Quantifying diagnosis and treatment practices of opioid use disorder in primary care practices using chart review data.

BACKGROUND: Opioid misuse is a significant public health crisis. The aim sought to identify potential gaps in opioid care in primary care practices. METHODS: American Academy of Family Physicians (AAFP) offered a monthly online educational series to seven U.S. practices. Practices were asked to complete up to 50 chart reviews for visits during two periods: February-April, 2019, and February-April, 2022. Each chart had to have an ICD-10 diagnosis of opioid misuse, opioid dependence, or opioid use. Chart reviews consisted of 14 questions derived from an American Academy of Addiction Psychiatry (AAAP) Performance in Practice activity, and then, scored based on practices' responses. Descriptive statistics and binary logistic and multinomial regressions were used. RESULTS: Both periods had 173 chart reviews (total: 346) from the six practices. Most chart reviews were for patients with a diagnosis of opioid dependence (2019: 90.2%; 2022: 83.2%). Three questions for assessing OUD treatment behaviors had high levels of documentation across both time periods (>85%): other drug use, treatment readiness, and treatment discussion. DISCUSSION: Results show a gap in the treatment of patients with OUD in primary care across several clinical practice recommendations. CONCLUSIONS: Expanding OUD treatment integration to primary care remains the most promising effort to combat the opioid crisis.

Integrated Behavioral Health Adaptations During the COVID-19 Pandemic.

INTRODUCTION: COVID-19 pandemic lockdowns threatened standard components of integrated behavioral health (IBH) such as in-person communication across care teams, screening, and assessment. Restrictions also exacerbated pre-existing challenges to behavioral health (BH) access. METHODS: Semistructured interviews were completed with clinicians from family medicine residency programs on the impact of the pandemic on IBH care delivery along with adaptations employed by care teams to ameliorate disruption. RESULTS: Participants (n = 41) from 14 family medicine residency programs described the rapid shift to virtual care, creating challenges for IBH delivery and increased demand for BH services. With patients and care team members at home, virtual warm handoffs and increased attention to communication were necessary. Screening and measurement were more difficult, and referrals to appropriate services were challenging due to higher demand. Tele-BH facilitated continued access to BH services but was associated with logistic challenges. Participants described adaptations to stay connected with patients and care teams and discussed the need to increase capacity for both in-person and virtual care. DISCUSSION: Most practices modified their workflows to use tele-BH as COVID-19 cases increased. Participants shared key learnings for successful implementation of tele-BH that could be applied in future health care crises. CONCLUSION: Practices adapted readily to challenges posed by pandemic restrictions and their ability to sustain key elements of IBH during the COVID-19 pandemic demonstrates innovation in maintaining access when in-person care is not possible, informing strategies applicable to other scenarios.

Integrated Behavioral Health Implementation and Training in Primary Care: A Practice-Based Research Network Study.

INTRODUCTION: Integrating behavioral health services into primary care has a strong evidence base, but how primary care training programs incorporate integrated behavioral health (IBH) into care delivery and training has not been well described. The goal of this study was to evaluate factors related to successful IBH implementation in family medicine (FM) residency programs and assess perspectives and attitudes on IBH among program leaders. METHODS: FM residency programs, all which are required to provide IBH training, were recruited from the American Academy of Family Physicians National Research Network. After completing eligibility screening that included the Integrated Practice Assessment Tool (IPAT) questionnaire, 14 training programs were included. Selected practices identified 3 staff in key roles to be interviewed: medical director or similar, behavioral health professional (BHP), and chief medical officer or similar. RESULTS: Forty-one individuals from 14 FM training programs were interviewed. IPAT scores ranged from 4 (Close Collaboration Onsite) to 6 (Full Collaboration). Screening, outcome tracking, and treatment differed among and within practices. Use of curricula and trainee experience also varied with little standardization. Most participants described similar approaches to communication and collaboration between primary care clinicians and BHPs and believed that IBH should be standard practice. Participants reported space, staff, and billing support as critical for sustainability. CONCLUSIONS: Delivery and training experiences in IBH varied widely despite recognition of the value and benefits to patients and care delivery processes. Standardizing resources and training and simplifying and assuring reimbursement for services may promote sustainable and high quality IBH implementation.

Implementation and Evaluation of Primary Care Team Participation in Opioid Use Disorder Learning Sessions.

