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PURPOSE Despite being key to better health outcomes for patients from racial and ethnic minority groups, the proportion of underrepresented in medicine (URiM) physicians remains low in the US health care system. This study linked a nationally representative sample of family physicians (FPs) with Medicaid claims data to explore the relative contributions to care of Medicaid populations by FP race and ethnicity. METHODS This descriptive cross-sectional study used 2016 Medicaid claims data from the Transformed Medicaid Statistical Information System and from 2016-2017 American Board of Family Medicine certification questionnaire responses to examine the diversity and Medicaid participation of FPs. We explored the diversity of FP Medicaid patient panels and whether they saw [greater than or equal to]150 beneficiaries in 2016. Using logistic regression models, we controlled for FP demographics, practice characteristics, and characteristics of the communities in which they practiced. RESULTS Of 13,096 FPs, Latine, Hispanic, or of Spanish Origin (LHS) FPs and non- LHS Black FPs saw more Medicaid beneficiaries compared with non-LHS White and non-LHS Asian FPs. The patient panels of URiM FPs had a much greater proportion of Medicaid beneficiaries from racial and ethnic minority groups. Overall, non-LHS Black and LHS FPs had greater odds of seeing [greater than or equal to]150 Medicaid beneficiaries in 2016. CONCLUSIONS These findings clearly show the critical role URiM FPs play in caring for Medicaid beneficiaries, suggesting physician race and ethnicity are correlated with Medicaid participation. Diversity in the health care workforce is essential for addressing racial health inequities. Policies need to address problems in pathways to medical education, including failures to recruit, nurture, and retain URiM students. Key words: health workforce diversity; Medicaid; racial health inequities, https://doi.org/10.1370/afm.3140 INTRODUCTION Despite evidence supporting the positive effects of workforce diversity on equity in scientific investigation and access to care, racial disparities are persistent in the composition of the US [...]

PURPOSE The COVID-19 pandemic not only exacerbated existing disparities in health care in general but likely worsened disparities in access to primary care. Our objective was to quantify the nationwide decrease in primary care visits and increase in telehealth utilization during the pandemic and explore whether certain groups of patients were disproportionately affected. METHODS We used a geographically diverse primary care electronic health record data set to examine the following 3 outcomes: (1) change in total visit volume, (2) change in in-person visit volume, and (3) the telehealth conversion ratio defined as the number of pandemic telehealth visits divided by the total number of prepandemic visits. We assessed whether these outcomes were associated with patient characteristics including age, gender, race, ethnicity, comorbidities, rurality, and area-level social deprivation. RESULTS Our primary sample included 1,652,871 patients from 408 practices. During the pandemic we observed decreases of 7% and 17% in total and in-person visit volume and a 10% telehealth conversion ratio. The greatest decreases in visit volume were observed among pediatric patients (-24%), Asian patients (-11%), and those with more comorbidities (-9%). Telehealth usage was greatest among Hispanic or Latino patients (17%) and those living in urban areas (12%). CONCLUSIONS Decreases in primary care visit volume were partially offset by increasing telehealth use for all patients during the COVID-19 pandemic, but the magnitude of these changes varied significantly across all patient characteristics. These variations have implications not only for the long-term consequences of the COVID-19 pandemic, but also for planners seeking to ready the primary care delivery system for any future systematic disruptions. Key words: COVID-19; access to primary care; telemedicine; primary health care https://doi.org/10.1370/afm.3134, INTRODUCTION Primary care is the largest platform for health care delivery in the United States, (1) and an adequate supply of primary care physicians is associated with positive and more [...]

