Impact of COVID-19 on American Family Physicians' Intent to Retreat from Clinical Care.

PURPOSE: This survey evaluated whether the COVID-19 pandemic was a traumatic stress event for family physicians associated with burnout, changes in life priorities, and intentions to retreat from clinical practice. METHODS: We report on 683 clinically active family physicians surveyed through the Council of Academic Family Medicine's Educational Research Alliance (CERA) in the fall of 2021. RESULTS: Overall, 35.2% of family physicians experienced the pandemic as a traumatic stress like event. This was associated with changing life priorities (OR 2.6, CI 1.8-3.9), burnout (OR 1.6, CI 1.1 to 2.4), and withdrawal from clinical practice in various ways. Those who changed their priorities in life were more likely to restrict scope of practice (OR 3.9, CI 2.6-5.9), reduce clinical work effort (OR 3.4, 2.3 to 5.1), relocate (OR 3.1, CI 2.0 to 4.8), retire (OR 2.7, CI 1.4-4.9), reroute their career away from patient care (OR 2.1, CI 1.4-3.1) and less likely to avoid redesigning the practice to improve well-being (OR 0.3, CI 0.2-0.7). Those who experienced burnout were more likely to retire (OR 5.5, CI 2.8 to 10.5), reduce clinical work effort (OR 4.2, CI 2.9-6.1), reroute their career away from patient care (OR 3.9, CI 2.6-5.8), relocate (OR 3.8, CI 2.4 to 5.9), and restrict scope of practice (OR 3.3, CI 2.3 to 4.9). Overall, 48.5% of family physicians expressed some intention to retreat from clinical practice. CONCLUSION: The COVID-19 pandemic impacted family physician's career plans. Remedying burnout is a high-yield opportunity for retaining clinically active family physicians. Physicians retreating from clinical medicine related to changing life's priorities needs further exploration.

Telehealth to improve continuity for patients receiving buprenorphine treatment for opioid use disorder.

Context: Buprenorphine is medication-assisted treatment for opioid use disorder. It is a controlled substance and most states limit the dispensing to a 30-day supply. Patients with opioid use disorder often have social determinants of health barriers that make it difficult to engage with the health system to obtain a new supply of buprenorphine every month. Telehealth can be used to reduce barriers to accessing care and improve continuity of care for patients receiving buprenorphine treatment. Objective: To assess the rates of patient continuity for patients receiving buprenorphine treatment via tele-health versus in-person in a primary care outpatient setting. Study Design: Review of patients receiving buprenorphine treatment for opioid use disorder and rates of continuity by visit type during a 2-year time period May 2019-May 2021. Dataset: EPIC electronic medical records from an urban university-affiliated ambulatory primary care practice in New Jersey. Population Studied: Patients scheduled for a visit in the outpatient primary care clinic. Approximately 69% were African American, 22% Hispanic, and 9% other. The majority were enrolled in Medicaid. 80% of patients faced one or more barriers to social determinants of health including transportation, housing, and economic stability. Intervention: Establishment and implementation of HIPAA compliant tele-health following approved state guidelines for buprenorphine prescribing via tele-health. Appointments were scheduled in-person or tele-health by patients' preference. Outcome Measures: Rates of continuity by visit type for patients receiving buprenorphine treatment during the study time period compared by chi-square. Results: Of the 487 patients seen via tele-health, 297 (61%) continued to receive follow up care. Of the 811 patients seen in-person, 400 (49.3%) continued to receive follow up care, p<.0001. The patients who did not continue to receive follow up care were lost to follow up despite attempts to reach patients to re-engage in care. Conclusions: Our study shows that rates of continuity of care are higher using tele-health for patients receiving medication assisted therapy for opioid use disorder. In an urban underserved population, tele-health can result in improved continuity of care for patients with opioid use disorder. Telehealth may reduce barriers to accessing care including transportation, work schedule, childcare, and other competing demands.

An interprofessional collaboration of care to improve clinical outcomes for patients with diabetes.