INTRODUCTION: Previous studies show that some primary care clinicians do not feel equipped to treat patients with opioid use disorder (OUD). This study addressed the gaps in confidence and knowledge of primary care physicians and other participants (i.e., participants who were not physicians) in diagnosing, treating, prescribing, and educating patients with OUD through interactive learning sessions. METHODS: The American Academy of Family Physicians National Research Network held monthly OUD learning sessions from September 2021 to March 2022 with physicians and other participants (n = 31) from 7 practices. Participants took baseline (n = 31), post-session (n = 11-20), and post-intervention (n = 21) surveys. Questions focused on confidence, knowledge, among others. We used non-parametric tests to compare individual responses pre-versus-post participation as well as to compare responses between groups. RESULTS: All participants experienced significant changes in confidence and knowledge for most topics covered in the series. When comparing physicians to other participants, physicians had greater increases in confidence in dosing and monitoring for diversion (P = .047), but other participants had greater increases in confidence in the majority of topic areas. Physicians also had greater increases in knowledge than other participants in dosing and monitoring for safety (P = .033) and dosing and monitoring for diversion (P = .024), whereas other participants had greater increases in knowledge in most remaining topics. Participants agreed that sessions provided practical knowledge, except for relevancy of the case study portion of the session to current practice (P = .023) and the session improved participant ability to care for patients (P = .044). CONCLUSION: Through participating in interactive OUD learning sessions, knowledge and confidence increased among physicians and other participants. These changes may impact participants' decisions to diagnose, treat, prescribe, and educate patients with OUD.

A Team-Based Training for Continuous Glucose Monitoring in Diabetes Care: Mixed Methods Pilot Implementation Study in Primary Care Practices.

BACKGROUND: The American Academy of Family Physicians (AAFP) develops and maintains continuing medical education that is relevant to modern primary care practices. One continuing medical education modality is AAFP TIPS, which are comprised of resources designed for family medicine physicians and their care teams that aid in quick and accessible practice improvement strategies, with actionable steps. Evaluating physicians' use of and satisfaction with this modality's content and implementation strategies has not been prioritized previously. Continuous glucose monitoring (CGM) plays an increasing role in the treatment of diabetes; uptake occurs more rapidly in endocrinology settings than in primary care settings. To help address such differences in CGM uptake and diabetes care, AAFP TIPS on Continuous Glucose Monitoring (AAFP TIPS CGM) was developed, using published evidence and input from content experts (family medicine faculty; AAFP staff; and an advisory group comprised of other primary care physicians, patients, a pharmacist, and a primary care practice facilitator). A pilot implementation project was conducted in 3 primary care practices. OBJECTIVE: To evaluate AAFP TIPS CGM in primary care practices, the research team assessed use of and satisfaction with the content and assessed barriers to and facilitators for strategy and workflow implementation. METHODS: In total, 3 primary care practices participated in a mixed methods pilot implementation of AAFP TIPS CGM between June and October 2021. Practice champions at each site completed AAFP TIPS CGM and baseline practice surveys to evaluate practice characteristics and CGM prescribing. They conducted team trainings (via webinars or in person), with the goals of implementing CGM into practice and establishing or improving CGM workflows. Practice champions and team training participants completed posttraining surveys to evaluate the training, AAFP TIPS materials, and likelihood of implementing CGM. Interviews were conducted with 6 physicians, including practice champions, 2 months after team training. Satisfaction surveys were also distributed to those who completed the AAFP TIPS CGM course via the internet during the study period. RESULTS: Of the 3 practices, 2 conducted team trainings. The team training evaluation survey showed that practice staff understood their role in implementing CGM in practice (19/20, 95%), and most (11/20, 55%) did not have questions after the training. Insurance coverage for CGM was a remaining knowledge gap and potential barrier to implementing CGM in practice. Physicians and interdisciplinary care team members who took the AAFP TIPS CGM course via the internet, as well as those who attended in-person team training, expressed a high degree of satisfaction with the education, content, and applicability of the course. CONCLUSIONS: This pilot implementation of AAFP TIPS CGM offers pertinent and timely information for primary care practices that desire to initiate or expand CGM use to best meet the needs of their patients with diabetes.

Evaluating a Web-Based Adult ADHD Toolkit for Primary Care Clinicians.

