excluded if they had been taking the antidepressant for more than 4 weeks or if they had undergone PGx testing in the past. Physician participants completed a baseline survey to assess demographics, as well as knowledge, feasibility, and acceptability of PGx testing for this population. At the conclusion of the study, physician participants will complete a survey to assess knowledge, satisfaction, feasibility, acceptability, perceived effectiveness, and barriers to widespread adoption of PGx testing. Patient participants will complete a baseline, 3-month, and 6-month assessment, and control patient participants will have an additional 9-month assessment. Data collected will include the reason for antidepressant use, self-reported medication adherence, side effects, patient health questionnaire 8-item depression scale, generalized anxiety disorder 7-item scale, 12-Item Short-Form Health Survey, work status or changes, and physician and emergency department visits. PGx knowledge and perceptions (including acceptability and feasibility) as well as demographic information will also be obtained. Results: We recruited 23 physician participants between November 2017 and January 2019, and 52 patient participants between January 2018 and April 2019. Currently, all physician and patient participants have been recruited, and we expect data collection to conclude in January 2020. Conclusions: This study will examine the preliminary effectiveness of PGx testing after treatment initiation and determine the feasibility and acceptability of PGx testing for use in primary care. Through this study, we expect to demonstrate the benefit of PGx testing and lay the foundation for translating this approach into use within primary care. Trial Registration: ClinicalTrials.gov NCT03270891; https://clinicaltrials.gov/ct2/show/NCT03270891 International Registered Report Identifier (IRRID): RR1-10.2196/13848 We help JMIR researchers to raise funds to pursue their research and development aimed at tackling important health and technology challenges. If you would like to show your support for this author, please donate using the button below. The funds raised will directly benefit the corresponding author of this article (minus 8% admin fees). Your donations will help this author to continue publishing open access papers in JMIR journals. Donations of over $100 may also be acknowledged in future publications. Suggested contribution levels: $20/$50/$100 [ABSTRACT FROM AUTHOR]

Introduction: Hearing loss (HL) is the second most common disability in the U.S., yet is clinically underdiagnosed. To manage its common adverse psychosocial and cognitive outcomes, early identification of HL must be improved.Methods: A feasibility study conducted to increase screening for HL and referral of patients aged ≥55 years arriving at two family medicine clinics. Eligible patients were asked to complete a self-administered consent form and the Hearing Handicap Inventory (HHI). Independently, clinicians received a brief educational program after which an electronic clinical prompt (intervention) alerted them (blinded to HHI results) to screen for HL during applicable patient visits. Pre- and post-intervention differences were analyzed to assess the proportion of patients referred to audiology and those diagnosed with HL (primary outcomes) and the audiology referral appropriateness (secondary outcome). Referral rates for those who screened positive for HL on the HHI were compared with those who scored negatively.Results: There were 5,520 eligible patients during the study period, of which 1,236 (22.4%) consented. After the intervention's implementation, audiology referral rates increased from 1.2% to 7.1% (p<0.001). Overall, 293 consented patients (24%) completed the HHI and scored >10, indicating probable HL. Of these 293 patients, 28.0% were referred to audiology versus only 7.4% with scores <10 (p<0.001). Forty-two of the 54 referred patients seen by audiology were diagnosed with HL (78%). Overall, the diagnosis of HL on problem lists increased from 90 of 4,815 patients (1.9%) at baseline to 163 of 5,520 patients (3.0%, p<0.001) over only 8 months.Conclusions: The electronic clinical prompt significantly increased audiology referrals for at-risk patients for HL in two family medicine clinics. Larger-scale studies are needed to address the U.S. Preventive Services Task Force call to assess the long-term impact of HL screening in community populations. [ABSTRACT FROM AUTHOR]

Introduction: Colorectal cancer screening (CRCS) remains underutilized. Decision aids (DAs) can increase patient knowledge, intent, and CRCS rates compared with "usual care," but whether interactivity further increases CRCS rate remains unknown.Study Design: A two-armed RCT compared the effect of a web-based DA that interactively assessed patient CRC risk and clarified patient preference for specific CRCS test to a web-based DA with the same content but without the interactive tools.Setting/participants: The study sites were 12 community- and three university-based primary care practices (56 physicians) in southeastern Michigan. Participants were men and women aged 50-75 years not current on CRCS.Intervention: Random allocation to interactive DA (interactive arm) or non-interactive DA (non-interactive arm).Main Outcome Measures: Primary outcome was medical record documentation of CRCS 6 months after the intervention. Secondary outcome was patient decision quality (i.e., knowledge, preference clarification, and intent) measured immediately before and after DA use, and immediately after the office visit. To determine that either DA had a positive effect on CRCS adherence, usual care CRCS rates were determined from the three university-based practices among patients eligible for but not participating in the study.Results: Data were collected between 2012 and 2014; analysis began in 2015. At 6 months, CRCS rate was 36.1% (95% CI=30.5%, 42.2%) in the interactive arm (n=284) and 40.5% (95% CI=34.7%, 46.6%) in the non-interactive arm (n=286, p=0.29). Usual care CRCS rate (n=440) was 18.6% (95% CI=15.2%, 22.7%), significantly lower than both arms (p<0.001). Knowledge, attitude, self-efficacy, test preference, and intent increased significantly within each arm versus baseline, but the rate was not significantly different between the two arms.Conclusions: The interactive DA did not improve the outcome compared to the non-interactive DA. This suggests that the resources needed to create and maintain the interactive components are not justifiable.Trial Registration: This study is registered at www.clinicaltrials.gov NCT01514786. [ABSTRACT FROM AUTHOR]