This project addressed interprofessional team-based care to improve management and outcomes of complex patients with diabetes. A collaborative model between Family Medicine and Nursing was developed to determine if having nursing students as case managers would improve the quality of care. From 2015-2016, patients with diabetes at greatest risk for poor outcomes (N = 58) received an intervention from senior nursing students (N = 6) at a Family Practice Center. Nursing students shared responsibilities with physicians, medical students, and medical assistants to deliver high quality care. For the intervention, nursing students reviewed charts, called patients for follow-up visits, and facilitated patients' adherence to providers' recommendations. Students also conducted group education sessions on nutrition, medication adherence, obesity, and exercise for patients. The control group included 61 randomly selected patients with diabetes who did not receive the intervention during the same period of time. Compared to the control group, the intervention group showed significantly improved outcomes in HgA1C levels (66% vs. 40.8%; p = .009), blood pressure control (61.1% vs. 36.8%; p = .009), and urine microalbumin test completion (87.5% vs. 48.3%; p<  .0001). Outpatient practices offer an optimal opportunity for nursing students to practice case management. This team-based care approach suggests better outcomes for patients with diabetes.

Bleeding and spotting with the levonorgestrel 13.5 mg intrauterine system: the impact of insertion timing.

OBJECTIVE: To assess the impact of early versus late menstrual cycle insertion on bleeding/spotting in the 90 days following levonorgestrel (LNG) 13.5 mg intrauterine system (IUS) insertion. STUDY DESIGN: In this observational study, participants received a LNG 13.5 mg IUS and provided 90 days of bleeding/spotting data by answering the following daily text: "Have you had no flow (0), spotting (1), or bleeding (2) today?" We dichotomized insertion timing as early (days 1-7 from last menstrual period) and late (remainder of menstrual cycle) and compared bleeding/spotting between the two groups in the 90- and 30-day reference periods. We used multivariate regression methods to study associations between cycle day at insertion, parity, historical bleeding, recent hormonal contraceptive use and bleeding/spotting. RESULTS: In the 90-day dichotomous analysis (n=125), we found no differences in the number of days of bleeding/spotting, bleeding or spotting between the early and late insertion groups. In the 30-day dichotomous analysis (n=131), early insertion was associated with fewer days of bleeding than late insertion (5±3 vs. 7±4 days, p<.01). Recent hormonal contraceptive users experienced fewer days of bleeding than new users (5±4 vs. 7±3 days, p<.01). In the 90- and 30-day regression models, earlier insertion was associated with fewer days of bleeding (p=.02, p=.02). Recent contraceptive use was associated with fewer days of bleeding/spotting (90-day, p=.03) and fewer days of bleeding (30-day, p<.01). Nulliparity was associated with spotting (30-day, p=.04). CONCLUSIONS: Early cycle insertion does not impact 90-day bleeding/spotting. Early cycle insertion and recent hormonal contraceptive use decrease 30-day bleeding. IMPLICATIONS: The LNG 13.5 mg IUS may be inserted throughout the menstrual cycle with small differences in bleeding patterns in the 30 but not the 90 days following insertion. Shared decision making should determine timing of insertion.

Birth Outcomes in Relation to Intimate Partner Violence.

