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

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

Objectives: Patient satisfaction remains a critical tool for assessing quality of care in the emerging context of patient-centered care. The objective of this study was to assess patient satisfaction with services received at a tertiary family medicine clinic in Calabar, Nigeria. Material and Methods: This was a cross-sectional descriptive study with data collected from 208 adults by systematic random sampling using a validated self-administered patient satisfaction questionnaire-46. Data were analyzed using SPSS version 18. Results: Most respondents (188, 90.4%) were generally satisfied with overall services. Highest prevalence of satisfaction was with doctors (95.7%), while least prevalence of satisfaction was with facility (27.9%). Satisfaction with nurses and appointment each had prevalence rate of 69.2%, while 65.9% were satisfied with access to care. Proportionally, subjects who were satisfied with each of the five domains access, doctors and nurses care, appointment, and facility were also satisfied generally and vice versa (P < 0.05). Conclusion: In conclusion, a significant proportion of patients were satisfied with services received at the family medicine clinic. The level of patient satisfaction was dependent on the entire chain of service delivery. Patient satisfaction could be further improved by improving the five domains assessed, especially the condition of care environment at the clinic. Findings of this study may contribute significantly to improved patient care, add to existing local literature and further studies.

Background: Diabetes mellitus is a chronic illness that represents a global issue and requires continuous therapy to manage the disease effectively. Adherence to diabetes medication is necessary to maintain the blood glucose level and avoid the consequence of hyperglycemia. Adherence among patients is low, and this low level of adherence is associated with several factors. The present study was aimed at investigating the patients’ factors affecting adherence to diabetic medication. Methodology: This cross-sectional study enrolled diabetic patients using an online questionnaire from August to October 2020. The questionnaire assessed the socio-demographic, clinical characteristics, health literacy, and medication adherence of the patients. Results: Two hundred fifty diabetic patients participated in this study; the mean ± SD of patients was 50 ± 8.1 years old. 39.2% reported four times medication per day; the most common oral and injected medications were alpha-glucosidase inhibitors (35.2%) and glucagon-like peptide1-receptor agonists (33.65), respectively. There were 68% subjects who had inadequate health literacy, and 64.4% had low adherence to diabetes medication. Conclusion: There were low health literacy and low adherence to diabetes medication among diabetic patients; improvement of patients’ health literacy is necessary to increase their medication adherence.

This 3-month quality improvement project, conducted in a Genesee County, Michigan, family medicine clinic using a pre-post design, was designed to increase provider compliance with the 2013 United States Preventive Services Task Force lung cancer screening guidelines for using low-dose computed tomography (LDCT). Clinic staff received education on these guidelines and on a new phone script for identifying at-risk patients. The number of LDCT scans ordered during the 3-month postintervention period was compared with the number ordered during the same period 2 years prior. Results showed a statistically significant increase in postimplementation LDCT scan orders.

There abound many strategies to control hypertension, however, many patients still have difficulty adhering to medications and this results to poor Blood Pressure (BP) control.

Dermatology is an area that appears at the top of general practitioners (GPs)' educational needs. Our curriculum in undergraduate classes is inadequate to equip us for the real clinical scenarios. Pediatric skin conditions pose a special dilemma to primary care practitioners. On the one hand, dermatologic problems are so common in childhood that the primary care physician is forced to become involved with many of them. On the other hand, the scope of dermatologic conditions found in children is so broad as to be beyond the skills of most primary care physicians. The secret to managing dermatologic problems in children within a primary care setting is to recognize that a relatively small group of conditions encompass the vast majority of reasons for which a primary care physician will be consulted. By recognizing those conditions and becoming expert in the treatment of these well-defined areas, the primary care physician can manage these better. Diagnosing pediatric skin conditions and recognizing the importance of early referral of the cases that fall outside one's expertise is an important measure of the primary care physician's competence as seen by patients and their families. In this article, I would like to highlight few pediatric dermatological cases that came to our family medicine clinic, where correct diagnosis and treatment led to good outcomes.