INTRODUCTION: Approximately 5% of the US adult population has Attention Deficient Hyperactivity Disorder (ADHD) that can negatively impact quality of life. Health care professionals report a need to increase their knowledge of and confidence in treating adult ADHD. The American Academy of Family Physicians National Research Network (AAFP NRN) collaborated with a panel of experts to create a web-based AAFP Adult ADHD Toolkit composed of resources to aid in the diagnosis, management, and treatment of adults with ADHD. OBJECTIVES: Assess the impact of using an AAFP Adult ADHD Toolkit in a practice setting. METHODS: Ninety-seven primary and behavioral health care professionals from AAFP NRN practices (n=6) used the Toolkit for 17 weeks. Data on Toolkit use, usefulness, implementation, impact, and changes in knowledge and confidence were collected via pre-post and weekly surveys. Mixed methods, regression analyses, t-tests, and mixed ANOVA were used to assess change over time. RESULTS: Use of the Toolkit improved health care providers' knowledge by midpoint relative to baseline in areas related to treatment effects, side effects, and outcomes (3.6 vs 3.0; P = .004); existing ADHD resources (3.3 vs 2.9; P = .03); and management of ADHD in patients with comorbid conditions (3.2 vs 2.7; P = .01). By the end of the study, Toolkit use was associated with increased confidence in mental health and life history interview techniques (3.5 vs 3.0; P = .03); treatment options for ADHD with comorbid mental health disorders (3.2 vs 2.3; P ≤ .001); and treatment options for ADHD with coexisting substance use disorders (3.0 vs 2.3; P = .003). By the end of the study, most participants (n=47, 87%) reported the Toolkit addressed most of their needs related to diagnosis, treatment, and management of adult ADHD. CONCLUSION: Availability and adoption of the Toolkit into the routine care of adults with ADHD measurably increased health care professionals' knowledge especially in those providers who regularly see adult patients with ADHD.

COVID-19's Financial Impact on Primary Care Clinicians and Practices.

INTRODUCTION: Coronavirus disease 2019 (COVID-19) disrupted and undermined primary care delivery. The goal of this study was to examine the financial impacts the pandemic has had on primary care clinicians and practices. METHODS: The American Academy of Family Physicians National Research Network and the Robert Graham Center distributed weekly surveys from March 27, 2020, through June 15, 2020, to a network of more than 1960 physicians. Responses to the question, "Could you please tell us about any financial impact the COVID-19 pandemic has had on your practice, if any?" were analyzed using a grounded theory approach of qualitative analysis. The number of unique respondents who answered the financial impact question totaled 461 over the 12 weeks. RESULTS: Severe declines in patient visits, causing drastic revenue reductions, greatly impacted the ability to serve patients. Primary care clinicians and practices experienced significant changes in several areas about financial implications: patient visits, financial strain, staffing and telehealth. DISCUSSION: Preliminary findings revealed that even with Coronavirus Aid, Relief, and Economic Security Act, also known as CARES Act, funding, business viability remains questionable for some primary care practices. CONCLUSIONS: Low patient visits directly resulted in decreased revenues, which in turn, impacted staffing decisions and fueled telehealth implementation. It is difficult to predict whether patient visits will increase after June. Alternate payment models could provide some financial stability and address business viability.

Feasibility of Implementing the All Nations Breath of Life Culturally Tailored Smoking Cessation Program for American Indians in Multi-Tribal Urban Communities.