OBJECTIVES: Intimate partner violence (IPV)during pregnancy is a significant public health problem. Approximately 324,000 IPV victimizations occur during pregnancy each year. However, research on the impact of IPV on birth outcomes yields conflicting findings. This study examines the association of IPV with birth outcomes among pregnant women. STUDY DESIGN: We used a retrospective cohort study design to analyze data from chart reviews of a random sample of 1542 pregnant women. These women were seen between 2003 and 2009 at an urban university affiliated prenatal clinic and gave birth at the on-site hospital. Victims of IPV were defined as those who scored equal to or higher than 10 on an IPV screening tool: HITS (Hit, Insult, Threaten, and Scream). Three measures were included in birth outcomes. Preterm delivery was defined as gestational age less than 37 weeks. Low birth weight was defined as infants born weighing <2500 g. Neonatal intensive care was measured by prevalence of receiving intensive care. RESULTS: The prevalence of IPV was 7.5%. Compared to non-abused women, abused women were more likely to have preterm deliveries (18.3% vs. 10.3%; p = .016). Compared to infants of non-victims, infants of victims were more likely to have low birth weight (21.5% vs. 11.0%; p = .003) and to receive neonatal intensive care (23.4% vs. 7.8%; p = .000). Results from multivariate analyses indicated that victims were more likely to have preterm deliveries than non-victims (OR = 1.72; 95% CI: 1.22-2.95). More infants of victims had low birth weight (OR = 2.03; 95% CI: 1.22-3.39) and received neonatal intensive care than those of non-victims (OR = 4.04; 95% CI: 2.46-6.61). CONCLUSIONS: Abused pregnant women had poorer birth outcomes compared to non-abused pregnant women. Healthcare providers should be trained to screen and identify women for IPV, and interventions should be designed to reduce and prevent IPV and thereby improve health outcomes for victims and their children.

Sp1-mediated microRNA-182 expression regulates lung cancer progression.

Our recent study indicated that overexpression of Sp1 enhances the proliferation of lung cancer cells, while represses metastasis. In this study, we found that the transcriptional activity of FOXO3 was increased, but its protein levels decreased following Sp1 expression. Sp1 increased expression of miR-182, which was then recruited to the 3'-untranslated region of FOXO3 mRNA to silence its translational activity. Knockdown of miR-182 inhibited lung cancer cells growth, but enhanced the invasive and migratory abilities of these cells through increased N-cadherin expression. Repression of FOXO3 expression in the miR-182 knockdown cells partially reversed this effect, suggesting that miR-182 promotes cancer cell growth and inhibits cancer metastatic activity by regulating the expression of FOXO3. The expression of several cancer metastasis-related genes such as ADAM9, CDH9 and CD44 was increased following miR-182 knockdown. In conclusion, in the early stages of lung cancer progression, Sp1 stimulates miR-182 expression, which in turn decreases FOXO3 expression. This stimulates proliferation and tumor growth. In the late stages, Sp1 and miR-182 decline, thus increasing FOXO3 expression, which leads to lung metastasis.

Intimate partner violence: office screening for victims and perpetrators of IPV.

Intimate partner violence (IPV) affects more than 12 million individuals annually. Power and control are central concepts underlying abusive relationships. Physicians may see IPV victims, perpetrators, and their children for annual examinations, as well as for injuries and health conditions associated with abuse. In 2013, the US Preventive Services Task Force recommended that women of childbearing age (ie, 14 to 46 years) be screened for IPV. Brief, validated screening tools, such as the 4-item Hurt, Insult, Threaten, and Scream (HITS), can be used to facilitate screening. Physicians should always assess patients whose medical histories or presenting symptoms or injuries are consistent with abuse. Risk factors for IPV and consequences of abuse include general health conditions (eg, asthma, irritable bowel syndrome), reproductive issues (eg, gynecologic disorders, unintended pregnancies), psychological conditions (eg, depression, sleep disturbances), and risky health behaviors (eg, substance use, poor health care adherence). Tools for identifying perpetrators are under investigation. To prepare the practice to address IPV, physicians should educate themselves and staff and learn about community and national resources. By identifying and responding to IPV, clinicians may be able to reduce IPV and interrupt the intergenerational cycle of violence.

Intimate partner violence: counseling, community resources, and legal issues for IPV victims and perpetrators.

