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Chronic spontaneous urticaria (CSU) is a debilitating inflammatory skin condition, often impacting quality of life. International guidelines recommend omalizumab, an anti-immunoglobulin E antibody, for second-line treatment. Our objective was to understand patient characteristics associated with prescription of omalizumab, and assess real-world outcomes in patients with CSU treated with omalizumab. We analyzed data from the Adelphi Real World CSU Disease Specific Programme, a cross-sectional survey with retrospective data collection (December 2020–October 2021) from physicians and patients with CSU in the United States. Data from allergists (n = 45), dermatologists (n = 51), and primary care physicians (PCPs; n = 20) were included. At the time of data collection, one-third of patients were receiving omalizumab (n = 220) and 67% were eligible for but not receiving omalizumab (n = 455). Using logistic regression, the odds of receiving omalizumab were higher in patients whose entire bodies were affected by hives [odds ratio (OR) = 2.551; 95% confidence interval (CI) 1.502–4.333; p < 0.001] or with deteriorating/unstable prognoses at treatment initiation [OR = 2.219; 95% CI 1.031–4.777; p = 0.042], and lower in patients managed by PCPs [OR = 0.276; 95% CI 0.130–0.584; p < 0.001]. Estimates from an inverse probability weighted regression adjustment model indicated that patients receiving omalizumab had higher treatment satisfaction, improvements in itching, hives, angioedema, insomnia, and anxiety, and lower impact on work productivity, compared with patients not receiving omalizumab. Around two-thirds of patients with CSU considered eligible for omalizumab were not receiving the guideline-recommended therapy. Patients receiving omalizumab had better real-world outcomes compared with patients not receiving omalizumab. Ensuring patients receive the most appropriate treatment could benefit patients with CSU. People with a skin rash known as chronic spontaneous urticaria (also called long-lasting hives) have itchy spots that last longer than 6 weeks. People with long-lasting hives may be treated with a medicine called omalizumab to help their itching. We asked doctors why they gave some people omalizumab. We found that only one out of every three people with long-lasting hives were given omalizumab. Doctors gave some people omalizumab because they had long-lasting hives on their whole body or their hives were getting worse. Other people received omalizumab because they were seeing a specialist doctor (allergist) instead of a primary care physician (also called a general practitioner). When compared with people who received other medicines, people being treated with omalizumab had reduced itching, less anxiety, and better well-being. These findings could help doctors choose the right medicine for people with long-lasting hives. [ABSTRACT FROM AUTHOR]

Introduction. New Zealand's health care system faces significant shortages in health care workers. To address workforce challenges and meet the population's health needs, health care systems around the world have introduced new clinical roles, such as physician associates/assistants (PAs) into existing health care teams. Aim. This article aims to examine the benefits, challenges, and broader implications of regulating PAs in the context of New Zealand's primary care sector, with a specific emphasis on how it may impact general practice. Methods. A range of literature surrounding the role, impact, and perception of PAs were selected and included in this article. Results. The PA profession can significantly strengthen New Zealand's primary care workforce, improving patient access and continuity of care. However, the global deployment of PAs has faced scrutiny due to concerns about its potential risks to patient safety and the overall viability of such a role. Discussion. If regulated, the PA profession can reshape New Zealand's primary care, offering a partial solution to current medical staff shortages. Trained under a generalised medical model similar to doctors, PAs possess the necessary skills to perform both routine and non-routine medical tasks. This dual capability can significantly improve primary care service provision, reduce existing workloads, and allow for a more efficient deployment of doctor expertise. However, medico-legal issues and the supervisory burden can impede widespread integration into general practice. Despite challenges, the success of the PA role relies on mutual trust, respect, and support from other clinical team members within primary health care. [ABSTRACT FROM AUTHOR]

Rates of depression among the college-aged population are alarming, particularly in light of the coronavirus disease 2019 pandemic. It is important for providers who care for this population to have proper screening and referral processes to meet growing student needs. The purpose of this literature review was to examine current best practices for depression screening among college students. Comprehensive searches of PubMed, CINAHL, Embase, and Cochrane databases were completed with the assistance of a medical librarian. A total of 775 studies were screened, and 17 articles were included in the review. Evidence supports universal-based depression screenings; use of screening methods to include brief and online screenings; use of validated screening tools, including the Patient Health Questionnaire (PHQ) -2 and PHQ-9; and the importance of a proper referral process and adequate access to treatment measures. An appropriate depression screening and referral process within campus health centers is critical to meet the needs of college students. [Journal of Psychosocial Nursing and Mental Health Services, 62(6), 13–17.] [ABSTRACT FROM AUTHOR]

This content is provided by the American Academy of Family Physicians. [ABSTRACT FROM AUTHOR]

Historically, congregational leaders did the work of chaplaincy. In the past century, the professions have diverged and chaplaincy has diversified in form and function. We ask which congregational leaders currently also serve as chaplains to identify the extent of overlap between these two types of religious leaders in the contemporary United States. We analyze data from the National Survey of Religious Leaders (NSRL), a nationally representative sample of 1,600 clergy collected in 2019 to 2020, to determine how many congregational leaders are also working or volunteering as chaplains. Though some overlap exists between the occupational roles of chaplains and congregational leaders, our study shows that they are largely distinct professions, with only 17.1% of primary congregational leaders also working or volunteering as chaplains. Catholic primary leaders and Hispanic primary leaders are more likely than their peers to also work as chaplains. Researchers studying each group should be attentive to the ways these professional groups overlap and diverge, and the corresponding possible confusion among religious practitioners and the general public. Theological educators should consider the specific training and support needs of the portion of clergy who serve as chaplains alongside of their congregational positions. [ABSTRACT FROM AUTHOR]

Child abuse pediatrics (CAP) subspecialists evaluate, diagnose, and treat children when abuse or neglect is suspected. Despite the high rates of child maltreatment across the United States, CAP remains the smallest pediatric subspecialty. The CAP workforce faces numerous challenges, including few fellows entering the field, decreased financial compensation compared with other fields of medicine, and threats to workforce retention, including secondary trauma and harmful exposure in the media. A microsimulation model that estimates the future of the US CAP workforce over the next 20 years shows that, although the number of child abuse pediatricians in the field is expected to increase, the growth is smaller than that of every other pediatric subspecialty. In addition to the low overall CAP workforce in the United States, other workforce issues include the need to increase CAP subspecialists who are underrepresented in medicine and unequal geographic distribution across the country. To meet the medical needs of suspected victims of maltreatment, especially in CAP-underserved areas, many children are evaluated by providers who are not board-certified in CAP, such as general pediatricians, family medicine physicians, emergency medicine physicians, and advanced practice providers, whose CAP experience and training may vary. Current child abuse pediatricians should continue introducing the field to medical students and residents, especially those who identify as underrepresented in medicine or are from CAP-underserved areas, and offer mentorship, continuing education, and oversight to non-CAP physicians meeting this population's medical needs. [ABSTRACT FROM AUTHOR]