PURPOSE COVID-19 is a condition that can lead to other chronic conditions. These conditions are frequently diagnosed in the primary care setting. We used a novel primary care registry to quantify the burden of post-COVID conditions among adult patients with a COVID-19 diagnosis across the United States. METHODS We used the American Family Cohort, a national primary care registry, to identify study patients. After propensity score matching, we assessed the prevalence of 17 condition categories individually and cumulatively, comparing patients having COVID-19 in 2020-2021 with (1) historical control patients having influenza-like illness in 2018 and (2) contemporaneous control patients seen for wellness or preventive visits in 2020- 2021. RESULTS We identified 28,215 patients with a COVID-19 diagnosis and 235,953 historical control patients with influenza-like illness. The COVID-19 group had higher prevalences of breathing difficulties (4.2% vs 1.9%), type 2 diabetes (12.0% vs 10.2%), fatigue (3.9% vs 2.2%), and sleep disturbances (3.5% vs 2.4%). There were no differences, however, in the postdiagnosis monthly trend in cumulative morbidity between the COVID-19 patients (trend = 0.026; 95% CI, 0.025-0.027) and the patients with influenza- like illness (trend = 0.026; 95% CI, 0.023-0.027). Relative to contemporaneous wellness control patients, COVID-19 patients had higher prevalences of breathing difficulties and type 2 diabetes. CONCLUSIONS Our findings show a moderate burden of post-COVID conditions in primary care, including breathing difficulties, fatigue, and sleep disturbances. Based on clinical registry data, the prevalence of post-COVID conditions in primary care practices is lower than that reported in subspecialty and hospital settings. Key words: long COVID; post-COVID conditions; post-infectious disorders; primary health care; family practice; chronic illness; morbidity https://doi.org/10.1370/afm.3131, INTRODUCTION The direct and immediate impact of COVID-19 on the health of the US population has been of generational significance, and the secondary wave of persistent symptoms and new conditions [...]

Robust school-university partnerships can create continuous systems of educator learning that focus on systemic change and the simultaneous renewal of both educators and the organizations within which they work to improve outcomes, opportunities, and access for P-12 students and their teachers. This article is a case of the Project PREP school-university partnership, a complex integrated systems approach towards rethinking recruitment, preparation, support, and development of diverse teachers and leaders. We show how Project PREP has begun to design aligned and enhanced systems for teacher education that embody clinical practice, coaching, and high-quality professional learning for both practicing and future teachers and leaders.

PURPOSE This mixed methods study sought to describe the extent to which family physicians in urban communities serve socially vulnerable patients and to better understand their practices, their challenges, and the structural supports that could facilitate their patient care. METHODS We conducted a quantitative analysis of questionnaire data from 100% of US physicians recertifying for family medicine from 2017 to 2020. We conducted qualitative analysis of in-depth interviews with 22 physician owners of urban, small, independent practices who reported that the majority of their patients were socially vulnerable. RESULTS In 2020, in urban areas across the United States, 19.3% of family physicians served in independent practices with 1 to 5 clinicians, down from 22.6% in 2017. Nearly one-half of these physicians reported that >10% of their patients were socially vulnerable. Interviews with 22 physicians who reported that the majority of their patients were socially vulnerable revealed 5 themes: (1) substantial time spent addressing access issues and social determinants of health, (2) minimal support from health care entities, such as independent practice associations and health plans, and insufficient connection to community-based organizations, (3) myriad financial challenges, (4) serious concerns about the future, and (5) deep personal commitment to serving socially vulnerable patients in independent practice. CONCLUSIONS Small independent practices serving vulnerable patients in urban communities are surviving because deeply committed physicians are making personal sacrifices. Health equity-focused policies could decrease the burden on these physicians and bolster independent practices so that socially vulnerable patients continue to have options when seeking primary care. Key words: primary care; health equity; delivery of health care; independent practice; safety net https://doi.org/10.1370/afm.3068, INTRODUCTION Advancing health equity in the United States requires improved access to high-quality primary care, especially for socially vulnerable populations. (1) For the purpose of the present study, the term [...]

Purpose: The purpose of this study was to determine the association between lens thickness and cataract in participants aged 0 to 5 years. Design: This was a prospective, multicenter, case–control study. Participants: We enrolled 118 participants (171 eyes) aged 0 to 5 years, mean age 14.6 ± 17.0 months, range 0 to 60 months. Methods: Lens thickness was measured on 342 ultrasound biomicroscopy (UBM) images. Main Outcome Measures: Lens thickness; feasibility of lens thickness measurement from UBM images. Results: The mean lens thickness among noncataracts was 3.60 ± 0.17 mm, compared with 3.16 ± 0.61 mm among cataracts (P < 0.0001). Lens thickness

Despite the diversity of the American student population, the current teacher force and cohorts of future teachers are overwhelmingly white women from middle class backgrounds. In addition to the work around race, gender, and disability status, there is a clear need for us to help future teachers reconsider how they think about children experiencing poverty in urban schools and communities. Based on its use in an elementary education foundations course, this article provides a first-person accounting of how the pedagogical tool photovoice helped future teachers critically reflect on their perceptions of students from these backgrounds and offered their professor entry points for knowledge and skill development related to teaching students living in impoverished backgrounds.