The family physician's office is a potentially safe place to discuss intimate partner violence (IPV). RADAR (Remember to ask routinely, Ask directly [in private], Document findings, Assess safety, Review options) is a tool for identifying and responding to IPV. Physicians should ask permission to document abuse, consider using a body map, and ensure confidentiality. They should also assess immediate safety by asking about weapons in the home, children's safety, and the likelihood that the perpetrator will harm him- or herself or others. Federal privacy laws require physicians to inform patients about health information disclosure. Because mandatory reporting varies by state, physicians should communicate clearly the office's responsibilities. Interventions are based on an advocacy model that requires appropriate training and establishment of links to community-based resources. Brief advocacy includes providing information cards, whereas intensive intervention includes IPV education, danger assessment, prevention options, safety planning, and community referrals. The Stages of Change Model may help physicians understand a patient's readiness and ability to make a change. For the IPV survivor who has left an abusive partner, physicians should be aware of the challenges of safety, health, legal, and financial issues; protection orders are a possible safety strategy. The most common intervention for perpetrators is a batterer intervention program. Couples counseling by family physicians is contraindicated.

Intimate partner violence: childhood exposure to domestic violence.

Children who are exposed to domestic violence (DV) may experience many short- and long-term negative effects. They are up to 3.8 times more likely to become perpetrators or victims in adulthood than are children not exposed to DV. They also are at high risk of health problems, risky health behaviors, violence, and social functioning problems. Girls who witness intimate partner violence (IPV) are more likely to experience depression, anxiety, and trauma symptoms, and boys exposed to IPV are more likely to exhibit aggression and delinquent behaviors. To prepare the practice to identify and assist children exposed to DV, physicians should undergo training, implement screening protocols, use caution when documenting findings, collaborate with local agencies, and learn about the state's reporting laws. State and local DV service programs or other community resources can provide assessment and intervention assistance. Social workers, mental health professionals, and child and DV advocates can assist in providing treatment for children exposed to violence. Physicians should schedule follow-up appointments for children who need treatment, monitor behavior, and coordinate intervention services.

Intimate partner violence: IPV in the LGBT community.

Nationally, the rates of intimate partner violence (IPV) among lesbian, gay, bisexual, or transgender (LGBT) individuals are similar to or greater than rates for heterosexuals. Many have experienced psychological and physical abuse as sexual minorities, making it difficult for them to seek help for IPV. Physician behavior, such as not assuming that all patients are heterosexual, being nonjudgmental, and using inclusive language, can empower LGBT patients to disclose IPV. Also, physicians should ascertain the degree to which the patient is out. The threat of being outed can be an aspect of the power and control exerted by an abusive partner and a significant barrier to seeking help. Physicians should screen for IPV and intervene in a similar manner with LGBT and non-LGBT patients, but they should be aware of potential limitations in resources for LGBT patients, such as shelters. As sexual minorities experiencing IPV, LGBT individuals are at greater risk of depression and substance abuse than are non-LGBT individuals. Minority stress, resulting from stigmatization and discrimination, can be exacerbated by IPV. Physicians should learn about legal issues for LGBT individuals and the availability of community or advocacy programs for LGBT perpetrators or victims of IPV.

Intimate partner violence and cancer screening among urban minority women.

PURPOSE: To evaluate the association of intimate partner violence (IPV) with breast and cervical cancer screening rates. METHODS: We conducted retrospective chart audits of 382 adult women at 4 urban family medicine practices. Inclusion criteria were not being pregnant, no cancer history, and having a partner. Victims were defined as those who screened positive on at least one of 2 brief IPV screening tools: the HITS (Hurt, Insult, Threat, Scream) tool or Women Abuse Screening Tool (short). Logistic regression models were used to examine whether nonvictims, victims of emotional abuse, and victims of physical and/or sexual abuse were up to date for mammograms and Papanicolaou smears. RESULTS: Prevalence of IPV was 16.5%. Compared with victims of emotional abuse only, victims of physical and/or sexual abuse aged 40 to 74 were associated with 87% decreased odds of being up to date on Papanicolaou smears (odds ratio, 0.13; 95% CI, 0.02-0.86) and 84% decreased odds of being up to date in mammography (odds ratio, 0.16; 95% CI, 0.03-0.99). There was no difference in Papanicolaou smear rates among female victims and nonvictims younger than 40. CONCLUSIONS: Because of the high prevalence of IPV, screening is essential among all women. Clinicians should ensure that victims of physical and/or sexual abuse are screened for cervical cancer and breast cancer, particularly women aged 40 or older. Cancer screening promotion programs are needed for victims of abuse.