Background and Objectives: Burnout among physicians who work in primary care is an important problem that impacts health care quality, local communities, and the public's health. It can degrade the quality of primary care services in an area and exacerbate workforce shortages. This study conducted a review of the published research on burnout among family physicians working in the United States. Methods: We used a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-guided approach and several article databases to identify, filter, and analyze published research on US family physician burnout that uses data collected from 2015 onward. Results: Thirty-three empirical studies were identified with findings that included US family physician burnout prevalence and/or associations between burnout and specific personal and contextual drivers. Mean family physician burnout prevalence across studies that measured it was 35%. Almost half of the studies classified one-third or more of their family physician samples as burned out. Physician gender (being female), age (being younger), and job/work-related factors (workload, time pressures) were the most commonly identified correlates of family physician burnout. The vast majority of studies were cross-sectional and used secondary data. Conclusions: The extant research literature on family physician burnout in the United States shows that burnout is currently a meaningful problem. Several important correlates of the problem can be identified, some of which managers and health care organizations can proactively address. Other correlates require managers and health care organizations also viewing family physicians in differentiated ways. The collective literature can be improved through a more consistent focus on similar burnout correlates across studies; inclusion of interventions aimed at lessening the effects of key burnout correlates; employment of more robust longitudinal and quasi-experimental research designs; and additional pandemic-era data collection on burnout. [ABSTRACT FROM AUTHOR]

The primary care (PC) physician workforce has consistently been projected as requiring additional numbers to meet the needs of the U.S. The Health Resources and Service Administration (HRSA) has reported the PC nurse practitioner (NP) workforce to be 90,000 NPs more than required to meet the PC needs of the U.S. With both clinician types contributing to the PC workforce in the country, it is difficult to understand such an oversupply of NPs with continued deficit in PC physicians. The purpose of this study was to investigate results and methods used for HRSAs current PC workforce projections and compare those with the same used for Bureau of Labor Statistics (BLS) and American Association of Medical Colleges (AAMC) projections. Methods included a review of technical documents, dashboards, and published reports. Interviews with subject matter experts were also completed. Projections were found to differ significantly, as did data and assumptions. Two of the three projections modeled physicians as the sole provider of PC. An integrated model gives the most comprehensive and accurate picture of PC workforce needs. The utilization of NPs as PC providers has been demonstrated to be safe and effective, with the potential to alleviate predicted shortages, improve patient care outcomes, reduce cost, and address PC inequities. Implications include improving workforce data, creating projections that mirror clinical integration in PC, adjusting workforce preparation funding, incentivizing interprofessional collaboration in research, addressing barriers to practice among non-physician providers, and leveraging growth in the NP workforce. [ABSTRACT FROM AUTHOR]

Achieving equitable access has been a central goal in healthcare for years; access by low-income Americans is a major concern for policymakers. We examined the differences in post-discharge primary care follow-up visits and 30-day post discharge ER visits across several characteristics. The results suggest that higher housing density, percent minority population, percent unemployed, and percent uninsured point to lower rates of PCP follow-up care and higher rates of post-discharge ER visits. These findings have implications for developing cost-effective programs targeting hospital to PCP communication, especially in densely populated areas. [ABSTRACT FROM AUTHOR]

Little is known regarding the outcomes and distinguishing characteristics of lawsuits related to endodontic procedures. This study used a verdict-based data from United States of America to analyze the factors associated with endodontic malpractice lawsuits and mitigate the risk of litigation. The LexisNexis legal database was used to search for endodontic malpractice cases from January 1, 2000 to December 31, 2021 using the terms "medical malpractice" and (I) "endodontist" (II) "endodontics" (III) "root canal" (IV) "dental pulp." Each case was reviewed for reported medical characteristics and litigation outcomes. A total of 650 cases were initially identified, and 97 cases were included in the final analysis. Eighty-four (86.6%) of the 97 defendants were general practitioners; 42 cases favored the plaintiff, 53 (54.6%) favored the defendant, 1 was partial win/loss, and 1 was settled. The annual case mean was 4.41 ± 2.17 (Mean ± SD). The major allegations favored for the patients involving paresthesia, root perforation, rubber dam not use, wrong tooth therapy, and infections. Plaintiffs who claimed with post-procedural reasons had a significantly higher winning rate than non-post-procedural reasons (P < 0.05). In the present study, 54.6% of endodontic litigation favored the dentists in the US. The authors recommend that general practitioners refer complicated cases to endodontists and treat carefully to avoid paresthesia, canal perforation and infections. Clinicians should always diagnose and treat correctly, shared decision making with the patient, use rubber dam routinely, and timely management to prevent malpractice claims. [ABSTRACT FROM AUTHOR]

Discordance between physicians and patients' health beliefs can impede health communication efforts. However, little research considers physicians' perceptions of patient beliefs, despite the importance of perceptions in shaping communication. In the current work, we examine instances of actual and perceived discordance between physicians and U.S. adults' beliefs regarding the causes and controllability of type 2 diabetes. 229 family physicians completed an online survey measuring their health beliefs and perceptions of their patients' beliefs. Physicians' responses were contrasted against beliefs from a national survey sample of 1,168 U.S. adults. T-tests assessed whether (a) physicians' beliefs diverged from the national sample's beliefs (actual discordance), (b) physicians perceived that their health beliefs diverged from their patients' beliefs (perceived discordance), and (c) physicians' perceptions of patient beliefs diverged from the national sample's beliefs (accuracy of perceived discordance). Findings revealed evidence of actual discordance; compared to the national sample, physicians were more likely to attribute type 2 diabetes to genes (versus lifestyle factors) and perceived greater control over developing diabetes. Moreover, although physicians perceived discordance between their own and their patients' beliefs, data from the national sample suggested that these gaps were less substantial than physicians expected. In particular, findings showed that physicians generally overestimated discordance, expecting that people would be less likely to (1) attribute the development of diabetes to lifestyle factors (versus genes), and (2) perceive control over developing diabetes, than was actually reported. Implications of actual and perceived discordance for effective health communication and patient education are discussed. [ABSTRACT FROM AUTHOR]

Context: The abuse of opioids and opioid-related harms, including deaths, in the United States are well documented. In the European Union, opioid use has also been increasing, particularly of fentanyl.Objective: We assessed the prevalence of off-label prescribing of transmucosal immediate-release fentanyl (TIRF), in France, in 2019. We looked at the patients' and prescribers' characteristics and compared the population of patients who received TIRF in off-label prescriptions with those taking it on-label. We also examined the differences between the patients with and without cancer in the off-label use population.Methods: This was a population-based cross-sectional study conducted in 2019, using the French national insurance claims database Système National d'Informations Inter-Régimes de l'Assurance Maladie, covering 98.8% of the French population, or 66 million people.Results: We selected 224,000 patients with fentanyl prescriptions. Among them, 23,209 had at least one TIRF delivered. The median age was 71 years (59-85) and most patients were female (55.8%). The prevalence of off-label prescribing of TIRF was 51.8% (n = 12,031), corresponding to 9827 patients not diagnosed with cancer. The three main pharmaceutical TIRF specialties prescribed in two groups were Abstral, Pecfent, and Instanyl. Overall, TIRF was mainly prescribed by private general practitioners (64.8%).Conclusion: The prevalence of off-label prescribing of TIRF in France is extremely high. A field survey is now needed 1) to better understand why TIRF is used in conditions not indicated in its marketing authorization, and in what clinical situations, and 2) to determine whether the benefit/risk ratio of such use is favorable. [ABSTRACT FROM AUTHOR]