Diisoamyl (1R,4S)-7-oxabicyclo[2.2.1]hept-5-ene-2,3-dicarboxylate (2) was prepared by reacting exo-7-oxabicyclo[2.2.1]hept-5-ene-2,3-dicarboxylic anhydride (1) with isoamyl alcohol in the presence of a sulfuric acid catalyst under sonication conditions. Compound 2 was characterized by 1H, 13C NMR, DEPT-135, infrared, and UV-vis spectroscopy. Gas chromatography–mass spectrometry, elemental analysis, and melting point determination were used to assess purity. The structure of compound 2 was also determined by single-crystal X-ray diffraction. It crystallizes in the monoclinic space group P21/c (14) with cell values of a = 15.5647(3) Å, b = 12.8969(2) Å, c = 9.0873(2) Å; β= 99.3920(10)°.

This study examined preservice teacher coursework and experiences related to student trauma, classroom management, and self-care during a junior-year clinical placement (N = 25), as well as through follow-up interviews with a subgroup of participants one year later (N = 8). An inductive, thematic analysis led to the identification of four broad themes related to teacher-student relationships, field-based learning, adopting a philosophy of control versus flexibility, and the professional practice of self-care. All participants observed the impact of trauma in their classrooms, but only a few witnessed trauma-informed strategies that centered relationships and the humanistic side of teaching. Preservice teachers placed in trauma-informed classrooms felt the most prepared to implement trauma-informed strategies, while most preservice teachers questioned their ability to create a positive and responsive space for students who had experienced trauma. Data were used to create a conceptual model of findings to help guide future work with preservice teachers and clinical experiences.

Abstract Background Understanding which patient-reported outcome measures are being collected and utilized in clinical practice and research for patients with neck pain will help to inform recommendations for a core set of measures that provide value to patients and clinicians during diagnosis, clinical decision-making, goal setting and evaluation of responsiveness to treatment. Therefore, the aim of this study was to conduct a review of systematic reviews using a qualitative synthesis on the use of patient-reported outcome measures (PROMs) for patients presenting with neck pain to physical therapy. Methods An electronic search of systematic reviews and guideline publications was performed using MEDLINE (OVID), Embase (Elsevier), CINAHL Complete (EBSCOhost), and Web of Science (Clarivate) databases to identify reviews that evaluated physical therapy interventions or interventions commonly performed by a physical therapist for individuals with neck pain and included at least one patient-reported outcome measure. The frequency and variability in which the outcome measures were reported among the studies in the review and the constructs for which they measured were evaluated. The evaluation of a core set of outcome measures was assessed. Risk of bias and quality assessment was performed using A Measurement Tool to Assess systematic Reviews 2. Results Of the initial 7,003 articles, a total of 37 studies were included in the final review. Thirty-one PROMs were represented within the 37 reviews with eleven patient-reported outcome measures in three or more reviews. The eleven PROMs assessed the constructs of disability, pain intensity, psychosocial factors and quality of life. The greatest variability was found amongst individual measures assessing psychosocial factors. Assessment of psychosocial factors was the least represented construct in the included studies. Overall, the most frequently utilized patient reported outcome measures were the Neck Disability Index, Visual Analog Scale, and Numeric Pain Rating Scale. The most frequently used measures evaluating the constructs of disability, pain intensity, quality of life and psychosocial functioning included the Neck Disability Index, Visual Analog Scale, Short-Form-36 health survey and Fear Avoidance Belief Questionnaire respectively. Overall risk of bias and quality assessment confidence levels ranged from critically low (2 studies), low (12 studies), moderate (8 studies), and high (15 studies). Conclusion This study identified a core set of patient-reported outcome measures that represented the constructs of disability, pain intensity and quality of life. This review recommends the collection and use of the Neck Disability Index and the Numeric Pain Rating Scale or Visual Analog Scale. Recommendation for a QoL measure needs to be considered in the context of available resources and administrative burden. Further research is needed to confidently recommend a QoL and psychosocial measure for patients presenting with neck pain. Other measures that were not included in this review but should be further evaluated for patients with neck pain are the Patient Reported Outcomes Measurement Information System (PROMIS) Physical function, PROMIS Pain Interference and the Optimal Screening for Prediction of Referral and Outcome Yellow Flag (OSPRO-YF) tool.