Relation of domestic violence to health status among Hispanic women.

Little research has addressed the association of domestic violence (DV) with physical and mental health in Hispanic women. We conducted a cross-sectional study with 146 Hispanic women patients in 2002 at an urban family medicine practice. Twenty-one percent of the women were identified as current victims of DV. Two-fifths of victims (41.9%) experienced physical and/or sexual abuse. Approximately two-thirds (64.5%) had depressive symptoms. Poorer mental health was associated with all forms of abuse. Relatively low socioeconomic status and acculturation level may lead to disparities in obtaining services for DV intervention. Culturally appropriate protocols are needed in primary care settings to prevent and intervene among Hispanic women at risk for DV.

Mapping the elder mistreatment iceberg: U.S. hospitalizations with elder abuse and neglect diagnoses.

PURPOSE: This study describes U.S. hospitalizations with diagnostic codes indicating elder mistreatment (EM). METHOD: Using the 2003 Nationwide Inpatient Sample (NIS) of the Healthcare Costs and Utilization Project (HCUP), inpatient stays coded with diagnoses of adult abuse and/or neglect are compared with stays of other hospitalized adults age 60 and older. RESULTS: Few hospitalizations (< 0.02%) were coded with EM diagnoses in 2003. Compared to other hospitalizations of older adults, patients with EM codes were twice as likely to be women (OR = 2.12, 95% CI = 1.63-2.75), significantly more likely to be emergency department admissions (78.0% vs. 56.8%, p < .0001), and, on average, more likely to have longer stays (7.0 vs. 5.6 days, p = 0.01). Patients with EM codes were also three to four times more likely to be discharged to a facility such as a nursing home rather than "routinely" discharged (i.e., to home or self-care) (OR = 3.66, 95% CI = 2.92-4.59). Elder mistreatment-coded hospitalizations compared to all other hospitalizations had on average lower total charges ($21,479 vs. $25,127, p < .001), with neglect cases having the highest charges in 2003 ($29,389). IMPLICATIONS: Knowledge about EM is often likened to the "tip of the iceberg." Our study contributes to "mapping the EM iceberg"; however, findings based on diagnostic codes are limited and should not be used to minimize the problem of EM. With the so-called graying of America, training is needed in recognizing EM along with research to improve our nation's response to the mistreatment of our elderly population.

Family physicians' knowledge and screening of chronic hepatitis and liver cancer.

BACKGROUND AND OBJECTIVES: Studies show that primary care providers may suboptimally diagnose, treat, or refer patients with hepatitis C virus (HCV) infection. In addition, little is known about family physicians' knowledge and practices regarding chronic hepatitis B virus (HBV) infection or monitoring for hepatocellular carcinoma (HCC). METHODS: We used a cross-sectional mail survey of members of the New Jersey Academy of Family Physicians (n=217). Outcome measures were knowledge of risk factors, screening, counseling for chronic HCV and HBV, and screening for HCC. RESULTS: Mean knowledge score for risk factors was 79% (HBV) and 70% (HCV). Physicians who diagnosed >or= six cases per year had higher knowledge of HBV risk factors. Physicians in practice >20 years had lower knowledge of HCV risk factors. Mean knowledge score for counseling was 77%. About 25% screened for liver cancer. Screening for HCC in patients with HBV was related to years in practice, female physicians, and group practice. Physicians in academic settings were more likely to screen patients with HCV for HCC. Forty-two percent and 51% referred patients with chronic HBV and chronic HCV, respectively, to the specialist for total management. CONCLUSIONS: Family physicians have insufficient knowledge about screening and counseling for chronic hepatitis and hepatocellular carcinoma.

The effect of patient navigation on time to diagnosis, anxiety, and satisfaction in urban minority women with abnormal mammograms: a randomized controlled trial.