Introduction: Prevalence of cigarette smoking is highest among American Indians, yet few culturally appropriate smoking cessation programs have yet been developed and tested for multi-tribal American Indian adult populations. This study examined implementation of the All Nations Breath of Life culturally tailored smoking cessation program in multi-tribal urban and suburban American Indian communities in seven locations across five states (N = 312). Methods: This single-arm study used community-based participatory research to conduct a 12-week intervention whose primary purpose was to curb commercial tobacco use among American Indians. Participants were followed through month 6 in person and month 12 via telephone. The primary outcome was continuous abstinence from recreational cigarette smoking at 6 months post-baseline, verified through voluntary provision of salivary cotinine levels. Results: At program completion (12 weeks post-baseline), 53.3% of program completers remained abstinent; labeling those lost to follow-up as smokers resulted in a 41.4% quit rate. At 6 months post-baseline (primary endpoint), 31.1% of retained participants quit smoking (p < .0001 compared to the highest quit rates among multi-tribal populations reported in the literature, 7%); final quit rate was 22.1% labeling those lost to follow-up as smokers (p = .002). Retention rate at endpoint was 71.2%. 12-month follow-up was attempted with all participants and had a retention rate of 49.0%. Of those participants reached, 34.0% were smoke-free. Conclusions: All Nations Breath of Life shows promise as a smoking cessation program for multi-tribal urban American Indian communities. It can be successfully implemented in a variety of urban settings. Implications: This is the first large feasibility study of a culturally tailored smoking cessation program for American Indians with good cessation and retention rates in a multi-tribal urban American Indian population. It shows that All Nations Breath of Life can be implemented in multiple urban settings across five states. To our knowledge, this is the first program of its kind to be implemented across multiple heterogeneous urban locations and to include salivary cotinine testing for verification of self-report data across these locations.

COLORECTAL CANCER SCREENING PRACTICES AMONG THREE AMERICAN INDIAN COMMUNITIES IN MINNESOTA.

Colorectal cancer (CRC) is a leading cause of cancer morbidity and mortality. Effective prevention and early detection may be achieved through screening, but screening rates are low, especially in American Indian (AI) populations. We wanted to understand perceptions of CRC screening among AI located in the Great Lakes region. Focus groups were recorded and transcribed verbatim (N = 45). Data were analyzed using qualitative text analysis. Themes that deterred CRC screening were low CRC knowledge, fear of the procedure and results, cost and transportation issues, and a lack of quality and competent care. Suggestions for improvement included outreach efforts and culturally-tailored teaching materials.

Recruitment and Baseline Characteristics of American Indian Tribal College Students Participating in a Tribal College Tobacco and Behavioral Survey.

INTRODUCTION: American Indians (AIs) have the highest cigarette smoking rates of any racial/ethnic group in the United States. Although the overall smoking prevalence in the United States for nonminority populations has decreased over the past several decades, the same pattern is not observed among AIs. The purpose of this observational study was to collect cigarette smoking and related information from American Indian tribal college students to inform tailored interventions. METHODS: We conducted a repeated cross-sectional survey of American Indian tribal college students, Tribal College Tobacco and Behavior Survey (TCTABS), with a focus on recruiting all incoming freshman at three participating tribal colleges in the Midwest and Northern Plains regions. A total of 1256 students participated in the baseline surveys between April 2011 and October 2014. RESULTS: The overall smoking prevalence of this sample was 34.7%, with differences by region (Northern Plains-44.0% and Midwest-28%). The majority, 87.5% of current smokers reported smoking 10 or less cigarettes per day, 41% reported smoking menthol cigarettes, 52% smoked Marlboro brand, and the mean age of their first cigarette was 14 years. The majority, 62% had made at least one quit attempt in the past year. The overwhelming majority of respondents, regardless of their smoking status, thought that the current smoking prevalence on campus was greater than 41% and approximately one-third believed that it was as high as 61%. CONCLUSIONS: Very few studies of smoking have been conducted in this population and results from our study confirm the need for effective interventions. IMPLICATIONS: AIs have the highest cigarette smoking rates compared to other racial/ethnic groups in the United States. Furthermore, limited studies have examined the epidemiology of cigarette smoking among tribal college students. This study addresses health disparities related to smoking among college students by examining the demographic, cultural, and environmental characteristics of smoking and quitting. Results from this study could lead to the development of a culturally-tailored smoking cessation and prevention program for American Indian tribal college students.

Health status among black African-born women in Kansas City: a preliminary assessment.