A comprehensive body of literature has focused on White teachers working in high-poverty schools (Emdin, 2016; Ullucci, 2011) as well as White teachers working with students of color (Brown-Buchanan, 2015; Emdin, 2016; Ladson-Billings, 1995; Milner, 2010). However, limited studies have focused on how teacher candidates connect race and social class with respect to teaching in high-poverty schools and what support they need from teacher preparation programs to successfully teach in schools with both students who are living in poverty and students of color. In this article, the authors share findings from a study exploring how six elementary teacher candidates who completed clinical experiences in high-poverty elementary schools perceive students who attend these schools (Bertrand, 2017). Using semistructured interviews, visual data using "photovoice," and group "photovoice" discussion sessions, they examined the following research questions: (1) How do elementary education teacher candidates perceive students who attend high-poverty schools? and (2) What do teacher candidates believe they will need from their teacher preparation program to feel prepared to teach in high-poverty elementary schools? Drawing on critical race theory (CRT; Delgado & Stefancic, 2017), and specifically the concept of intersectionality, the authors attempt to disrupt deficit discourses of students living in poverty. Based on their findings, they discuss approaches within teacher education coursework and clinical practice for supporting teacher candidates in feeling prepared to teach in high-poverty schools

PURPOSE Interpersonal continuity has been shown to play an essential role in primary care's salutary effects. Amid 2 decades of rapid evolution in the health care payment model, we sought to summarize the range of peer-reviewed literature relating continuity to health care costs and use, information critical to assessing the need for continuity measurement in value-based payment design. METHODS After comprehensively reviewing prior continuity literature, we used a combination of established medical subject headings (MeSH) and key words to search PubMed, Embase, and Scopus for articles published between 2002 and 2022 on 'continuity of care' and 'continuity of patient care,' and payor-relevant outcomes, including cost of care, health care costs, cost of health care, total cost of care, utilization, ambulatory care-sensitive conditions, and hospitalizations for these conditions. We limited our search to primary care key words, MeSH terms, and other controlled vocabulary, including primary care, primary health care, family medicine, family practice, pediatrics, and internal medicine. RESULTS Our search yielded 83 articles describing studies that were published between 2002 and 2022. Of these, 18 studies having a total of 18 unique outcomes examined the association between continuity and health care costs, and 79 studies having a total of 142 unique outcomes assessed the association between continuity and health care use. Interpersonal continuity was associated with significantly lower costs or more favorable use for 109 of the 160 outcomes. CONCLUSIONS Interpersonal continuity today remains significantly associated with lower health care costs and more appropriate use. Further research is needed to disaggregate these associations at the clinician, team, practice, and system levels, but continuity assessment is clearly important to designing value-based payment for primary care. Key words: continuity of care; primary care; health care costs; health care utilization; measurement; value-based health care; health services; health services research; health services needs and demand; health policy https://doi.org/10.1370/afm.2961, INTRODUCTION Interpersonal continuity of care, defined as the ongoing relationship between the physician and the patient, was labeled a core attribute of high-quality primary care in 2 seminal reports from [...]

Integrating behavioral health into primary care can improve access to behavioral health and patient health outcomes. We used 2017-2021 American Board of Family Medicine continuing certificate examination registration questionnaire responses to determine the characteristics of family physicians who work collaboratively with behavioral health professionals. With a 100% response rate, 38.8% of 25,222 family physicians reported working collaboratively with behavioral health professionals, with those working in independently owned practices and in the South having substantially lower rates. Future research exploring these differences could help develop strategies to support family physicians implement integrated behavioral health to improve care for patients in these communities. Key words: behavioral medicine; integration of care; mental health services; primary health care https://doi.org/10.1370/afm.2947, INTRODUCTION The complexity of patients presenting in primary care continues to grow with an estimated 1 in 3 adults in the United States presenting with multiple chronic conditions. (1) The [...]