Background Patient-reported outcomes (PROs) can promote patient engagement, shared-decision making and improve the overall experience of care. However, PRO integration in the primary care clinical setting is limited. Exploring the perspectives of primary care physicians (PCPs) on PROs is key to understanding how they are being used in the clinical setting. We sought to elucidate this clinical perspective at one of the largest US health systems that has integrated a wide range of PROs into routine primary care. Methods Mixed methods study with both anonymous online surveys and in-person qualitative semistructured interviews conducted with PCPs to understand their clinical perspectives on the applications of the existing PROs. PCPs from the 19 affiliated clinics were prompted to complete the survey. Interviewed PCPs were selected via a combination of random and purposive selection from the PCP directory. Results Of 172 PCPs, 117 (68%) completed the online survey and 28 completed semistructured interviews. Most PCPs (77%) reviewed PRO responses with their patients. PCPs endorsed that PROs improve clinic efficiency and clinical management. However, PCPs have heterogeneous perspectives on the relevance of PROs in clinical practice, likely due to variations in clinic practice. For specific PRO instruments, PCPs reported anxiety and depression screening PROs to be most helpful. PCPs felt that PROs assisted with completing screening questions that are required by regulatory bodies. Barriers to using PROs include poor user-interface for both clinicians and patients and inadequate training. Conclusions Most PCPs regularly use PRO data though there are mixed opinions about their clinical relevance. An adaptable, user-friendly PRO system has the potential to have meaningful clinical applications in primary care. [ABSTRACT FROM AUTHOR]

Background: Despite efforts to improve access to Medications for Opioid Use Disorder (MOUD), such as buprenorphine, the number of opioid overdoses in the United States continues to rise. In April 2021, the Department of Health and Human Services removed the mandatory training requirement to obtain a buprenorphine waiver; the goal was to encourage more providers to prescribe buprenorphine, thus improving access. Little is known about the attitudes on buprenorphine prescribing after this policy change. Objective: The primary objective was to assess attitudes among primary care providers toward the removal of the buprenorphine waiver training requirement. A secondary objective was to identify other barriers to prescribing buprenorphine. Methods: We conducted a survey between September 15 and October 13, 2021 to assess the overall beliefs on the effectiveness of MOUD and attitudes toward the removal of the waiver training, current knowledge of buprenorphine, current practice styles related to screening for and treating OUD, and attitudes toward prescribing buprenorphine in the future. This survey was sent to 890 Mayo Clinic primary care providers in 5 US states. Results: One hundred twenty-three respondents (13.8%) completed the survey; 35.8% respondents agreed that the removal of the waiver training was a positive step. These respondents expressed a greater familiarity with the different formulations, pharmacology, and titration of buprenorphine. This group was also more likely to prescribe (or continue to prescribe) buprenorphine in the future. Approximately one-third (34.4%) of respondents reported perceived institutional support in prescribing buprenorphine. This group expressed greater confidence in diagnosing OUD, had greater familiarity with the different formulations, pharmacology, and titration of buprenorphine, and was more likely to prescribe (or continue to prescribe) buprenorphine in the future. Respondents who have been in practice for 11 to 20 years since completion of training were most likely to refer all OUD patients to specialists. Conclusions: Results of our survey suggests that simply removing the mandatory waiver training requirement is insufficient in positively changing attitudes toward buprenorphine prescribing. A key barrier is the perceived lack of institutional support. Future studies investigating effective ways to provide such support may help improve providers' willingness to prescribe buprenorphine. [ABSTRACT FROM AUTHOR]

As higher-valent pneumococcal conjugate vaccines (PCVs) become available for pediatric populations in the US, it is important to understand healthcare provider (HCP) preferences for and acceptability of PCVs. US HCPs (pediatricians, family medicine physicians and advanced practitioners) completed an online, cross-sectional survey between March and April 2023. HCPs were eligible if they recommended or prescribed vaccines to children age <24 months, spent ≥25% of their time in direct patient care, and had ≥2 y of experience in their profession. The survey included a discrete choice experiment (DCE) in which HCPs selected preferred options from different hypothetical vaccine profiles with systematic variation in the levels of five attributes. Relative attribute importance was quantified. Among 548 HCP respondents, the median age was 43.2 y, and the majority were male (57.9%) and practiced in urban areas (69.7%). DCE results showed that attributes with the greatest impact on HCP decision-making were 1) immune response for the shared serotypes covered by PCV13 (31.4%), 2) percent of invasive pneumococcal disease (IPD) covered by vaccine serotypes (21.3%), 3) acute otitis media (AOM) label indication (20.3%), 4) effectiveness against serotype 3 (17.6%), and 5) number of serotypes in the vaccine (9.5%). Among US HCPs, the most important attribute of PCVs was comparability of immune response for PCV13 shared serotypes, while the number of serotypes was least important. Findings suggest new PCVs eliciting high immune responses for serotypes that contribute substantially to IPD burden and maintaining immunogenicity against serotypes in existing PCVs are preferred by HCPs.

In the United States, Black and Latinx youth remain disproportionately affected by HIV. Oral antiretroviral pre-exposure prophylaxis (PrEP) is a proven effective HIV prevention strategy. PrEP is approved for use in people younger than the age of 18 years, but little is known about provider comfort and preparedness with prescribing it to adolescents. In this study, physicians provide their perspectives on the facilitators and barriers to PrEP access among adolescents. Focus groups (n = 23) were conducted with pediatric and family practitioners practicing in an urban community hospital setting to assess PrEP awareness and receptivity to use among adolescents. Most providers were unfamiliar with clinical guidelines for PrEP use, especially in determining adolescent candidates for PrEP use, including appropriate dosing regimen and follow-up procedures. Overall, providers had low intent on prescribing PrEP, citing concerns about consent, medication adherence, and appropriateness of primary care providers in prescribing and managing adolescent PrEP use. Strategies that will address provider education and comfort in prescribing PrEP to adolescents are required to increase PrEP access and uptake among communities disproportionally affected by HIV. [ABSTRACT FROM AUTHOR]

Objectives: General gynecologists are often the first to face a newly diagnosed adnexal mass. Bothering mass symptoms, fertility issues, and the effect of a possible surgical intervention on fertility in term of mechanical factor and ovarian follicular reserve are all considerations that should be accounted for. This study summarizes and compares five different adnexal mass management guidelines, enabling clinicians to peruse consensus and controversy issues, thus choosing the optimal management method.Design: We retrieved, reviewed and compared the most recent national guidelines of adnexal mass management from the national societies of the United States (American College of Obstetricians and Gynecologists), England (the Royal College of Obstetricians and Gynecologists), Canada (the Society of Obstetricians and Gynaecologists of Canada), Australia (the Royal Australian College of General Practitioners), and France (French College of Gynaecologists and Obstetricians).Results: There is a broad consensus regarding the role of transvaginal ultrasound as part of the initial evaluation of an adnexal mass and the radiological characteristics suggesting it being malignant. The role of transabdominal ultrasound or doppler mode is controversial. The use of MRI in cases of indeterminate adnexal masses is widely accepted. Ultrasound-guided aspiration is generally not recommended. There is a broad consensus that CA-125 should not be used as an ovarian cancer disease screening tool, though its role in the initial evaluation of adnexal masses is controversial. Risk prediction models are generally accepted, particularly the 'International Ovarian Tumor Analysis simple rules' and the 'Risk of Malignancy Index'.Conclusion: Adnexal mass management national guidelines, though similar, had noticeable variations in the content, references cited, and recommendations made. While this variation might raise a concern as to the reproducibility of synthesizing literature, it can help practitioners present all spectra of recommendations and available data. [ABSTRACT FROM AUTHOR]

