Research to Improve Clinical Care in Family Medicine: Big Data, Telehealth, Artificial Intelligence, and More.

This issue highlights changes in medical care delivery since the start of the COVID-19 pandemic and features research to advance the delivery of primary care. Several articles report on the effectiveness of telehealth, including its use for hospital follow-up, medication abortion, management of diabetes, and as a potential tool for reducing health disparities. Other articles detail innovations in clinical practice, from the use of artificial intelligence and machine learning to a validated simple risk score that can support outpatient triage decisions for patients with COVID-19. Notably one article reports the impact of a voluntary program using scribes in a large health system on physician documentation behaviors and performance. One article addresses the wage gap between early-career female and male family physicians. Several articles report on inappropriate testing for common health problems; are you following recommendations for ordering Pulmonary Function Tests, mt-sDNA for colon cancer screening, and HIV testing?

[Organization and practice in family medicine. What's new in the 2024 literature?] / Organisation des soins en médecine de famille. Quoi de neuf dans la littérature scientifique en 2024 ?

This is a selection of some important studies recently published and dealing with several key organization and functioning features of family medicine. This year, the articles focus on organizational responses to emergencies in family medicine. In this field, the use of primary care professionals other than physicians is an interesting solution. One article examines direct access to a physiotherapist, with very positive results, while a second explores the wide-ranging skills of advanced practice nurses in the emergency field. In some countries, such as Belgium, the use of teleconsultation in primary care is also being considered to avoid inappropriate use of hospital emergencies. Finally, more macroscopic organizational aspects of the healthcare system and the role of primary care in health emergencies will be considered in the last article.

Cet article présente une sélection d'études récemment publiées et explorant différents aspects du fonctionnement de la médecine de famille (MF). Elles sont centrées sur les réponses organisationnelles face à l'urgence en MF. Dans ce domaine, le recours à d'autres professionnels de soins primaires que les médecins est une approche intéressante. Ainsi un premier article porte sur l'accès direct au physiothérapeute et montre des résultats très positifs ; un second décrit les compétences des infirmières de pratique avancée mobilisables dans l'urgence. Le recours à la téléconsultation est aussi envisagé pour une utilisation plus appropriée des urgences hospitalières dans certains pays. Enfin, les aspects organisationnels plus macroscopiques sur la place des soins primaires dans l'urgence sanitaire sont réfléchis dans un dernier article.

Screening for cardiac amyloidosis in patients with tenosynovial red flags: A collaboration between family medicine and cardiology.

BACKGROUND: Amyloid deposition in tenosynovial structures precedes cardiac involvement up to 20 years. Therefore, a cardiological screening in patients with a history of tenosynovial manifestations of cardiac amyloidosis (CA) could lead to an increased number of early diagnoses. METHODS: Patients with tenosynovial manifestations of CA (carpal tunnel syndrome, atraumatic biceps tendon rupture, lumbar spinal stenosis) have been identified by general practitioners and evaluated in a Referral Center for CA. Patients with a high suspicion of CA underwent the CA diagnostic pathway. RESULTS: Among 50 General Practitioners (GP) contacted, 10 (20%) agreed to participate in the study for a total of 5615 patients ≥60 years. One hundred forty-five patients met the inclusion criteria, 2 of them already had a diagnosis of CA, and 57 agreed to undergo a cardiological evaluation (electrocardiography, echocardiography, NTproBNP assay). The median age was 73 [67-80] years and 31 (54%) were women. Eight patients were suggested to start the CA diagnostic pathway, five of them underwent a complete diagnostic evaluation for CA, three refused to complete the diagnostic exams and no new diagnoses were made. CONCLUSION: A screening program for CA in patients with tenosynovial manifestations identified by general practitioners is feasible, but may not yield a high rate of new diagnosis. In this study, we identified two patients who already had a diagnosis of CA, and among patients at high risk for CA, 37% refused to complete the diagnostic pathway. Increased awareness of CA among patients might increase participation and diagnostic yield in screening studies. Further validation of this protocol is needed to evaluate its diagnostic performance.

Family Medicine Team Perspectives on Screening for Health-Related Social Needs.