The artificial intelligence (AI) revolution has arrived for the health care sector and is finally penetrating the far-reaching but perpetually underfinanced primary care platform. While AI has the potential to facilitate the achievement of the Quintuple Aim (better patient outcomes, population health, and health equity at lower costs while preserving clinician wellbeing), inattention to primary care training in the use of AI-based tools risks the opposite effects, imposing harm and exacerbating inequalities. The impact of AI-based tools on these aims will depend heavily on the decisions and skills of primary care clinicians; therefore, appropriate medical education and training will be crucial to maximize potential benefits and minimize harms. To facilitate this training, we propose 6 domains of competency for the effective deployment of AI-based tools in primary care: (1) foundational knowledge (what is this tool?), (2) critical appraisal (should I use this tool?), (3) medical decision making (when should I use this tool?), (4) technical use (how do I use this tool?), (5) patient communication (how should I communicate with patients regarding the use of this tool?), and (6) awareness of unintended consequences (what are the 'side effects' of this tool?). Integrating these competencies will not be straightforward because of the breadth of knowledge already incorporated into family medicine training and the constantly changing technological landscape. Nonetheless, even incremental increases in AI-relevant training may be beneficial, and the sooner these challenges are tackled, the sooner the primary care workforce and those served by it will begin to reap the benefits. https://doi.org/10.1370/afm.2887, INTRODUCTION The artificial intelligence (AI) revolution is here, and primary care clinicians must adapt. (1-3) This call for change follows the years of unrealized promise of electronic health records (EHRs), [...]

Objective The objective of this research was to examine how different measurements of poverty (household-level and neighborhood-level) were associated with asthma care utilisation outcomes in a community health centre setting among Latino, non-Latino black and non-Latino white children.Design, setting and participants We used 2012–2017 electronic health record data of an open cohort of children aged 200% FPL (55%). Overall, neighbourhood poverty (

ObjectiveHousing insecurity has been linked to high-risk behaviors and chronic disease, although less is known about the pathways leading to poor health. We sought to determine whether housing insecurity is associated with access to preventive and primary care.MethodsWe conducted weighted univariate, bivariate, and multivariate analyses by using 2011 to 2015 Behavioral Risk factor Surveillance Survey data (N = 228,131 adults). The independent variable was housing insecurity derived from the question on worry about paying rent or mortgage. The outcome measures were health services utilization (no usual source of care, no routine checkup in the past 1 year, and delayed medical care due to cost), self-rated health (number of days reported physical, mental health not good, and poor overall health), and number of chronic diseases (0, 1, 2 or more). The covariates included age, sex, race/ethnicity, income, level of education, marital status, and number of children in the family. We also adjusted for state fixed effects and survey year. We performed χ2 tests and binary logistic regressions on categorical variables and ran t tests and estimated linear regression models on continuous variables. Multinomial logistic regressions were estimated for the number of chronic diseases.ResultsOf the 228,131 adults in the study sample, 28,704 adults reported housing insecurity. We found that those with housing insecurity were more likely to forgo routine check-ups and lack usual sources of care. Low-income individuals, minorities, the unmarried, and middle-aged adults were more likely to report housing insecurity.ConclusionHousing insecurity is associated with worse access to preventive and primary care. Interventions to enhance access for these patients should be developed and studied.

The recently released National Academies of Sciences, Engineering, and Medicine report counts development of strong and coordinated primary care leadership among the 7 critical facilitators required for the United States [...]

As recent extreme weather events demonstrate, climate change presents unprecedented and increasing health risks, disproportionately so for disadvantaged communities in the U.S. already experiencing health disparities. As patients in these frontline communities live through extreme weather events, socioeconomic and health stressors are compounded; thus, their healthcare teams will need tools to provide precision ecologic medicine approaches to their care. Many primary care teams are taking actionable steps to bring community-level socioeconomic data (“community vital signs”) into electronic medical records, to facilitate tailoring care based on a given patient’s circumstances. This work can be extended to include environmental risk data, thus equipping healthcare teams with an awareness of clinical and community vital signs and making them better positioned to mitigate climate impacts on health. For example, if healthcare teams can easily identify patients who have multiple chronic conditions and live in an urban heat island, they can proactively arrange to “prescribe” an air conditioner, heat pump, and/or air purifier. Or, when a severe storm/heat event/poor air quality event is predicted, they can take preemptive steps to get help to patients at high medical and socioeconomic risk, rather than waiting for them to arrive in the emergency department. Advances in health information technologies now make it technically feasible to integrate a wealth of publicly-available community-level data into EMRs. Efforts to bring this contextual data into clinical settings must be accelerated to equip healthcare teams to provide precision ecologic medicine interventions to their patients.