Purpose: The United States Advisory Committee on Immunization Practices (ACIP) recommends vaccination against meningococcal serogroups A, C, W, and Y (MenACWY) for all 11-12-year-olds, with a booster dose for 16-year-olds, and against meningococcal serogroup B (MenB) for 16-23-year-olds under shared clinical decision-making (SCDM). However, uptake of the MenB vaccine and the MenACWY booster dose is low. This study investigated United States physicians' knowledge, attitudes, and practices regarding recommending MenB and MenACWY vaccines to non-high-risk older adolescents and young adults., Methods: An online survey was conducted in April-May 2022 among pediatricians, family physicians (FPs), general practitioners (GPs), and internists who had recommended the MenB and/or the MenACWY vaccine(s) to at least one 16-23-year-old in the past year., Results: Among 407 participants, 50% correctly identified MenB as the leading cause of meningococcal disease among adolescents and young adults. Furthermore, 46% of physicians (47% of pediatricians, 40% of FPs and GPs, 53% of internists) answered correctly that MenB vaccination is recommended under SCDM, and 82% of physicians (96% of pediatricians, 70% of FPs and GPs, 65% of internists) answered correctly that MenACWY vaccination is routinely recommended. Among MenB-vaccinators, 78% reported having received some training or other information on implementing SCDM, and 65% rated recommending MenB vaccination as very important., Discussion: Knowledge gaps, which varied by specialty, were identified regarding meningococcal disease and vaccine recommendations, particularly regarding MenB. Targeted education of physicians may facilitate discussions about MenB vaccination., (Copyright © 2024 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Despite the strong evidence supporting guideline-directed medical therapy (GDMT) in patients with heart failure with reduced ejection fraction (HFrEF), prescription rates in clinical practice are still lacking., Methods: A survey containing 20 clinical vignettes of patients with HFrEF was answered by a national sample of 127 cardiologists and 68 internal/family medicine physicians. Each vignette had 4-5 options for adjusting GDMT and the option to make no medication changes. Survey respondents could only select one option. For analysis, responses were dichotomized to the answer of interest., Results: Cardiologists were more likely to make GDMT changes than general medicine physicians (91.8% vs. 82.0%; OR 1.84 [1.07-3.19]; p = 0.020). Cardiologists were more likely to initiate beta-blockers (46.3% vs. 32.0%; OR 2.38 [1.18-4.81], p = 0.016), angiotensin receptor blocker/neprilysin inhibitor (ARNI) (63.8% vs. 48.1%; OR 1.76 [1.01-3.09], p = 0.047), and hydralazine and isosorbide dinitrate (HYD/ISDN) (38.2% vs. 23.7%; OR 2.47 [1.48-4.12], p < 0.001) compared to general medicine physicians. No differences were found in initiating angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACEi/ARBs), initiating mineralocorticoid receptor antagonist (MRA), sodium-glucose transporter protein 2 (SGLT2) inhibitors, digoxin, or ivabradine., Conclusions: Our results demonstrate cardiologists were more likely to adjust GDMT than general medicine physicians. Future focus on improving GDMT prescribing should target providers other than cardiologists to improve care in patients with HFrEF., (© 2024. The Author(s).)

Prescribing is a significant activity undertaken by physicians, physician associates/assistants (PAs), and nurse practitioners (NPs). We analyzed prescribing data to understand better the growing presence of PAs and NPs in older adults. A trend in frequently prescribed medications was compared with other physicians. All prescriptions in Medicare Part D were grouped into broad categories of drugs and linked to each type of provider. The analysis spanned 9 years (2013-2021). The results revealed that all five providers similarly prescribed the top three main drug classes (antacids, antihypertensives, and statins). In addition, there was a decline in the number of unique prescribers and prescriptions for all three types of physicians (family medicine, internal medicine, and general practice physicians). Concurrently, the number and share of prescriptions for NPs and PAs increased yearly. The findings are consistent with data that PAs and NPs are backfilling physician shortages in treating older adults., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: In June 2019, the Advisory Committee on Immunization Practices recommended discontinuing the routine use of the pneumococcal conjugate vaccine (PCV13) among adults aged ≥65 years and instead recommended PCV13 be used based on shared clinical decision making (SCDM). Objectives: We wanted to assess among primary care physicians (1) knowledge and attitudes regarding the new SCDM PCV13 recommendation and (2) how the new recommendation will affect their likelihood of recommending PCV13 to adults aged ≥65 years. Design This was done by mail and internet‐based survey, which was conducted October 2019 through January 2020. The study was carried out on a nationally representative sample of general internists (GIMs) and family physicians (FPs). Results: The response rate was 64% (617/968, GIM 57%, FP 71%). Only 41% of respondents were aware of the SCDM PCV13 recommendation in adults aged ≥65 years; 76% agreed (37% "Strongly," 39% "Somewhat") that their patients aged ≥65 years will get confused by having a SCDM recommendation for PCV13 and a routine recommendation for the pneumococcal polysaccharide vaccine (PPSV23); 60% agreed (18% "Strongly," 42% "Somewhat") that they were unsure of what points to emphasize when having a SCDM conversation with an adult aged ≥65 years about receiving PCV13. Just over 50% reported they would be less likely to recommend PCV13 for adults aged ≥65 years as a result of the new recommendation, but 42% reported that their recommendation for PCV13 would not change. Conclusions: Word of the new ACIP recommendation for PCV13 for adults aged ≥65 years needs to be further disseminated. Investigation into why some physicians do not plan to change their recommendations is warranted. [ABSTRACT FROM AUTHOR]

To describe the prescribing practices for gabapentin as an analgesic within the veterinary community. Anonymous online voluntary survey. A total of 718 veterinarians within the United States and Canada, including general practitioners and diplomates of the American Colleges of Veterinary Anesthesia and Analgesia, Emergency and Critical Care, Surgery and Internal Medicine. An anonymous online survey was used to gather information about individual prescribing practices for gabapentin including frequency of use, reasons for prescribing and procedures for authorizing refill requests. Questions specific to gabapentin covered mechanisms of action, perceptions of efficacy and the potential for abuse in people. Dunn's test for multiple comparisons and pairwise Mann–Whitney U test were used to evaluate relationships between veterinary specialty and survey responses. A total of 718 veterinarians responded to the survey, 528 (73.5%) answered all questions of the survey to completion. Frequency of prescribing was high with 365/529 (69.0%) of respondents prescribing gabapentin as an analgesic on a daily or weekly basis. Surgeons and general practitioners used gabapentin significantly more frequently than other groups, with surgeons more likely to prescribe gabapentin for postoperative pain. The most common reason [254/517 (49.1%)] survey respondents prescribed gabapentin as an analgesic was because administration of a non-steroidal anti-inflammatory medication was contraindicated for that animal. The majority of survey respondents [362/527 (68.7%)] considered the abuse potential of gabapentin to be low in people. Veterinary prescribing practices for gabapentin closely mirrored that of human physicians, with gabapentin being prescribed frequently and for uses largely unrelated to its labeled indication. The perception of the potential for abuse of gabapentin is low within the veterinary community. [ABSTRACT FROM AUTHOR]

Background: While the social determinants of health (SDOH) have a greater impact on individual health outcomes than the healthcare services a person receives, healthcare providers face barriers to addressing these factors in clinical settings. Previous studies have shown that providers often lack the necessary knowledge and resources to adequately screen for and otherwise assist patients with unmet social needs. This study explores the perceptions and behaviors related to SDOH among healthcare providers in the United States (US)., Methods: This cross-sectional study analyzed data from a 22-item online survey using Reaction Data's research platform of healthcare professionals in the US. Survey items included demographic questions as well as Likert scale questions about healthcare providers' perceptions and behaviors related to SDOH. Descriptive statistics were calculated, and further analyses were conducted using t-tests and analysis of variance., Results: A total of 563 respondents completed the survey, with the majority being male (72.6%), White (81%), and located in urban areas (82.2%). In terms of perceptions, most providers agreed or strongly agreed that SDOH affect the health outcomes of all patients (68.5%), while only 24.1% agreed or strongly agreed that their healthcare setting was set up to address SDOH. In terms of behavior, fewer than half currently screened for SDOH (48.6%) or addressed (42.7%) SDOH in other ways. Most providers (55.7%) wanted additional resources to focus on SDOH. Statistical analyses showed significant differences by gender, with females being more likely than males to prioritize SDOH, and by specialty, with psychiatrists, pediatricians, and family/general medicine practitioners being more likely to prioritize SDOH., Conclusion: Most healthcare providers understand the connection between unmet social needs and their patients' health, but they also feel limited in their ability to address these issues. Ongoing efforts to improve medical education and shift the healthcare system to allow for payment and delivery of more holistic care that considers SDOH will likely provide new opportunities for healthcare providers. In addition to what they can do at the institutional and patient levels, providers have the potential to advocate for policy and system changes at the societal level that can better address the root causes of social issues., (© 2024. The Author(s).)