BACKGROUND: Health information and statistics for Black foreign-born women in the United States are under-reported or not available. Black foreign-born women typically are classified under the general category of African American, ignoring the heterogeneity that exists in the United States Black population. It is important to identify health issues and behaviors of African-born women to effectively address health disparities. METHODS: Black African-born women (N = 29), 20 years or older completed a survey about general and women's health, health history, acculturation, lifestyle, social and health challenges, beliefs about breast cancer. Data were analyzed using SPSS 14.0 software. Categorical variables were summarized with frequencies and percentages and continuous variables were summarized with means and standard variation. A Likert scale (strongly agree, agree, disagree, and strongly disagree) was used to assess beliefs about breast cancer. RESULTS: Most (71.4%) participants had a high school education or more, 70% were employed, and 50% had health insurance. Two-thirds received health care from primary care doctors, 20.7% from health departments, and 39.3% got annual checkups. Lack of jobs, healthcare cost, language barrier, discrimination, and child care were the top social issues faced by participants. High blood pressure, obesity, oral health, HIV/AIDS, and diabetes were indicated as the most common health problems. The percent of participants (60%) that had not had a mammogram within the previous 2 years was more than the state average (24%) for women 40 years and older reported by the Kansas Department of Health and Environment. The percent of participants (40%) that had a mammogram within the previous 2 years was lower than the national average (73.2%) for African American women. CONCLUSIONS: Study provides a snapshot of social concerns and health issues in an African population residing in Midwestern United States. Understanding the socio-cultural characteristics of this population is necessary to address health disparities.

Creating a Bridge of Understanding between Two Worlds: Community-Based Collaborative-Action Research with Sudanese Refugee Women.

OBJECTIVE: To explore the process of partnership between university researchers, students, and South Sudanese refugee women to address the health challenges associated with their resettlement transition to the United States. DESIGN AND SAMPLE: This qualitative study used a community-based collaborative action research (CBCAR) framework in the design, collection, and analysis of the qualitative data. Twenty refugee women participated in this study. INTERVENTION: Five health education seminars followed by an audio-recorded focus group were held over 9 months. A final focus group was held to confirm derived themes and develop an action plan. RESULTS: The partnership between the refugee women and researchers resulted in awareness of how power structures and differing expectations affected the process. The dialog in the focus groups provided an opportunity for refugee women to voice challenges to their health in resettlement. A pattern was recognized about how political and sociocultural events affected the process of CBCAR. Dialog and sharing differing worldviews and perspectives led to insights about ways to improve the health of the South Sudanese refugee community. CONCLUSIONS: CBCAR is a useful framework to address health concerns of a refugee community. Insights from this study provided a foundation for a future intervention research project with the refugee women.

Barriers to autism screening in family medicine practice: a qualitative study.

AIM: We explored potential barriers to adoption of recommended screening for autism by family physicians at 18- and 24-month well-child visits. BACKGROUND: The American Academy of Pediatrics recommends early detection and intervention of autism through the use of a standardized autism-specific screening tool on all children at the 18- and 24-month well-child visits. However, not all family physicians screen for autism. METHODS: Three focus groups and six semi-structured interviews were conducted with 15 family physicians in the Kansas City metropolitan area. Verbatim transcripts were inductively coded; data were analyzed using standard text analysis. FINDINGS: Participants had differing views on the increased incidence of autism. Most participants attributed the increase to changes in diagnostic criteria. There was no consensus on the benefit of implementing universal screening for autism during the 18- or 24-month visit. Many preferred to identify potential problems through general developmental assessments and observations. No participants used specific screening tools for autism, and only one participant was aware of such a tool (M-CHAT). Lack of adequate training on child development and screening methods as well as limited availability of community-based resources to manage children with autism was seen as major barriers to routine screening. Suggested solutions included working toward a stronger evidence base, improving physician training and continuing education, and making systemic changes in healthcare. In conclusion, universal screening for autism at the 18- and 24-month visits is not widely accepted, nor is it implemented by family physicians.

A pilot study of health priorities of Somalis living in Kansas City: laying the groundwork for CBPR.

African immigrant and refugee communities remain medically underserved in the United States. Formative efforts are being directed to address the local needs of communities by researchers, community agencies, and local populations. However, there is a paucity of data and sparse documentation regarding these efforts. The objectives for this pilot study were to identify the health priorities of the Kansas City Somali community and to establish a working relationship between an academic medical university and the local Somali community. Our team used community-based participatory research principles and interviewed Somali community members (n = 11). Participants stated that chronic and mental health conditions were of primary concern. Medical system navigation and literacy struggles were identified as barriers. Participants offered possible solutions to some health issues, e.g., using community health workers and Qur'anic readers. Preliminary findings will help guide future research and inform strategies to improve the health and well-being of this community.

American Indian Men's Perceptions of Breast Cancer Screening for American Indian Women.

