Academic Family Medicine Center Research Articles

Addressing equity and access to care: How an academic family medicine practice manages human immunodeficiency virus, hepatitis C, and substance use disorders in rural Appalachia

AbstractRural populations struggle with health care access and are influenced by social determinants of health, lack of available resources, and fragmented care. Longstanding disparity and inequity have led to increased prevalence and poor outcomes of preventable and treatable disease states, including human immunodeficiency virus (HIV), hepatitis C, and substance use disorders (SUD). This article describes how an academic family medicine center addresses access to care in a rural population with a high prevalence of HIV, hepatitis C, and SUD. The goal is to provide strategies that other practice sites could use to develop and expand their own services to enhance equity and improve outcomes in this patient population. Strategies include co‐locating medical services to address multiple needs in one visit, leveraging telehealth to reduce barriers to care, utilizing multidisciplinary teams to promote comprehensive care, collaborating with community partners to address social determinants of health, and training health care learners to increase capacity and sustainability. The role of the pharmacist is highlighted as a leader of a team‐based interdisciplinary care model that can meet complex patients' comprehensive care needs.

The Financial Cost of Medical Assistant Turnover in an Academic Family Medicine Center.

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. 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. 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. 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.

Improved Breastfeeding Outcomes Following an On-site Support Intervention in an Academic Family Medicine Center.

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. 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. 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). 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.

Implementing Lean in Academic Primary Care.

Lean is emerging as a quality improvement (QI) strategy in health care, but there has been minimal adoption in primary care teaching practices. This study describes a strategy for implementing Lean in an academic family medicine center and provides a formative assessment of this approach. A case study of the University of North Carolina Family Medicine Center that used the Consolidated Framework for Implementation Research to guide a formative evaluation. The implementation strategy included partnering with Lean content experts and creating a leadership team; planning and completing QI events and Lean training modules; and evaluating and reporting activities related to QI and training. During the initial period of Lean implementation, there was (1) minimal to no change in the quality of care as determined by the Preventive Care Index (46-48); (2) a decrease patient appointment cycle time from 89 minutes to 65 minutes; (3) an increase in overall practice productivity from $8144 to $9160; (4) a decrease in patient satisfaction from 94% to 91%; and (5) an increase in monthly visit volume from 4112 to 5076. Lean had an uneven effect on QI in an academic primary care practice during the first year of implementation.

Validation of a combined health literacy and numeracy instrument for patients with type 2 diabetes

ObjectivesThis study aimed to validate a new consolidated measure of health literacy and numeracy (health literacy scale [HLS] plus the subjective numeracy scale [SNS]) in patients with type 2 diabetes (T2DM). MethodsA convenience sample (N = 102) of patients with T2DM was recruited from an academic family medicine center in the southeastern US between September-December 2017. Participants completed a questionnaire that included the composite HLS/SNS (22 questions) and a commonly used objective measure of health literacy—S-TOFHLA (40 questions). Internal reliability of the HLS/SNS was assessed using Cronbach’s alpha. Criterion and construct validity was assessed against the S-TOFHLA. ResultsThe composite HLS/SNS had good internal reliability (Cronbach’s alpha = 0.83). A confirmatory factor analysis revealed there were four factors in the new instrument. Model fit indices showed good model-data fit (RMSEA = 0.08). The Spearman’s rank order correlation coefficient between the HLS/SNS and the S-TOFHLA was 0.45 (p < 0.01). ConclusionsOur study suggests that the composite HLS/SNS is a reliable, valid instrument.

Identifying frailty in primary care: a qualitative description of family physicians\u2019 gestalt impressions of their older adult patients

BackgroundMany tools exist to guide family physicians’ impressions about frailty status of older adults, but no single tool, instrument, or set of criteria has emerged as most useful. The role of physicians’ subjective impressions in frailty decisions has not been studied. This study explores how family physicians conceptualize frailty, and the factors that they consider when making subjective decisions about patients’ frailty statuses.MethodsDescriptive qualitative study of family physicians who practice in a large urban academic family medicine center as they participated in one-on-one “think-aloud” interviews about the frailty status of their patients aged 80 years and over. Of 23 eligible family physicians, 18 shared their impressions about the frailty status of their older adult patients and the factors influencing their decisions. Interviews were audio-recorded, transcribed, and thematically analyzed.ResultsFour themes were identified, the first of which described how physicians conceptualized frailty as a spectrum and dynamic in nature, but also struggled to conceptualize it without a formal definition in place. The remaining three themes described factors considered before determining patients’ frailty statuses: physical characteristics (age, weight, medical conditions), functional characteristics (physical, cognitive, social) and living conditions (level of independence, availability of supports, physical environment).ConclusionsFamily physicians viewed frailty as multifactorial, dynamic, and inclusive of functional and environmental factors. This conceptualization can be useful to make comprehensive and flexible evaluations of frailty status in conjunction with more objective frailty tools.

Patient factors associated with documented provision of JNC 7-recommended hypertension care at an academic family medicine office.