Background and Objectives: Proficiency in procedural care achieved during residency is a major driver of family physician scope of practice. To date, no inventory exists of the advanced procedures and clinical skills performed by teaching family physicians. This study comprises the first such survey and assesses the attitude of respondents toward the importance of family physicians performing procedures., Methods: We sent a clinical skills inventory to a convenience sample of teaching family physicians employed at 18 medical school-affiliated, community, and military residency programs across the United States., Results: The overall response rate was 46% (N=337). Respondents performed a median of 12 advanced procedures and clinical skills (IQR: 8-18). Endorsed procedures ranged from skin biopsy (n=316, 93.8%) and joint injection (n=279, 82.8%) to colonoscopy (n=21, 6.2%) and cesarean delivery (n=23, 6.8%), and reported skills ranged from medication-assisted treatment (n=181, 53.7%) to highly active antiretrovial therapy (n=35, 10.4%). Gender and career stage were associated with statistically significant differences in endorsement of specific procedures. For example, fracture management was more likely to be performed by late- versus early-career faculty (54.1% vs 24.2%, P&lt;.001) and by male versus female respondents (54.9% vs 24.2%, P&lt;.001). Most respondents (84.3%) agreed that future family physicians should learn procedures and advanced clinical skills., Conclusions: Family medicine teaching faculty perform a wide array of procedures and advanced skills. Apparent differences by career stage and gender identity in the performance of some of the procedural and skill areas may portend a shift in the procedural training of future family physicians.

Objective: Presumptive recommendations that assume parents want to vaccinate can increase human papillomavirus (HPV) vaccine uptake. We sought to examine how visit characteristics affect health care professionals' (HCPs) intention to use this evidence-based recommendation style., Methods: In 2022, we conducted an online experiment with 2527 HCPs who had a role in adolescent vaccination in the United States. Participants read 1 of 8 randomly assigned vignettes about a well-child visit. Using a 2 × 2 × 2 between-subjects factorial design, the vignettes varied the following visit characteristics: patient age (9 vs. 12-year-old), prior parental vaccine refusal (yes vs. no), and time pressure on the HCP (low vs. high). HCPs reported on their intention to use a presumptive HPV vaccine recommendation, as well as on related attitudes, subjective norms, and self-efficacy. Analyses used 3-way analysis of variance and parallel mediation., Results: Participants were pediatricians (26%), family/general medicine physicians (22%), advanced practitioners (24%), and nursing staff (28%). Overall, about two-thirds of HCPs (64%) intended to use a presumptive recommendation. Intentions were higher for older children (b = 0.23) and parents without prior vaccine refusal (b = 0.39, both p < 0.001). Time pressure had no main effect or interactions. HCPs' attitudes and self-efficacy partially mediated effects of patient age and prior vaccine refusal (range of b = 0.04-0.28, all p < 0.05)., Conclusion: To better support visits with younger children and parents who have refused vaccines, HCPs may need more training for making presumptive recommendations for HPV vaccine. Reinforcing positive attitudes and self-efficacy can help HCPs adopt this evidence-based recommendation style., Competing Interests: Declaration of Competing Interest Noel T. Brewer has served as a paid advisor for the Centers for Disease Control and Prevention, Merck & Co., Moderna, Novavax, Sanofi, and the World Health Organization. Sachiko Ozawa has received funding through the Merck Investigator Studies Program. The remaining authors declare no potential conflicts of interest., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: Over half of infant boys born in the United States undergo newborn circumcision. However, available data indicate that boys who are publicly insured, or Black/African American, have less access to desired newborn circumcision, thus concentrating riskier, more costly operative circumcision among these populations. This study ascertains perinatal physician perspectives about barriers and facilitators to providing newborn circumcisions, with a goal of informing future strategies to ensure more equitable access., Methods: Qualitative interviews about newborn circumcision care were conducted from April-June 2020 at eleven Chicago-Area hospitals. Physicians that provide perinatal care (pediatricians, family medicine physicians, and obstetricians) participated in qualitative interviews about newborn circumcision. Inductive and deductive qualitative coding was performed to identify themes related to barriers and facilitators of newborn circumcision care., Results: The 23 participating physicians (78% female, 74% white, median 16 years since medical school graduation [range 5-38 years], 52% hospital leadership role, 78% currently perform circumcisions) reported multiple barriers including difficulty with procedural logistics and inconsistent clinician availability and training; corresponding suggestions for operational improvements were also provided. Regarding newborn circumcision insurance coverage and reimbursement, physicians reported limited knowledge, but noted that some insurance reimbursement policies financially disincentivize clinicians and hospitals from offering inpatient newborn circumcision., Conclusions: Physicians identified logistical/operational, and reimbursement-related barriers to providing newborn circumcision for desirous families. Future studies and advocacy work should focus on developing clinical strategies and healthcare policies to ensure equitable access, and incentivize clinicians/hospitals to perform newborn circumcisions., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Transient ischemic attacks (TIA), as precursors of cerebral strokes, occupy an important place among all forms of cerebrovascular insufficiency. Regarding epidemiology of transient ischemic attacks (TIA), there are no accurate data in most countries. In the United States, up to 5 million adult citizens per year suffer from these episodes, many TIA remain undiagnosed. These episodes of a sudden and short-term neurological deficit have long been considered as benign and harmless. Most general practitioners and patients misunderstand or insufficiently understand TIA's nature and significance, perhaps, this is the reason of insufficient medical interest, lack of statistical data on this nosological unit. Transient ischemic attacks (TIA) are clinically defined as rapidly developing focal and sometimes diffuse (cerebral) dysfunctions of the brain that are caused by local ischemia and last no longer than a day1. Over the past two decades, many views on TIA have changed significantly, approaches to the diagnosis and treatment of patients have become much more intense and aggressive. Modern knowledge about TIA is of paramount importance both for proper organization of patient care and educational programs among the population; their importance can hardly be overestimated. [ABSTRACT FROM AUTHOR]

Supplement sponsors: American Academy of Family Physicians; American College of Nurse-Midwives; American College of Obstetricians and Gynecologists; and Association of Women's Health, Obstetric and Neonatal Nurses [ABSTRACT FROM AUTHOR]

People with type 1 diabetes may receive a significant portion of their care from primary care providers (PCPs). To understand the involvement of PCPs in delivering type 1 diabetes care, we performed surveys in California and Florida, two of the most populous and diverse states in the United States. PCPs fill insulin prescriptions but report low confidence in providing type 1 diabetes care and difficulty accessing specialty referrals to endocrinologists. [ABSTRACT FROM AUTHOR]