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

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

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

Pandemics are global events that have always existed in the history of the world and that can cause profound changes. The Severe Acute Respiratory syndrome-coronavirus-2 pandemic, which appeared in China in December 2019, was also a current pandemic that affected life all over the world and in our country. Like many countries, Turkey has directed its existing strong health system to fight this pandemic. Family physicians who are the first to encounter pandemics have taken an important place in this fight by taking part in every step of the work to combat the Coronavirus Disease-2019 (COVID-19) pandemic. In this study, it was aimed to examine the duties and responsibilities of Okmeydani Family Medicine Clinic in COVID-19 pandemic both in the 1st and 3rd step health care.

The article deals with the theoretical and practical aspects of developing an enterprise development strategy. Based on the analysis of the external and internal marketing environment developed and proposed measures aimed at strengthening of the organization’s market position.

Background: The use of skin-lightening creams is common and widespread in African, Asian, and North American colored no brown to dark. Use of skin-bleaching agents has been reported in Saudi Arabia. The long-term use of these products for several months to years may cause cutaneous or systemic side effects. Purpose: This study aimed to assess the prevalence of self-use of skin-bleaching agents among Saudi women as well as the level of awareness, attitudes, and practice toward the use of these agents. Methods: A cross-sectional study was conducted by the selection of systematic random sampling of female attending the Family Medicine Clinic at Prince Mansour Military Hospital. The data collected by a structured questionnaire included information about background variables and attitudes, awareness, and practice regarding the use of skin-bleaching agents. The data were analyzed using statistical software to yield descriptive and inferential statistics. Results: A total of 358 women aged between 18 and 55 years were included in this study. Nearly 25% of the women were current users of skin-bleaching agents, while 39.6% were only previous users. About a third of women used bleaching creams in the treatment of hypo or hyperpigmented skin and 29.4% used them for cosmetic purposes. Regarding the source of these agents, 38% of women obtained them by medical prescription and 27.8% were from pharmacy without prescription. The reason for using skin-bleaching creams varied: 51.6% of females used creams to increase beauty, 51% for making a new look, 6% for increasing self-confidence, and 4.3% to increase the stability of marriage. Almost 56% of the women reported that cortisone is the most dangerous component in the skin-bleaching agents. Nearly 33% of the women reported being willing to use a quick whitening agent from an unknown source. Higher education and higher income were associated with greater use of skin-lightening creams. Conclusion: The lifetime use of skin-bleaching agents was relatively high, divided evenly on cosmetic and curative purposes. The level of awareness about these agents is low because a considerable proportion of respondents agreed to use agents from unknown sources, in addition to the high use of skin-bleaching agents obtained without medical or pharmacist consultation.

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

Aim: Night Eating Syndrome is thought to pose a risk for the development of cardiovascular system, endocrinological and psychiatric diseases. The aim of our study was to investigate the frequency of night-eating syndrome and risk factors related to night eating syndrome. Methods: This cross-sectional, descriptive study was carried out among 525 people who admitted to the Family Medicine Clinic of a tertiary hospital between 01 October and 30 November 2018. The night-eating questionnaire was applied to the partcipants using face-to-face interview. Persons with a psychiatric disorder, who have a history of chronic medication or disease, who have alcohol and drug addiction and who are working on the night shift were excluded from the study. p values < 0.05 were considered as statistically significant. Results: Fifty-one (9.7%) of the 525 patients admitted to our clinic met the criteria of Night Eating Syndrome. In our study, there were statistically significant difference between night eating syndrome and non-night eating syndrome groups with respect to smoking status and body mass index. Conclusion: Night eating syndrome is a hidden public health problem which is related to cardiovascular system diseases, diabetes mellitus and psychiatric disorders besides obesity. Because of the presence of serious health problems associated with night eating syndrome, it is very important to determine night eating syndrome in primary care.