Delay in follow-up after an abnormal mammogram is associated with advanced disease stage, poorer survival, and increased anxiety. Despite the implementation of many patient navigator programs across the country, there are few published, peer-reviewed studies documenting its effectiveness. We tested the effectiveness of a patient navigator in improving timeliness to diagnosis, decreasing anxiety, and increasing satisfaction in urban minority women after an abnormal mammogram. Women with suspicious mammograms were randomly assigned to usual care (N=50) or usual care plus intervention with a patient navigator (N=55). There were no demographic differences between the two groups. Women in the intervention group had shorter times to diagnostic resolution (mean 25.0 vs. 42.7 days; p=.001), with 22% of women in the control group without a final diagnosis at 60 days vs. 6% in the intervention group. The intervention group also had lower mean anxiety scores (decrease of 8.0 in intervention vs. increase of 5.8 in control; p<.001), and higher mean satisfaction scores (4.3 vs. 2.9; p<.001). Patient navigation is an effective strategy to improve timely diagnostic resolution, significantly decrease anxiety, and increase patient satisfaction among urban minority women with abnormal mammograms.

Randomized comparison of 3 methods to screen for domestic violence in family practice.

PURPOSE: We undertook a study to compare 3 ways of administering brief domestic violence screening questionnaires: self-administered questionnaire, medical staff interview, and physician interview. METHODS: We conducted a randomized trial of 3 screening protocols for domestic violence in 4 urban family medicine practices with mostly minority patients. We randomly assigned 523 female patients, aged 18 years or older and currently involved with a partner, to 1 of 3 screening protocols. Each included 2 brief screening tools: HITS and WAST-Short. Outcome measures were domestic violence disclosure, patient and clinician comfort with the screening, and time spent screening. RESULTS: Overall prevalence of domestic violence was 14%. Most patients (93.4%) and clinicians (84.5%) were comfortable with the screening questions and method of administering them. Average time spent screening was 4.4 minutes. Disclosure rates, patient and clinician comfort with screening, and time spent screening were similar among the 3 protocols. In addition, WAST-Short was validated in this sample of minority women by comparison with HITS and with the 8-item WAST. CONCLUSIONS: Domestic violence is common, and we found that most patients and clinicians are comfortable with domestic violence screening in urban family medicine settings. Patient self-administered domestic violence screening is as effective as clinician interview in terms of disclosure, comfort, and time spent screening.

Cancer screening in women: body mass index and adherence to physician recommendations.

BACKGROUND: The reasons that obese women are less likely to obtain mammograms and Papanicolaou tests (Pap smears) are poorly understood. This study evaluated associations between body mass index (BMI) and receipt of and adherence to physician recommendations for mammography and Pap smear. METHODS: Data from the 2000 National Health Interview Survey (8289 women aged 40 to 74 years) were analyzed in 2006 using logistic regression. Women with previous hysterectomy were excluded from Pap smear analyses (n=5521). Outcome measures were being up-to-date with screening, receipt of physician recommendations, and women's adherence to physician recommendations for mammography and Pap smear. RESULTS: After adjusting for sociodemographic variables, healthcare access, health behaviors, and comorbidity, severely obese women (BMI > 40 kg/m(2)) were less likely to have had mammography within 2 years (odds ratio [OR]=0.50, 95% confidence interval [CI]=0.37-0.68) and a Pap smear within 3 years (OR=0.43, 95% CI=0.27-0.70). Obese women were as likely as normal-weight women to receive physician recommendations for mammography and Pap smear. Severely obese women were less likely to adhere to physician recommendations for mammography (OR=0.49, 95% CI=0.32-0.76). Women in all obese categories (BMI > 30 kg/m(2)) were less likely to adhere to physician recommendations for Pap smear (ORs ranged from 0.17 to 0.28, p<0.001). CONCLUSIONS: Obese women are less likely to adhere to physician recommendations for breast and cervical cancer screening. Interventions focusing solely on increasing physician recommendations for mammography and Pap smears will probably be insufficient for obese women. Additional strategies are needed to make cancer screening more acceptable for this high-risk group.