Purpose: General practitioners (GPs) are part of the US physician workforce, but little is known about who they are, what they do, and how they differ from family physicians (FPs). We describe self-identified GPs and compare them with board-certified FPs.Methods: Analysis of data on 102,604 Doctor of Medicine and Doctor of Osteopathy physicians in direct patient care in the United States in 2016, who identify themselves as GPs or FPs. The study used linking databases (American Medical Association Masterfile, American Board of Family Medicine [ABFM], Area Health Resource File, Medicare Public Use File) to examine personal, professional, and practice characteristics.Results: Of the physicians identified, 6,661 self-designated as GPs and 95,943 self-designated as FPs. Of the self-designated GPs, 116 had been ABFM certified and were excluded from the study. Of the remaining 102,488 physicians, those who self-designated as GPs but were never ABFM certified constituted the GP group (n = 6,545, 6%). Self-designated FPs that were ABFM certified made up the FP group (n = 79,449, 78%). The remaining self-designated FPs not ABFM certified constituted the uncertified group (n = 16,494, 16%). GPs differed from FPs in every characteristic examined. Compared with FPs, GPs are more likely to be older, male, Doctors of Osteopathy, graduates of non-US medical schools, and have no family medicine residency training. GPs practice location is similar to FPs, but GPs are less likely to participate in Medicare or to work in hospitals.Conclusions: GPs in the United States are a varied group that differ from FPs. Researchers, educators, and policy makers should not lump GPs together with FPs in data collection, analysis, and reporting. [ABSTRACT FROM AUTHOR]

Rationale and objective: To evaluate the relationship between receipt of annual physicals and the receipt of provider recommendation for preventive services, during a period when Medicare did not cover annual physicals (before 2011). Methods: Electronic medical records of patients aged 65 years and older from a US health care system were extracted for the 2001 to 2007 period. A fixed‐effects logistic model was used to assess the relationship between receipt of periodic health examination (PHE) and receipt of provider recommendation for mammogram screening for 6466 female Medicare beneficiaries. Logistic regression models were used to assess the relationship between receipt of PHE and receipt of provider recommendation for colonoscopy screening and pneumococcal vaccination for 10 318 Medicare beneficiaries. Nine primary care providers from the network were also interviewed, selected by random sampling stratified by care model. Results: Electronic medical record analyses suggest that patients with a PHE were more likely to obtain provider recommendations for mammogram screening (OR = 2.17, P < 0.0001), colonoscopy screening (OR = 1.54, P < 0.0001), and pneumococcal vaccination (OR = 1.10, P < 0.0001). Providers suggested that prevention care quality improves with the PHE because certain screening measures (eg, skin cancer screening, breast exam) would be neglected without it, and healthy patients could miss recommended preventive services entirely. Without the PHE, some providers reported having tried to incorporate discussions of preventive services by scheduling more frequent follow‐up chronic care visits than they would have otherwise, and some routinely charged Medicare for a more complex follow‐up visit than they would have charged without the preventive service discussions. Conclusion: Periodic health examination is important in connecting patients to recommended preventive services. Provider interviews suggested that, indirectly, Medicare ended up paying for the PHE via greater frequency of follow‐up visits or higher visit charges from providers integrating the services with other visits. [ABSTRACT FROM AUTHOR]

Assesses cardiac rehabilitation programs and practitioners in California. Courses applicable to the practice Importance of interpersonal skills and general clinical experience on practitioners; Implications for staffing decisions.

Introduction: The prescribing of opioids has increased internationally in developed countries in recent decades within primary and secondary care. The majority of patients with chronic non-malignant pain (CNMP) are managed by their general practitioner (GP). Recent qualitative studies have examined the issue of opioid prescribing for CNMP from a GP viewpoint. The aim of this study is to identify and synthesise the qualitative literature describing the factors influencing the nature and extent of opioid prescribing by GPs for patients with CNMP in primary care. Methods: MEDLINE, Embase, PsycINFO, Cochrane Database, International Pharmaceutical Abstracts, Database of Abstracts of Reviews of Effects, CINAHL and Web of Science were systematically searched from January 1986 to February 2018. The full text of included articles was reviewed using the Critical Appraisal Skills Programme (CASP) tool for qualitative research. The papers were coded by two researchers and themes organised using Thematic Network Analysis. Themes were constructed in a hierarchical manner, basic themes informed organising themes which informed global themes. A theoretical model was derived using global themes to explain the interplay between factors influencing opioid prescribing decisions. Results: From 7020 records, 21 full text papers were assessed, and 13 studies included in the synthesis; 9 were from the United States, 3 from the United Kingdom and 1 from Canada. Four global themes emerged: suspicion, risk, agreement and encompassing systems level factors. These global themes are inter-related and capture the complex decision-making processes underlying opioid prescribing whereby the physician both consciously and unconsciously quantifies the risk–benefit relationship associated with initiating or continuing an opioid prescription. Conclusion: Recognising the inherent complexity of opioid prescribing and the limitations of healthcare systems is crucial to developing opioid stewardship strategies to combat the rise in opioid prescription morbidity and mortality. [ABSTRACT FROM AUTHOR]

Promoting safe firearm storage in pediatric primary care is one way to address youth suicide by firearm. The study objective was to determine the perspectives of primary care physicians (PCPs) and leaders of primary care practices regarding the acceptability and use of screening, counseling, and firearm locks—all components of an adapted evidence-based intervention known as the Firearm Safety Check. In 2016, an online survey was conducted in two large US health systems. PCPs (n = 204) and leaders (n = 57) from 83 clinics were invited to participate. Respondents included 71 clinics (86%), 103 PCPs (50%), and 40 leaders (70%). Main outcomes included acceptability (6-point Likert scale, with higher scores indicating better acceptability) and use of the 3 intervention components (4-point Likert scale, with higher scores indicating greater use), as measured by an adapted validated instrument. Analyses were conducted in 2017. PCP acceptability of screening (mean = 4.28; standard deviation [SD] = 1.12) and counseling (mean = 4.56; SD = 0.89) were high, but acceptability for firearm lock provision was more neutral (mean = 3.78; SD = 1.16). Most PCPs endorsed sometimes screening (85%) and counseling (80%). Few PCPs offered firearm locks to caregivers (15%). Leaders reported consistent information. The acceptability of screening for firearms and safe storage counseling was high; both components were used commonly but not routinely. The acceptability of providing firearm locks was neutral, and use was rarely endorsed. This study provides important insights about areas of focus for future implementation efforts from policy and research perspectives. [ABSTRACT FROM AUTHOR]

General dentists (GDs) have the opportunity to examine their patients for oral premalignancy/malignancy. We estimated the annualized per dentist number of oral lesions suspicious for premalignancy/malignancy discovered by United States (U.S.) general dentists and the annualized per dentist number of histologically-confirmed cancers subsequently diagnosed. Eligible participants were licensed, clinically-active U.S. GDs who were members of the U.S. National Dental Practice-Based Research Network. An a priori sample size of 900 was determined; 2000 GDs were invited to participate; 1,073 completed the study. Self-reported, cross-sectional data were obtained via an online questionnaire during 4/12/2017-8/31/2017 and analyzed. The reported numbers of suspicious oral lesions and histologically-confirmed oral cancer cases diagnosed over the previous six months were quantified. Potential outcome predictors were evaluated as covariates in multivariable analyses. Crude and adjusted statistics were produced by regressing each outcome on each independent variable while assuming a Poisson distribution, log link and utilizing robust standard errors. Eighty-seven percent of dentists reported discovering 1+ lesion suspicious for oral premalignancy/malignancy during the preceding six months. The mean number of suspicious lesions/dentist/year was 9.5; adjusted mean: 9.6. Fifteen percent of participants reported discovering 1+ lesion confirmed as cancer during the same period, 213 confirmed cancer cases/6 months or 426/year. Crude and adjusted mean numbers of histologically-confirmed oral cancers were both 0.4 cancers/dentist/year. Our findings suggest that many U.S. general dentists are actively identifying oral lesions suspicious for premalignancy/malignancy, thereby aiding in the discovery of oral malignancies and representing an important component in the frontline against cancer. [ABSTRACT FROM AUTHOR]