INTRODUCTION: Social drivers of health (SDH) strongly influence health outcomes and disparities. Although systemic level change is vital to address the disparities driven by SDH, it is also crucial that health care organizations develop the ability to care for patients in a manner that accounts for social factors and their influence on patient health. Although primary care is a natural fit for health-related social needs (HRSN) screening and intervention, significant barriers can impede primary care's effectiveness in this area. METHODS: We conducted 3 focus groups with family medicine clinicians, clinical staff, and social care workers in an academic medical center using a semistructured discussion guide to explore current practices, perceived benefits, barriers, and potential opportunities and approaches for integrating routine HRSN screening in primary care. RESULTS: 3 primary themes emerged from the focus groups. They included 1) the barriers to routine screening in primary care, including time, workload, emotional burden, patient factors, and team members' fear of inadequacy of resources or their own ability; 2) the importance and benefit of HRSN screening, including the opportunity to improve patient care through increased care team awareness of the patient's context, interventions to address HRSN, and improved relationships between the care team and the patient; and 3) recommendations for implementing routine screening in primary care, including opportunities to optimize workflow and technology, the importance of an electronic medical record (EMR)-integrated resource database, and the centrality of teamwork. DISCUSSION: Family medicine health care teams embrace the importance of HRSN screening and the potential for positive impact. However, there are vital barriers and considerations to address for HRSN screening to be effectively integrated into primary care visits.

Abordaje contextual en la práctica del médico de familia / Contextual approach in the practice of the family physician

El contexto representa un conjunto de circunstancias que rodean una situación y, sin las cuales, esta no puede comprenderse en forma correcta. La relación médico paciente está enmarcada en un vínculo contextual. En la práctica cotidiana del médico de familia la atención del paciente se realiza de manera integral, sin disociar el cuerpo del contexto. En este artículo los autores desarrollan el abordaje contextual como herramienta diagnóstica y se describen con detalle dos instrumentos útiles para ponerla en práctica: la evaluación contextual y la entrevista de FOCO (Familia, Orientación y Contexto). (AU)

The context represents a set of circumstances that surround a situation without which it can not be properly understood.The patient-physician relationship is framed in a contextual link. In the daily practice of the family physician, patient careis carried out in an integral manner, without dissociating the body from the context. In this article the authors develop the contextual approach as a diagnostic tool and describe in detail two useful instruments to put it into practice: the contextual assessment and the FOCO interview (Family, Orientation and Context). (AU)

The Sentiworld project: global mapping of sentinel surveillance networks in general practice.

BACKGROUND: Sentinel networks composed of general practitioners (GPs) represent a powerful tool for epidemiologic surveillance and ad-hoc studies. Globalization necesitates greater international cooperation among sentinel networks. The aim of this study was to inventory GP sentinel networks involved in epidemiological surveillance on a global scale. METHODS: GP sentinel surveillance networks were inventoried globally between July 2016 and December 2019. Each identified network was required to fill out an electronic descriptive survey for inclusion. RESULTS: A total of 148 networks were identified as potential surveillance networks in general practice and were contacted. Among them, 48 were included in the study. Geographically, 33 networks (68.8%) were located in Europe and 38 (79.2%) had national coverage. The number of GPs registered in these networks represented between 0.1 and 100% of the total number of GPs in the network's country or region, with a median of 2.5%. All networks were involved in continuous epidemiologic surveillance and 47 (97.9%) monitored influenza-like illness. Data collection methods were paper-based forms (n = 26, 55.3%), electronic forms on a dedicated website (n = 18, 38.3%), electronic forms on a dedicated software program (n = 14, 29.8%), and direct extraction from electronic medical records (n = 14, 29.8%). Along with this study, a website has been created to share all data collected. CONCLUSIONS: This study represents the first global geographic mapping of GP sentinel surveillance networks. By sharing this information, collaboration between networks will be easier, which can strengthen the quality of international epidemiologic surveillance. In the face of crises like that of COVID-19, this is more imperative than ever before.

Family Practices in Transforming Clinical Practice Initiative Showed No Changes in Medicare Costs or Utilization.