This article delves into the uniquely layered barriers faced by mixed-race Indigenous college students in campus environments. Observations are provided on how to decolonize our practices to better support their identity development and inclusion.

Diisoamyl (1R,4S)-7-oxabicyclo[2.2.1]hept-5-ene-2,3-dicarboxylate (2) was prepared by reacting exo-7-oxabicyclo[2.2.1]hept-5-ene-2,3-dicarboxylic anhydride (1) with isoamyl alcohol in the presence of a sulfuric acid catalyst under sonication conditions. Compound 2 was characterized by 1H, 13C NMR, DEPT-135, infrared, and UV-vis spectroscopy. Gas chromatography–mass spectrometry, elemental analysis, and melting point determination were used to assess purity. The structure of compound 2 was also determined by single-crystal X-ray diffraction. It crystallizes in the monoclinic space group P21/c (14) with cell values of a = 15.5647(3) Å, b = 12.8969(2) Å, c = 9.0873(2) Å; β= 99.3920(10)°. [ABSTRACT FROM AUTHOR]

Some institutions have incorporated Indigenous Student Affairs (ISA) programs as an approach to retaining Indigenous college students--but how well do we understand and support ISA work? We interviewed six ISA directors at PWIs across the United States about their roles and experiences on campus and focus on a theme of how the directors' work is understood and supported within the institutional context of their campuses. We found that while ISA supports increased Indigenous student retention, PWIs still create institutional barriers for both ISA directors and their work. Implications show many potential methods of improvement.

BackgroundResearch ethics guidelines and emphasis on representation in research guide the inclusion of marginalized groups, including people with perinatal opioid use disorders (OUD) and people experiencing incarceration in the United States. However, insights from participants regarding the risks and benefits of participation are not adequately considered. The aim of this study was to examine the risks and benefits of research participation from the perspective of pregnant/postpartum people with OUD who have experienced incarceration.DesignWe recruited people who had experience with perinatal incarceration and were either currently pregnant or postpartum, and at least 18 years old. All participants met the clinical criteria for OUD. Our study did not have exclusion criteria based on gender, race, or ethnicity.SettingParticipants were either currently incarcerated at the North Carolina Correctional Institute for Women in Raleigh, North Carolina, United States or had previously experienced perinatal incarceration and were recruited from a perinatal substance use disorder treatment program located in North Carolina.ParticipantsBetween 9/2021-4/2022, we completed 12 interviews with pregnant/postpartum people with OUD, approximately half who were currently incarcerated and half with a recent history of perinatal incarceration.Intervention/measurementInterviews were conducted via Webex phone or video. The interviews followed a scripted interview guide and lasted one hour on average. Interview transcripts were analyzed using the Rigorous and Accelerated Data Reduction technique to produce an overarching thematic framework.FindingsOur analysis identified benefits, including the personal advantage of self-expression, helping others and contributing to change, and financial incentives. Risks included stigma and breach of confidentiality, misunderstanding of the distinction between research and advocacy, and limited ability to share their whole experience.ConclusionsParticipant-identified benefits of research mirrored those from other marginalized populations, though participant-identified risks were novel and nuanced. Recruitment and consent should move beyond normative research ethics committees protocol language to consider the perspectives of participants.

Objective: To learn from primary health care experts’ experiences from the COVID-19 pandemic across countries. Methods: We applied qualitative thematic analysis to open-text responses from a multinational rapid response survey of primary health care experts assessing response to the initial wave of the COVID-19 pandemic. Results: Respondents’ comments focused on three main areas of primary health care response directly influenced by the pandemic: 1) impact on the primary care workforce, including task-shifting responsibilities outside clinician specialty and changes in scope of work, financial strains on practices, and the daily uncertainties and stress of a constantly evolving situation; 2) impact on patient care delivery, both essential care for COVID-19 cases and the non-essential care that was neglected or postponed; 3) and the shift to using new technologies. Conclusions: Primary health care experiences with the COVID-19 pandemic across the globe were similar in their levels of workforce stress, rapid technologic adaptation, and need to pivot delivery strategies, often at the expense of routine care.