Context: Medical educators in the USA are interested in the ways medical students make career choices because shortages in key specialties, particularly primary care specialties, limit access to care. Although anticipated specialty income is a strong predictor of student interest, no studies have qualitatively explored the reasons why income is important to students. By better understanding students' perspectives on income and specialty choice, educators can help students make choices that fit their goals and better educate students about the specialties in which the need for expansion is greatest. Methods: In 2012, Year‐2 students at one USA medical school were invited to write an essay about how debt and anticipated income levels influence their career choices. A total of 132 essays (response rate: 67%) were qualitatively analysed using a hermeneutic phenomenology approach to conventional content analysis, in which themes emerge inductively from the data. Researchers employed peer debriefing, modified member checking, thick description, code–recode strategies, audit trails and reflexivity to ensure quality and rigour. Although this analysis initially focused on student perceptions of specialty income, prestige also emerged as an important related theme. Results: Three major findings emerged. Income is of varying importance to different students. Students value income because it provides freedom and flexibility, and power and security. Students recognise that high income confers social prestige. Students also define specialty prestige in other ways, including match competitiveness, perceived expertise, opportunities for advancement through fellowships, and power and autonomy. Conclusions: Medical students' perspectives of specialty income, specialty choice and prestige are more complex than previously reported. Medical educators should frame conversations about specialty choices in ways that incorporate varied perspectives on income and prestige. Health policymakers should recognise that income and prestige influence medical students' decisions in complex ways. These insights may inform strategies to counteract shortages in key specialties, including primary care specialties. Income, why do we love thee? Students report that high income influences their career decisions in many ways by providing freedom, flexibility, power, security, and social prestige. [ABSTRACT FROM AUTHOR]

To help health care practices transition away from fee-for-service reimbursement and toward value-based payment, the Transforming Clinical Practice Initiative was launched in October 2015. It was designed to provide clinicians support through peer-based Practice Transformation Networks (PTNs). A group of American Board of Family Medicine board-certified family physicians enrolled in PTNs described their expectations of and experiences with PTN participation; we analyzed open-text comments. Physicians expected and experienced PTN support in informatics and data, team building, and workflow and care coordination; however, expectations regarding patient care and engagement, costs and payment reform, and population and panel health were described less frequently. [ABSTRACT FROM AUTHOR]

The diagnostic process for patients presenting with cognitive decline and suspected dementia is complex. Physicians face challenges distinguishing between normal aging, mild cognitive impairment, Alzheimer's disease, and other dementias. Although there is some evidence for improving attitudes towards the importance of prompt diagnosis, there is limited information describing how physicians approach this diagnostic challenge in practice. This was explored in the present study. Across-sectional survey of primary care and specialist physicians, in 5 European countries, Canada, and the United States, was conducted. Participants were asked about their use of cognitive screening tools and diagnostic technologies, as well as the rationales and barriers for use. In total, 1365 physicians participated in the survey, 63% of whom were specialists. Most physicians stated they use objective cognitive tools to aid the early detection of suspected mild cognitive impairment or Alzheimer's disease in patients. The Mini-Mental State Examination was the most common tool used for initial screening; respondents cited speed and ease of use but noted its lack of specificity. Cerebrospinal fluid biomarker and amyloid positron emission tomography tests, respectively, had been used by only 26% and 32% of physicians in the preceding 6 months, although patterns of use varied across countries. The most commonly cited reasons for not ordering such tests were invasiveness (for cerebrospinal fluid biomarker testing) and cost (for amyloid positron emission tomography imaging). Data reported by physicians reveal differences in the approaches to the diagnostics process in Alzheimer's. A higher proportion of primary care physicians in the United States are routinely incorporating cognitive assessment tools into annual visits, but this is due to country differences in clinical practice. The value of screening tools and regular use could be discussed further with physicians; however, lack of specificity associated with cognitive tools and the investment required from patients and the healthcare system are limiting factors. [ABSTRACT FROM AUTHOR]

Importance: Neonatal abstinence syndrome (NAS) has increased over the last 2 decades, but limited data exist on its association with economic conditions or clinician supply.Objective: To determine the association among long-term unemployment, clinician supply (as assessed by primary care and mental health clinician shortage areas), and rates of NAS and evaluate how associations differ based on rurality.Design, Setting, and Participants: Ecological time-series analysis of a retrospective, repeated cross-sectional study using outcome data from all 580 counties in Florida, Kentucky, Massachusetts, Michigan, New York, North Carolina, Tennessee, and Washington from 2009 to 2015 and economic data from 2000 to 2015. Negative binomial models were used with year and county-level fixed effects. Interactions were tested and stratified analyses were conducted by metropolitan counties, rural counties adjacent to metropolitan counties, and rural remote counties.Exposures: County-level 10-year unemployment rate and mental health and primary care clinician supply obtained from the Health Resources and Services Administration Area Health Resources Files.Main Outcomes and Measure: Rates of NAS, excluding iatrogenic withdrawal, obtained from state inpatient databases.Results: The sample included observations from 580 counties over 7 years (1803 county-years from metropolitan counties, 1268 county-years from rural counties adjacent to metropolitan counties, and 927 county-years from rural remote counties). During the study period, there were 6 302 497 births and 47 224 diagnoses of NAS. The median rate of NAS was 7.1 per 1000 hospital births (interquartile range [IQR], 2.2-15.8), the 10-year unemployment rate was 7.6% (IQR, 6.4%-9.0%), and 83.9% of county-years were partial or complete mental health shortage areas. In the adjusted analyses, mental health shortage areas had higher NAS rates (unadjusted rate in shortage areas of 14.0 per 1000 births vs unadjusted rate in nonshortage areas of 10.6 per 1000 births; adjusted incidence rate ratio [IRR], 1.17 [95% CI, 1.07-1.27]), occurring primarily in metropolitan counties (adjusted IRR, 1.28 [95% CI, 1.16-1.40]; P = .02 for test of equivalence between metropolitan counties and rural counties adjacent to metropolitan counties). There was no significant association between primary care shortage areas and rates of NAS. The 10-year unemployment rate was associated with higher rates of NAS (unadjusted rate in highest unemployment quartile of 20.1 per 1000 births vs 7.8 per 1000 births in lowest unemployment quartile; adjusted IRR, 1.11 [95% CI, 1.00-1.23]) occurring primarily in rural remote counties (adjusted IRR, 1.34 [95% CI, 1.05-1.70]; P = .04 for test of equivalence between metropolitan counties and rural remote counties).Conclusions and Relevance: In this ecological analysis of counties in 8 US states, there was a significant association among higher long-term unemployment, higher mental health clinician shortage areas, and higher county-level rates of neonatal abstinence syndrome. [ABSTRACT FROM AUTHOR]