Little is known about patient factors associated with the provision of hypertension care as recommended by JNC 7. We conducted a retrospective chart review (n = 150) to compare documented provision of items recommended by JNC 7 with various patient factors, using a 15-point scoring tool (0% to 100%). The overall documentation of JNC guideline-recommended care was 78.3%. There was a significant effect of marital status; married patients received more guideline-recommended care than unmarried patients (80.4% vs 74.4%; P = .02). Men received more guideline-recommended care than women (80.7% vs 76.4%; P = .02). Multivariate analysis revealed that Medicaid patients had 7.1% lower rates of guideline-recommended care than patients with other insurance (P = .05). There was no significant difference in guideline-recommended care based on race/ethnicity; however, racial/ethnic disparities were identified for certain individual standards. Hypertension care in 2013 at an academic family medicine center was, for the most part, in agreement with guidelines; however, provision of some items varied based on sex, marital status, and insurance. Awareness of these predictors may help improve the implementation of guidelines, particularly relevant given the recent release of JNC 8.

Patient Satisfaction with Medical Student Participation in a Family Practice Clinic

Medical visits frequently include medical students, transforming the role of the patient into a medical educator as well as a person seeking care. Ensuring patient satisfaction with this arrangement is important for maintaining student access to clinical training. This study was conducted in an academic family medicine center where third-year medical students participate directly in outpatient visits. Two hundred twenty-two patients completed a nine-item survey assessing their satisfaction with their medical visits. Satisfaction ratings were compared between those patients that were seen by a medical student prior to seeing their physician and those patients who saw only their physician. Patients who saw both a medical student and their physician reported a higher rate of prolonged visits. There were no significant differences between the groups regarding satisfaction with wait time, satisfaction with time spent with their physician, addressing their medical concerns, or global satisfaction with their visits.

Incorporating Acupuncture in a University-Based Family Medicine Center: Lessons Learned

To evaluate the utilization, financial costs, and benefits of incorporating acupuncture into a university-based family medicine center. Retrospective billing records review. An academic family medicine center located within a university-based medical center. The entire population of consecutive patients seen in an acupuncture clinic from April, 2002 through October, 2006. Patient characteristics, number and types of visits, and charges and collections. Analysis of de-identified, electronic billing records. During the 4(1/2)-year study period, 788 unique patients were seen, accounting for a total of 4953 visits. The most common clinical conditions treated were back pain, headache, and neck pain. Mean charge and collection per visit was $82 and $53, respectively. Mean annual clinic revenues and expenses were $58,653 and $74,223, respectively. The authors' experience with an acupuncture clinic within an academic medical center has been generally positive, but we have not been able to turn a profit within the first 4(1/2) years of operation. Advantages of including physician-acupuncturists include improved patient access to third-party payers for clinical services, and possibly better acceptance by physician colleagues and the larger medical center system. Physician-acupuncturists, however, tend to have higher salary and liability costs associated with their services. Incorporating licensed acupuncturists allows for improved access to patients as well as lower operating expenses. We postulate that patients are generally more willing to pay cash for acupuncture services provided by a licensed acupuncturist compared to a physician, whose services are generally expected to be covered by medical insurance. Our findings suggest that incorporating acupuncture into existing medical practices may benefit patients, providers, the clinic as a whole, and the larger community, but the profit margin associated with providing acupuncture in these settings is likely to be negative or slim.

Chronic Daily Headache in a Primary Care Population: Prevalence and Headache Impact Test Scores

Population-based surveys estimate the prevalence of chronic daily headache (CDH) in the general community to be approximately 4%. The prevalence of CDH among patients seen in the primary care setting in the United States, however, is unknown. To estimate the prevalence and associated burden of suffering of CDH in a primary care patient population. Cross-sectional survey of a randomly selected sample of 1500 adult patients in an academic Family Medicine Center was done. Outcome measures include self-reported headache frequency and Headache Impact Test scores. Completed questionnaires were returned by 853 (57%) patients. The mean age of respondents was 49 years (SD = 16), with a range of 18 to 94 years. Two hundred ninety-six (58%) patients reported having had 1 or more severe headaches in the past month. Seventy-four (9%) patients reported a frequency of headache consistent with CDH, defined as the occurrence of headache 15 or more days in the past month. Twenty-four patients (32%) with CDH either believed that none of their doctors know that they experienced headaches or were not sure if their doctors were aware of their headaches, and 21 (28%) reported that they have not needed a doctor's care for their headaches. The prevalence of CDH is greater among a primary care patient population compared to the general community. A substantial proportion of patients with CDH do not bring their headaches to the attention of their health-care providers. In light of the advances in the development of effective medications for migraines and the growing body of evidence implicating medications as a contributing cause of CDH, it may be appropriate to encourage patients to inform their health-care providers about their headaches and to encourage providers to identify patients with frequent headaches.

Alternative models for academic family practices

BackgroundThe Future of Family Medicine Report calls for a fundamental redesign of the American family physician workplace. At the same time, academic family practices are under economic pressure. Most family medicine departments do not have self-supporting practices, but seek support from specialty colleagues or hospital practice plans. Alternative models for academic family practices that are economically viable and consistent with the principles of family medicine are needed. This article presents several "experiments" to address these challenges.MethodsThe basis of comparison is a traditional academic family medicine center. Apart of the faculty practice plan, our center consistently operated at a deficit despite high productivity. A number of different practice types and alternative models of service delivery were therefore developed and tested. They ranged from a multi-specialty office arrangement, to a community clinic operated as part of a federally-qualified health center, to a team of providers based in and providing care for residents of an elderly public housing project. Financial comparisons using consistent accounting across models are provided.ResultsAcademic family practices can, at least in some settings, operate without subsidy while providing continuity of care to a broad segment of the community. The prerequisites are that the clinicians must see patients efficiently, and be able to bill appropriately for their payer mix.ConclusionExperimenting within academic practice structure and organization is worthwhile, and can result in economically viable alternatives to traditional models.