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

Aims: To determine the 10-year cardiovascular risk (CV) and its association with socio-demographic characteristics of hypertensive patients. Study Design: This was a cross-sectional study. Place and Duration of Study: Family Medicine Clinic of the University College Hospital, Ibadan, Nigeria, between June 2013 and September 2013. Methodology: We included 345 hypertensive patients (84 men, 261 women) aged 30 years and above with no clinical history suggestive of cardiovascular disease. Data collection was with an interviewer-administered semi-structured questionnaire, physical examination and blood investigation. CV risk was determined by using General Framingham cardiovascular risk profile for use in primary care. Results: The mean+ SD age of the 345 respondents was 57.4+9.7 years and 75.7% were female. High proportion of the respondents (42.3%) were in the high CV risk category of 10-year risk for cardiovascular disease while 27.0% and 30.7% had intermediate and low CV risk respectively. CV risk was significantly associated with age (p < .001), sex (p < .001), family type (p= .047), level of education (p=.02), employment status (p

Introduction: Many studies have been conducted on non-adherence with the antihypertensive treatment regime in various countries, considering the burden of cardiovascular disease (CVD) on the public health system, it is essential to carry out studies in this regard. Methods: Patients with hypertension evaluated at the family medicine clinic of Tabriz University of Medical Sciences were enrolled using simple sampling. Data gathering tool was a questionnaire consisting of three sections including the Hill-Bone compliance questionnaire, the disease characteristics, and patients’ socioeconomic. Results: Of 254 patients with hypertension, gender, income satisfaction, the occupation and the level of education did not correlate with the acceptance of the treatment. However, the number of antihypertensive medications had a significant effect on adherence with dietary orders and appointment keeping (P

Collaborative practice in health-care has proven to be an effective and efficient method for the management of chronic diseases. This study describes a de novo collaborative practice between a pharmacist and a family physician. The primary objective of the study is to describe the collaboration model between a pharmacist and family physician. The secondary objective is to describe the pharmacist workload. A list of patients who had at least one interaction with the pharmacist was generated and printed from the electronic medical record. There were 389 patients on the patient panel. The pharmacist had at least one encounter with 159 patients. There were 83 females. The most common medical condition seen by the pharmacist was hypertension. A total of 583 patient consultations were made by the pharmacist and 219 of those were independent visits. The pharmacist wrote 1361 prescriptions. The expanded scope of practice for pharmacists in Alberta includes additional prescribing authority. The pharmacists’ education and clinical experience gained trust from the family physician. These, coupled with the family physician’s previous positive experience working with pharmacists made the collaboration achievable.

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

Aljohara S Almeneessier,1,2 Nada A AlYousefi,1,2 Lemmese F AlWatban,1,2 Abdulaziz A Alodhayani,1,2 Ahmed M Alzahrani,1,2 Saleh I Alwalan,1 Samaher Z AlSaad,1 Anas F Alonezan1 1Department of Family and Community Medicine, College of Medicine, King Saud University (KSU), Riyadh, Kingdom of Saudi Arabia; 2King Saud University Medical City, King Saud University, Riyadh, Kingdom of Saudi ArabiaCorrespondence: Aljohara S AlmeneessierDepartment of Family and Community Medicine, College of Medicine, King Saud University (KSU), Riyadh, Kingdom of Saudi ArabiaTel +96611505274489Email aljoharas@yahoo.comBackground/Objectives: Practicing independently in an ambulatory care setting demands mastering the knowledge and skills of commonly performed minor procedures. Educational hands-on activities are one way to ensure competent family medicine practitioners. This study aims to evaluate a minor procedure workshop for family medicine trainees using the Kirkpatrick model for short- and long-term workshop effectiveness and to identify facilitators and obstacles faced by the trainees during their practices to gain procedural skills.Methods: A cross-sectional study was conducted in four-time intervals: during the workshop (pre- and post-workshop), 12 weeks after the workshop to evaluate the short-term effectiveness and change of behavior, and 12 months after the workshop to evaluate the long-term effectiveness of the workshop. Statistical Package for Social Sciences 22 was used for data analysis.Results: Forty postgraduate trainees (R1-R4) attended the workshop and participated in the survey. Overall, the workshop was accepted and highly perceived by the trainees, and the pre-workshop confidence level was lower than the post-workshop confidence level. The workshop met the expectation of 100% in obstetric and gynecological procedures workshop with 97% satisfaction rate, followed by dermatology (97.5%, 90%), orthopedic (95%, 87%), general surgery (97.5%, 84%), combined ophthalmology and otorhinolaryngology workshop (82.5%, 74%). At 12 weeks, 24 postgraduate trainees (R2–R4) responded to the survey, and low competency occurred with uncommon procedures in practice. At 12 months only 16 trainees (R3–R4) responded to the survey. Learning effect was higher as post-workshop and varied with the passage of time. Changes in the competency level were noticed, with the number of procedures performed being not statistically significant (P> 0.05).Conclusion: Practicing family medicine in an ambulatory health-care setting safely needs the mastering of minor office procedure skills. Evaluating educational workshops is important to ensure effective outcomes and identify the factors of trainees, supervisors, institutions, and patients that influence or hinder the performance of minor procedures in a family medicine clinic.Keywords: educational activity, evaluation, family practice, minor procedures, simulation