Drug overdose is the leading cause of unintentional injury-associated death in the United States. Among 70,237 fatal drug overdoses in 2017, prescription opioids were involved in 17,029 (24.2%) (1). Higher rates of opioid-related deaths have been recorded in nonmetropolitan (rural) areas (2). In 2017, 14 rural counties were among the 15 counties with the highest opioid prescribing rates.* Higher opioid prescribing rates put patients at risk for addiction and overdose (3). Using deidentified data from the Athenahealth electronic health record (EHR) system, opioid prescribing rates among 31,422 primary care providers† in the United States were analyzed to evaluate trends from January 2014 to March 2017. This analysis assessed how prescribing practices varied among six urban-rural classification categories of counties, before and after the March 2016 release of CDC's Guideline for Prescribing Opioids for Chronic Pain (Guideline) (4). Patients in noncore (the most rural) counties had an 87% higher chance of receiving an opioid prescription compared with persons in large central metropolitan counties during the study period. Across all six county groups, the odds of receiving an opioid prescription decreased significantly after March 2016. This decrease followed a flat trend during the preceding period in micropolitan and large central metropolitan county groups; in contrast, the decrease continued previous downward trends in the other four county groups. Data from EHRs can effectively supplement traditional surveillance methods for monitoring trends in opioid prescribing and other areas of public health importance, with minimal lag time under ideal conditions. As less densely populated areas appear to indicate both substantial progress in decreasing opioid prescribing and ongoing need for reduction, community health care practices and intervention programs must continue to be tailored to community characteristics. [ABSTRACT FROM AUTHOR]

This study analyzes trends in the distribution of nurse practitioners and primary care physicians in low-income and rural areas. [ABSTRACT FROM AUTHOR]

Mental illness is a significant cause of disability worldwide, including here in the United States. Given the shortage of trained mental health professionals, a significant portion of patients needing care are managed in the primary care setting. Accountable Care Organizations (ACOs), for example, are seeking to improve the quality of care for this vulnerable population, but many are facing significant challenges relating to integration of new services. We sought to elucidate barriers faced by primary care practitioners (PCPs)—physicians, physician trainees and nurse practitioners—at a New York primary care clinic, which impede delivery of optimal care to those suffering from mental illness. The study was conducted with 32 PCPs in 2016-2017 at Mount Sinai Internal Medicine Associates in New York City. For the quantitative component of the study, a 54-item questionnaire was devised to assess their attitude, behavior and confidence in managing psychiatric patients. For the qualitative component, data was obtained from 3 open-ended questions. Responses were coded for salient themes. Analysis revealed a range of difficulties faced by PCPs. Overall, participants felt that the need to integrate mental health care into primary care was important, however they reported significant barriers in terms of lack of time, lack of resources, low confidence in treating more complex mental health conditions and difficulties with referring patient to mental health specialists. Despite a growing body of evidence that integration of mental health services in primary care leads to improved outcomes, addressing barriers to care will be key to ensuring feasibility of integration measures. [ABSTRACT FROM AUTHOR]

An editorial is presented which discusses the role of family physicians in the prevention of gun violence in the U.S. Topics include the paper developed by the American Academy of Family Physicians (AAFP), encouraging public health approach to prevent the violence, the increase in the number of gun homicides in the country, and the importance of motivational interviewing and counseling in reducing firearm access and improving the rates of safe gun storage.

The article presents a guide for offering medication-assisted treatment (MAT) for opioid use disorder in the office with buprenorphine. Topics discussed include buprenorphine's effectiveness as an alternative to methadone, and the first step of training and obtaining a waiver for its prescription. Also noted are the required practice champion identification, setting up of office protocols with readiness and security of pharmacy, laboratory, and counselling services, and creation of a workflow.

Women involved in the criminal justice system (WICJ) are at high risk of acquiring HIV and would benefit from HIV pre-exposure prophylaxis (PrEP) but there are no studies in this population to inform PrEP implementation programs. We conducted a cross-sectional survey of HIV-uninfected, cis-gender women on probation, parole and/or recently released from prison/jail to assess PrEP awareness, eligibility, potential barriers to uptake, and the PrEP care continuum. The 125 WICJ surveyed reported high rates of HIV risk behaviors including recent transactional sex (22.4%) and unsafe injection practices (14.4%). Despite 33% (n = 42) meeting eligibility criteria for PrEP, only 25% were aware of PrEP and one person was currently using it. Just 16.7% of those who were PrEP eligible perceived they were at risk for HIV. Following a brief explanation of PrEP, 90% said they would try it if recommended by their physician. Compared to those not PrEP eligible (n = 83), PrEP eligible women were less likely to be stably housed or have a primary care provider, and were more likely to be violence-exposed, charged with drug possession, have lifetime substance use, or living with Hepatitis C infection. WICJ frequently engage in HIV risk behaviors that make them eligible for PrEP. Uptake may be limited by lack of PrEP awareness or underestimation of personal HIV risk. WICJ report receptiveness to PrEP and represent an important population for targeted PrEP implementation programs. [ABSTRACT FROM AUTHOR]

The conventional wisdom that the United States has an imbalance of specialty and generalist physicians is supported by data from the Organisation for Economic Co-operation and Development (OECD), which show that just 12 percent of physicians in the United States are generalists and 88 percent are specialists. While it is undisputed that US physicians can choose to train in a striking array of medical specialties and subspecialties not seen elsewhere, the perception that the United States has a specialty-dominated workforce is not accurate. The US definition of generalist does not fit the OECD definition because the OECD considers only family and general practitioners as generalists. OECD numbers reinforce a tendency to define primary care as family and general practitioners, without recognizing the diversity of generalist physicians providing care. In addition, while other countries may have had more generalists that fit the OECD definition, many countries have seen a relative decline in the share of generalists that is slowly reshaping the generalist-specialty balance elsewhere. These two factors, along with changing international benchmarks against which the United States is compared, support the reassessment of the conventional wisdom. [ABSTRACT FROM AUTHOR]

The author conveys his thoughts about an argument by Miriam J. Laugesen on primary care in the U.S. Laugesen's analysis of physician workforce data suggests that 37 percent of local physicians offer primary care. The author said organizational arrangements are vital in assuring that patients have a medical home as the first point of entry. Laugesen noted the importance of social care in Germany and the Netherlands.

An introduction to the journal is presented that focuses on issues related to the U.S. health care system, including an allegation that the U.S. health care system is replete with waste, the evolution of public health in the U.S., France, and England, and the international standing of the U.S. on infant mortality.

Objectives: To characterize antibiotics prescribed to older adults to guide efforts to improve antibiotic use. Design: Descriptive analysis. Setting: Ambulatory. Participants: Adults aged 65 and older in the United States. Measurements: Information on outpatient antibiotic prescriptions dispensed for older adults from 2011 to 2014 was extracted from the IQVIA Xponent database. A chi‐square trend analysis was conducted to assess annual changes in antibiotic prescribing rates. A descriptive analysis of prescribing rates by antibiotic, age group, sex, state, Census region, and provider specialty was conducted. Results: From 2011 to 2014, outpatient antibiotic prescribing rates remained stable in older U.S. adults (P =.89). In 2014, older adults were dispensed 51.6 million prescriptions (1,115 prescriptions/1,000 persons). Persons aged 75 and older had a higher prescribing rate (1,157 prescriptions/1,000 persons) than those aged 65 to 74 (1,084 prescriptions/1,000 persons). Prescribing rates were highest in the South 1228 prescriptions/1,000 persons) and lowest in the West (854 prescriptions/1,000 persons). The most commonly prescribed class was quinolones, followed by penicillins and macrolides. Azithromycin was the most commonly prescribed drug, followed by amoxicillin and ciprofloxacin. Internists and family physicians prescribed 43% of antibiotic courses. Conclusion: On average, in 2014, U.S. adults aged 65 and older received enough outpatient antibiotic courses for every older adult to receive at least 1. Quinolones and azithromycin are potential targets for assessing the appropriateness of antibiotic prescribing in this population. Interventions to improve use targeting internists and family physicians in the South Census region might have the potential to have the greatest effect. [ABSTRACT FROM AUTHOR]