BACKGROUND: The Centers for Medicare and Medicaid Services proposed that the Transforming Clinical Practice Initiative (TCPI) would improve health outcomes for patients, reduce utilization of institutional services, and generate significant savings for payers by the end of September 2019. OBJECTIVE: The objective of this study was to investigate whether participation in TCPI's Practice Transformation Networks (PTNs) was associated with improved cost and utilization outcomes for Medicare patients of family medicine-based practices in the first 2 years, that is, 2016-2017, of the Initiative. STUDY DESIGN: A quasi-experimental design with a longitudinal cohort of family medicine-based practices and a propensity-matched comparison sample. SUBJECTS: A total of 761 PTN practices and 3451 non-PTN practices. MEASURES: To measure practice-level patient outcomes, we attributed patients to practice based on the plurality of office visits. We obtained Medicare claims from 2011 to 2017 to assess PTN participation effects for Medicare Part A and B costs, hospital admission, and emergency department visit rates using a Difference-in-Differences design, adjusting for baseline characteristics. RESULTS: The differences in Medicare Part A and B costs (-1.71%, P=0.25), annual rates of hospitalization (-0.59%, P=0.12) and emergency department visit (-0.29%, P=0.46) were not significantly lower among PTN practices (N=761) than among propensity score-matched non-PTN practices (N=3541). CONCLUSIONS: TCPI's transforming efforts, such as the outcomes examined in the study, might need a longer time frame to manifest and require evaluation after the full 4-year participation period. The indistinguishable effect of PTN participation may also be attributed to the fact that non-PTN practices might have participated in other initiatives that changed their care and curbed health care utilization and costs consequently.

Restorative reproductive medicine for infertility in two family medicine clinics in New England, an observational study.

BACKGROUND: Restorative reproductive medicine (RRM) seeks to identify and correct underlying causes and factors contributing to infertility and reproductive dysfunction. Many components of RRM are highly suitable for primary care practice. We studied the outcomes amongst couples who received restorative reproductive medicine treatment for infertility in a primary care setting. METHODS: Two family physicians in Massachusetts trained in a systematic approach to RRM (natural procreative technology, or NaProTechnology) treated couples with infertility. We retrospectively reviewed the characteristics, diagnoses, treatments, and outcomes for all couples treated during the years 1989 to 2014. We compared pregnancy and live birth by clinical characteristics using Kaplan-Meier analysis. We employed the Fleming-Harrington weighted Renyi test or the logrank test to compare the cumulative proportion with pregnancy or with live birth. RESULTS: Among 370 couples beginning treatment for infertility, the mean age was 34.8 years, the mean prior time trying to conceive was 2.7 years, and 27% had a prior live birth. The mean number of diagnoses per couple was 4.9. Treatment components included fertility tracking with the Creighton Model FertilityCare System (80%); medications to enhance cervical mucus production (81%), to stimulate ovulation (62%), or to support the luteal phase (75%); and referral to female laparoscopy by a surgeon specializing in endometriosis (46%). The cumulative live birth rate at 2 years was 29% overall; this was significantly higher for women under age 35 (34%), and for women with body mass index < 25 (40%). There were 2 sets of twins and no higher-order multiple gestations. Of the 63 births with data available, 58 (92%) occurred at term. CONCLUSIONS: Family physicians can provide a RRM approach for infertility to identify underlying causes and promote healthy term live births. Younger women and women with body mass index < 25 are more likely to have a live birth.

Urine drug screening: A guide to monitoring Tx with controlled substances.

Avoid error by ordering the appropriate test at a risk-based frequency. Be alert to sources of false-positives and adulteration. Be careful not to overreact to unexpected results.

Guarding against nonmelanoma skin cancer in solid organ transplant recipients.

Periodic skin examination and ongoing counseling are central in your posttransplantation care of these patients at high risk of skin malignancy.

Helping your obese patient achieve a healthier weight.

These tips will help identify underlying causes of obesity, address comorbid conditions, and provide patients with the tools they need to successfully lose weight.

Integrating primary care into a community mental health center.

Our initiation of a reverse-integration practice model revealed numerous advantages and rewards, as well as many challenges, for which we found solutions.

Confidently rule out CAP in the outpatient setting.

A focus on specific signs and symptoms-without imaging-may rule out community-acquired pneumonia in outpatients.

37-year-old man • cough • increasing shortness of breath • pleuritic chest pain • Dx?

► Cough ► Increasing shortness of breath ► Pleuritic chest pain.