A central tenet of patient-centered care is to truly and deeply understand how patients experience health care. One particular qualitative method, patient shadowing, holds the promise of seeing things through the patient’s eyes in real time. The purpose of this research is to utilize patient shadowing to capture the realities of patient experiences in an outpatient family medicine clinic and to report opportunities for improvement to clinic leadership. A total of twenty (20) patients were shadowed at a family medicine outpatient clinic over the course of eight (8) different days, providing a variety of circumstances including staffing levels, shift changes, patient volume, and other factors. Patient shadowing revealed many interesting observations, capturing many best practices in delivering patient experiences as well as a short list of recommendations that could improve patients’ and staff experiences. Areas for improvement include helping patients better understand the entire process, wayfinding from the exam room to check-out, and creating a checklist for patient follow-up items. Patient shadowing presents many benefits to health care organizations and employees, including enhanced communication and teamwork, a greater connection with patient experiences and hardships, and the opportunity to redesign processes to optimize efficiency and service quality. Experience Framework This article is associated with the Innovation & Technology lens of The Beryl Institute Experience Framework (https://www.theberylinstitute.org/ExperienceFramework). Access other PXJ articles related to this lens. Access other resources related to this lens

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

The Canadian Task Force on Preventive Health Care recommends against screening for colorectal cancer after age 75. This recommendation is based in part on lag time to mortality benefit and a reduced life expectancy in the very elderly. To explore the extent to which screening for colorectal cancer is appropriately ordered in primary care, we performed a cross sectional study in women aged 80-84 at an academic family medicine clinic in Montreal. Appropriateness was assessed using a validated life expectancy calculator, with a 10-year life expectancy of >50% serving as the threshold for appropriateness. Among women 80-84 years of age under the care of a physician in 2016 (N=144), 95 fecal immunochemical tests were ordered from 2016-2019. Of these, 41 were screening tests, and 16/41 (39%; 95% CI 24% to 54%) were deemed to be inappropriate. This finding suggests a need to improve screening decisions for elderly women followed in primary care.

Introduction: Hypertension is a major modifiable cause of cardiovascular disease affecting more than one billion people globally. Lifestyle modifications form the corner stone for the mitigation of identified risk factors and the prevention and control of hypertension. Some of these factors include cessation of cigarette smoking, weight reduction, increase in physical activity, moderation of dietary sodium and alcohol intake and following the DASH eating plan. They may also facilitate drug step-down and drug withdrawal in highly motivated individuals. The objective of this study was to determine the extent to which diagnosed hypertensive patients modify their lifestyle. Methods: This was a cross-sectional study among 230 patients with essential hypertension in the Family Medicine clinic in a tertiary hospital using a structured pretested questionnaire. Results: Most of the participants (149; 64.8%) were educated on lifestyle practices by health workers. Abstaining from tobacco products (230; 100%) and drinking alcohol (230; 100%) were the most used lifestyle practices. Dietary fruit consumption (93; 40.4%) and engagement in physical activity for thirty minutes per day (35; 15.2%) were the least used lifestyle practices. Conclusion: Health workers were the main source of education of the participants on lifestyle modification. Use of alcohol and consumption of tobacco products were not practiced by all the study participants. Dietary fruit consumption and engagement in physical activity were not popular lifestyle practices. It is recommended that primary care clinicians inquire about unhealthy lifestyles during clinical consultations as well as motivate hypertensive patients to adopt and adhere to appropriate lifestyle modifications.