Screening, especially screening mammography, is vital for decreasing breast cancer incidence and mortality. Screening rates in American Indian women are low compared to other racial/ethnic groups. In addition, American Indian women are diagnosed at more advanced stages and have lower 5-year survival rate than others. To better address the screening rates of American Indian women, focus groups (N=8) were conducted with American Indian men (N=42) to explore their perceptions of breast cancer screening for American Indian women. Our intent was to understand men's support level toward screening. Using a community-based participatory approach, focus groups were audio-taped, transcribed verbatim, and analyzed using a text analysis approach developed by our team. Topics discussed included breast cancer and screening knowledge, barriers to screening, and suggestions to improve screening rates. These findings can guide strategies to improve knowledge and awareness, communication among families and health care providers, and screening rates in American Indian communities.

Barriers to colorectal cancer screening among American Indian men aged 50 or older, Kansas and Missouri, 2006-2008.

American Indian (AI) men have some of the highest rates of colorectal cancer (CRC) in the United States but among the lowest screening rates. Our goal was to better understand awareness and discourse about colorectal cancer in a heterogeneous group of AI men in the Midwestern United States. Focus groups were conducted with AI men (N = 29); data were analyzed using a community-participatory approach to qualitative text analysis. Several themes were identified regarding knowledge, knowledge sources, and barriers to and facilitators of screening. Men in the study felt that awareness about colorectal cancer was low, and people were interested in learning more. Education strategies need to be culturally relevant and specific.

Breast cancer screening perceptions among American Indian women under age 40.

Breast cancer mortality rates are the second leading cause of cancer death in American Indian (AI) women. AI breast cancer screening rates have been decreasing, and AI women have some of the lowest screening rates compared to other racial/ethnic groups. Our research team investigated breast cancer and breast cancer screening education prior to recommended age for screening. It is imperative to examine the perspectives of young AI women toward breast cancer screening to better understand screening perceptions among AI women. Following a community-based participatory research approach, we conducted five focus groups and four interviews with AI women aged 25-39 (N = 48) in Kansas and Missouri. Nine themes emerged from the focus groups and relate to topics such as the following: knowledge of breast cancer and breast cancer screening, barriers to screening and treatment, suggestions to improve access, and perceptions and use of health-care systems. Specifically, we found that AI women lacked knowledge of details about screenings and their risks for getting breast cancer, cost was cited as a primary barrier to screening, additional education was needed (particularly materials that were AI focused), breast health was generally not discussed with others, and more instruction was requested for techniques used to identify bodily changes or abnormalities. Understanding attitudes of AI women not of recommended screening age may provide an insight into low screening rates among AI women. Furthermore, the results may inform outreach strategies to improve current and future screening rates.

Views, barriers, and suggestions for colorectal cancer screening among american Indian women older than 50 years in the midwest.

OBJECTIVE: Although colorectal cancer (CRC) mortality rates in the US population have shown a decline, American Indian (AI) CRC mortality rates appear to be increasing. CRC screening rates of AIs remain low when compared with other ethnic groups. The research team explored women's perceptions toward CRC screening, existing barriers, and suggestions to promote education and screening among AI women in Kansas and Missouri. METHODS: Using a community-based participatory research approach, the authors conducted 7 focus groups with AI women older than 50 years (N = 52) to better understand their perceptions of and attitudes toward CRC screening. RESULTS: Women recognized barriers to screening, such as embarrassment, privacy issues, fear, insurance, and cost. They countered perceived barriers through inventive suggestions for education and awareness via social support systems and intergenerational relationships. DISCUSSION: CRC screening interventions for AI must be culturally tailored.

American Indian perceptions of colorectal cancer screening: viewpoints from adults under age 50.

Colorectal cancer (CRC) mortality rates have decreased in the general US population; however, CRC mortality rates are increasing among American Indians (AI). AI CRC screening rates remain low when compared to other ethnic groups. Our team investigated CRC screening education prior to recommended age for screening to better understand screening perceptions among AI community members. Our research team conducted 11 focus groups with AI men and women aged 30-49 (N = 39 men and N = 31 women) in Kansas and Missouri. The results revealed that community members (1) have little knowledge of CRC, (2) do not openly discuss CRC, and (3) want additional CRC education. Variations existed among men and women's groups, but they agreed that preventive measures need to be appropriate for AI communities. Thus, AI CRC screening interventions should be culturally tailored to better meet the needs of the population.