In recent years, there is growing interest internationally to implement patient-centered medical homes (PCMHs), and Singapore is no exception. However, studies understanding the influence of contextual policy factors on the implementation of PCMHs are limited. We conducted 10 semi-structured in-depth interviews with general practitioners working in seven out of the nine PCMHs. Audio recordings were transcribed and analyzed by two study team members in NVivo 12 Software using grounded theory techniques. Power dynamics between the stakeholders and lack of shared decision-making among them in selecting the locale of the PCMH and formulating the practice fee and pharmacy structure were the key factors which negatively affected the implementation of PCMHs on a larger scale. Over time, lack of funding to hire dedicated staff to transfer patients and misalignment of various stakeholders’ interest to other right-siting programs also resulted in low number of patients with chronic conditions and revenue. Countries seeking to implement a successful PCMH may benefit from building trust and relationship between stakeholders, engaging in shared decision-making, ongoing cost-efficiency efforts, and formulating a clear delineation of responsibilities between stakeholders. For a healthcare delivery model to succeed in the primary care landscape, policies should be developed keeping mind the realities of primary care practice. Ministry of Health (MOH) National Medical Research Council (NMRC) Published version This research was funded by the National Medical Research Council (NMRC) and Ministry of Health, Singapore, Health Service Research Grant (HSRG), grant number NMRC/HSRG/0086/2018 and the Centre Grant Program Singapore Population Health Improvement Centre, grant number: NMRC/CG/C026/2017_NUHS.

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

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

Two clinical pharmacy faculty members from a college of pharmacy provide comprehensive medication management in a rural family medicine clinic. The data was assessed for patients with diabetes managed by the pharmacists from 1 January 2017 through to 31 December 2019 to determine the service&rsquo, s impact on patient outcomes. The primary outcome of this study is the change in the goal attainment rates of the three clinical goals of hemoglobin A1c, blood pressure, and appropriate statin therapy after pharmacist intervention. A total of 207 patients were included. At baseline, the patients had an average of 1.13 of the three goals met, improving to an average of 2.02 goals met after pharmacist intervention (p &lt, 0.001). At baseline, 4.8% of the patients had met all three clinical goals, improving to 30.9% after pharmacist intervention (p &lt, 0.001). There were significant improvements for the individual goal attainment rates of hemoglobin A1c (24.15% vs. 51.21%, p &lt, 0.001), blood pressure (42.51% vs. 85.51%, p &lt, 0.001), and appropriate statin therapy (45.89% vs. 65.70%, p &lt, 0.001). This data adds to the evidence supporting the integration of clinical pharmacists into primary care clinics to improve patient outcomes related to diabetes.

Background and Objectives: Chlamydia trachomatis is the most prevalent bacterial sexually transmitted infection (STI) in the United States. Annual chlamydia screening of asymptomatic, sexually active women age 16 to 24 years and of older women who are at increased risk for infection is recommended. This study built on prior work in which our university-based family medicine clinic implemented quality improvement (QI) interventions in 2016 and 2017 to increase our chlamydia screening rate. Our primary aim in the current study was to increase the screening rate by 10%. Our secondary aim was to determine the number of patient contacts that yielded maximum test rates. Methods: For the most recent QI cycle, we conducted a prospective cohort study from December 2017 through March 2018. Using the FOCUS-PDSA model, a resident-led, interdisciplinary QI team developed the aims and implemented an intervention to streamline patient outreach. We also retrospectively analyzed data from the previous QI cycle to determine the number of tests obtained after each patient contact. Results: Chlamydia testing increased from 54% to 56.3% between December 2017 and March 2018. The majority of tests were completed by four patient contacts; additional contacts yielded few additional tests. Conclusions: Persistent outreach increases chlamydia screening rates. This QI project could be replicated in other clinical settings to improve the screening of chlamydia or other diseases.

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

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

BACKGROUND: In April 2018, Ottawa Public Health identified a large-scale infection prevention and control (IPAC) lapse spanning 15 years related to inadequate reprocessing of reusable critical medical equipment used in a family medicine clinic. OBJECTIVES: To describe the public health response to, and estimate the risk of hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV) transmission from, this IPAC lapse. METHODS: Patients who underwent a procedure of concern (during which reusable equipment may have been used) at this clinic were identified using Ontario Health Insurance Plan data and individually notified. Testing for HBV, HCV and HIV at the Public Health Ontario Laboratory was recommended, and the odds of infection were estimated. RESULTS: Of 4,495 patients possibly exposed to improperly reprocessed equipment, 1,496 (33.3%) underwent testing within six months of notification. The prevalence of HBV, HCV and HIV infection in this group was lower than in the general Canadian population. Among patients first diagnosed with HBV after a procedure of concern, the odds of HBV transmission were not increased when the procedure occurred within seven or 28 days of another patient with a positive HBV test result (OR(7 days, age-adjusted)=0.59(,) 95% CI: 0.14–2.51; OR(28 days, age-adjusted)=1.35, 95% CI: 0.62–2.93). The odds of HCV and HIV transmission could not be estimated because no patient was diagnosed with HCV or HIV after having a procedure of concern within 28 days of another patient with a positive HCV or HIV test result. CONCLUSION: We found no evidence of HBV, HCV or HIV transmission associated with this IPAC lapse. However, transmission cannot be ruled out conclusively because only a third of possibly exposed patients underwent testing.

Background A growing number of health systems in the United States have integrated behavioral health team members to expand their capabilities and clinical effectiveness. Purpose To explore perceptions of interprofessional collaboration with integrated behavioral health providers among family medicine residents (FMR), family medicine faculty, and pharmacists (faculty/residents). Method An exploratory descriptive study was conducted in which five, 60-min focus groups were used to articulate perceptions of professional roles and team-based care in an interprofessional family medicine community-based clinical practice. Results Three key themes emerged: (1) interprofessional team-based practice: the influence of communication, collaboration, and colocation; (2) care delivery system processes: success and breakdown; and (3) commitment to holistic care practices. These findings suggest how FMR education can be improved to prepare learners for patient-centered, team-based collaborative practice with integrated behavioral health providers. Conclusion Integrating behavioral health in a family medicine clinical learning environment empowers physicians to better problem solve and provide enhanced patient care.

Introduction. Experience in treating patients under supervisionof faculty is an important factor in medical education at all levels.However, unpleasant patient experiences with a medical learnerduring clinical consultation can damage the relationship betweenthe medical learner, physician supervisor, and patient. A goal of thisstudy was to examine patient experiences and preferences regardingmedical learners during clinical consultation at a family medicineresidency clinic. Another goal was to determine factors relating topatients’ experiences and preferences regarding medical learners. Methods. This cross-sectional study relied on patients completinga survey designed from extant questionnaires to measure patients’experiences and preferences relating to interactions with medicallearners at a family medicine clinic. Data were collected from 216patients between December 2016 and August 2017. We correlatedpatients’ feelings, overall experiences with medical learners and theimportance of medical education. Results. There was a 93% participation rate. The patients rated theiroverall experiences with medical learners as 3.8 on a 5-point scale,suggesting positive experiences. Eighty-eight percent prefer not morethan three medical learners to be involved in their care during clinicalconsultation. Patients’ overall experiences with medical learnersparticipating in medical care correlated with their preferences regardingmedical learners’ involvement in their treatment (r[209] = .524;p = 0.01). Patients’ perception of medical learners participating inmedical care correlated with the importance of medical education(r[209] = .878; p = 0.01). Conclusions. The results showed that most patients have positiveexperiences with medical learners and are generally in favor ofmedical education.Kans J Med 2018;11(4):102-105.

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

Background: Rapid and right intervention of parents can limit disability and increase the chances of survival of the injured child and make a big difference in the outcome. Objectives: The objective of this study is to assess the knowledge and practice of first aid among parents attending PHCs in Al-Madinah city, 2017. Methods: A cross-sectional study was conducted in governmental primary healthcare centers in Al-Madinah Al-Munawwarah city (Saudi Arabia) during the year 2017. A representative sample of Saudi parents who live in Madinah and came to family medicine clinic in PHC was included. A pre-validated and self-administered questionnaire was used for data collection. Results: The study included 390 parents. More than half of them (55.6%) were males. The age of 40% of them ranged between 31 and 40 years whereas that of 31.5% ranged between 20 and 30 years. Majority of the parents (97.2%) were aware of first aid. The most commonly reported source of information about first aid was mass media (59%). Majority of the parents (93.3%) believe there must be training in first aid, and only 34.6% of them claimed that they attended a training course in first aid. The highest average knowledge percentage was observed regarding the first aid of diabetes mellitus (68.8%), followed by epilepsy (49.7%), incidents (37.5%) and finally injuries/fractures (36.7%). Higher educated parents, those with a moderate number of children (4–6), those reported nurses as the main source of information, those previously attended training in first aid, and those who had experience with incidents among their children expressed higher significantly first aid knowledge compared to their counterparts. Conclusions: First aid of various illnesses among parents in Al-Madinah city is not satisfactory, particularly regarding incidents, injuries, and fractures. However, the majority of them were willing to attend training courses in first aid at primary healthcare centers.

Objective. To evaluate patients, who apply to Lithuanian health science university hospital of Kaunas clinics Family medicine clinic, and compare the diet habits of those who have a medical education and who do not. Research method. The research was done during the year of 2016 by anonymous questionnaire 315 randomly selected patients over the age of 18 (221 women and 94 men) were questioned, who applied to Lithuanian health science university hospital of Kaunas clinics Family medicine clinic. The selected patients for the research are divided into two age groups (18-30 year olds and 31-78 year olds) and by medical education: those with a medical education (97 individuals) and those without a medical education (218 individuals). Diet habits compared between patients with a medical education and without. The data statistical analysis was performed using a statistical program package (SPSS Version 24.0 for Windows). The differences between the groups were evaluated using χ2 test. The disparity is considered statistically significant, when p

Adherence to 2011 Infectious Diseases Society of America (IDSA) guidelines for urinary tract infections (UTIs) remains low in primary care. Fluoroquinolones are commonly prescribed to treat uncomplicated cystitis, and most antibiotic prescriptions have durations that exceed current recommendations. We performed a difference-in-differences study to assess the effectiveness of a stewardship intervention in a family medicine clinic at an academic outpatient center from August 2016 to March 2019. During our intervention period, the FDA released 2 additional warnings about the side effects of fluoroquinolones. Methods: The study had 2 sites (intervention and comparison) and 3 periods: baseline, before the intervention, and the intervention. During the first 2 years, we obtained baseline data and performed interviews (preintervention period) exploring provider prescribing decisions for cystitis at both sites. During the intervention period at the intervention site only, we presented an educational lecture including an overview of the IDSA guidelines, definitions for various UTI syndromes and actual clinical examples, and instruction on use of a decision aid. During the audit and feedback phase, providers were contacted once per month in person or by phone to provide follow-up on whether their treatment decision adhered to the IDSA guidelines. We performed a log-binomial regression analysis of the primary outcome, adherence to the IDSA guidelines for management of uncomplicated cystitis, both to antibiotic choice and duration of therapy. Results: We performed 156 audit-and-feedback sessions with 13 providers during the intervention period (March 2018–2019). Patients in both sites were similar in terms of age and Charlson comorbidity index. Adherence to the guidelines for antibiotic choice and duration increased in the intervention period at both sites (Fig. 1). The treatment of cystitis in the intervention period of the intervention site was 11.5 times (95% CI, 6.1–21.6) as likely to be guideline-adherent as the treatment in the baseline period of the comparison site (Fig. 2). Conclusions: Adherence to IDSA guidelines for the choice of antibiotic and duration increased in both intervention and comparison sites. Even though the intervention site started with higher compliance, improvement was also greater in the intervention site. FDA warnings about the side effects of fluoroquinolones released during the intervention period may have contributed to the avoidance of fluoroquinolones at both sites. Our intervention was effective at improving antibiotic choice and duration, so our future plans include incorporating our decision-support algorithm into the electronic medical record.Funding: This study was supported by Zambon Pharmaceuticals.Disclosures: None

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

Thoracic outlet syndrome (TOS) is a condition that results from the compression of the neurovascular bundle of the upper extremities. It has generally been divided into neurogenic and vascular TOS with vascular further being divided into venous and arterial. This case report is of a healthy 24-year-old female who was misdiagnosed initially in an emergency department only to return two days later for reevaluation. Here, the patient's admission and workup are discussed after she presented to the family medicine clinic for a referral for further evaluation by a cardiothoracic surgeon. Physical exam provocative tests which are often overlooked are reviewed, and osteopathic manipulative techniques and principles are mentioned.

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