Refugee and migrants' involvement in participatory spaces in a US practice-based research network study: Responding to unanticipated priorities.

BACKGROUND: Refugees and migrants face suboptimal involvement in spaces for primary healthcare decision-making. Given the rising numbers of resettled refugees and migrants in primary care settings in the United States, there is an urgent need for patient-centred outcome research in practice-based research networks (PBRNs) with diverse ethnolinguistic communities. This study explored whether researchers, clinicians and patients would achieve consensus on (1) a common set of clinical problems that were applicable across a PBRN and (2) potential clinical interventions to address those problems to inform a patient-centred outcomes research (PCOR) study in a similar research network. METHODS: In this qualitative participatory health research study, patients from diverse ethnolinguistic communities and clinicians from seven practices in a US PBRN discussed preferences for PCOR responsive to patients and the clinicians who serve them in language-discordant settings. Researchers and an advisory panel that included patients and clinicians from each participating practice held regular advisory meetings to monitor progress on project milestones and solve emerging problems. Participants took part in 10 sessions using Participatory Learning in Action and the World Café methods to identify and prioritise their ideas, using questions set for them by the advisory panel. Data were analysed based on principles of qualitative thematic content analysis. RESULTS: Participants identified common barriers in language-discordant healthcare settings, principally patient-clinician communication barriers and suggestions to overcome these barriers. A key finding was an unanticipated consensus about the need for attention to healthcare processes rather than a clinical research priority. Negotiation with research funders enabled further analysis of potential interventions for care processes to improve communication and shared decision-making in consultations and the practice as a whole. CONCLUSION: PCOR studies should examine interventions for improving communication between patients from diverse ethnolinguistic communities and primary care staff if the sorts of harms experienced by patients experiencing language-discordant healthcare are to be reduced or prevented. Flexibility and responsiveness from funders to unanticipated findings are key structural supports for participatory health research in primary care clinical settings with this population and others who experience marginalisation and exclusion. PATIENT OR PUBLIC CONTRIBUTION: Patients and clinicians participated in the study both in the formulation of the study question, data collection, analysis and dissemination of these results; consented to their individual participation; and reviewed early drafts of the manuscript.

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.

Research interests of family physicians applying for research training.

BACKGROUND: There is an ongoing need for research to support the practice of high quality family medicine. The Family Medicine Discovers Rapid Cycle Scientific Discovery and Innovation (FMD RapSDI) program is designed to build capacity for family medicine scientific discovery and innovation in the United States. Our objective was to describe the applicants and research questions submitted to the RapSDI program in 2019 and 2020. METHODS: Descriptive analysis for applicant characteristics and rapid qualitative analysis using principles of grounded theory and content analysis to examine the research questions and associated themes. We examined differences by year of application submission and the applicant's career stage. RESULTS: Sixty-five family physicians submitted 70 applications to the RapSDI program; 45 in 2019 and 25 in 2020. 41% of applicants were in practice for five years or less (n = 27), 18% (n = 12) were in in practice 6-10 years, and 40% (n = 26) were ≥ 11 years in practice. With significant diversity in questions, the most common themes were studies of new innovations (n = 20, 28%), interventions to reduce cost (n = 20, 28%), improving screening or diagnosis (n = 19, 27%), ways to address mental or behavioral health (n = 18, 26%), and improving care for vulnerable populations (n = 18, 26%). CONCLUSION: Applicants proposed a range of research questions and described why family medicine is optimally suited to address the questions. Applicants had a desire to develop knowledge to help other family physicians, their patients, and their communities. Findings from this study can help inform other family medicine research capacity building initiatives.

Family medicine provider and staff identification and response to male patient intimate partner violence perpetration.

Context: One in five men report lifetime intimate partner violence (IPV) perpetration defined as using physical force against an intimate partner. Two in three male IPV perpetrators seek routine health services. Family medicine physicians can use IPV perpetration screening tools validated in healthcare, and potentially refer men to local battering intervention programs. However, family medicine physicians feel unprepared to screen male patients for IPV due to lack of knowledge and training. Objective: understand family medicine provider and staff feasibility and acceptability of identification and response to male patient IPV perpetration. Study Design and Analysis: individual online, audio-recorded interviews transcribed verbatim. Three research team members (family medicine physician, qualitative analyst, data scientist) used qualitative content analysis to develop codes and themes. Setting: two Midwestern academic family medicine outpatient centers. Population studied: family medicine clinic providers and staff. Outcome measures: interview guide reviewed experiences talking to male patients about and identification of IPV perpetration, reviewing screening results, referral, intervention, and organizational challenges. Results: 10 family medicine providers (medical director, physicians, psychologist, nurses, social workers) and staff (medical assistants) were interviewed 2020-2021. Providers and staff described few experiences speaking with male patients about IPV but reported knowledge of male IPV through discussion with patients' partners. IPV identification can occur through patient self-read questionnaire or by providers asking questions of patients with at-risk behaviors. Subjects recognized IPV perpetration screening barriers such as trust and patient comfort, and facilitators to screening including electronic medical record prompts and patient portal use. Providers described ways to increase patient use of interventions such as warm referral and virtual visits. Subjects described organizational challenges to IPV perpetration identification and response including limited time and resources, but hypothesized that training could improve implementation. Conclusions: family medicine providers and staff describe various methods to identify and respond to male patient IPV perpetration, including use of a team approach, warm referrals, recognizing patient and provider barriers, and building on continuity relationships already established in primary care.

Informing the American Academy of family Physician's Health Equity strategy - an environmental scan using the Delphi technique.

BACKGROUND: Many organizations have prioritized health equity and the social determinants of health (SDoH). These organizations need information to inform their planning, but, relatively few quantifiable measures exist. This study was conducted as an environmental scan to inform the American Academy of Family Physician's (AAFP's) health equity strategy. The objectives of the study were to identify and prioritize a comprehensive list of strategies in four focus areas: health equity leadership, policy, research, and diversity. METHODS: A Delphi study was used to identify and prioritize the most important strategies for reducing health inequities among the four aforementioned focus areas. Health equity experts were purposefully sampled. Data were collected in three rounds for each focus area separately. A comprehensive list of strategy statements was identified for each focus area in round one. The strategy statements were prioritized in round two and reprioritized in a final third round. Quantitative and qualitative data were integrated for the final analysis. RESULTS: Fifty strategies were identified across the four focus areas. Commitment to health equity, knowledge of health inequities, and knowledge of effective strategies to address the drivers of health inequities were ranked the highest for leadership. Universal access to health care and health in all policies were ranked highest for policy. Multi-level interventions, the effect of policy, governance, and politics, and translating and disseminating health equity interventions into practice were ranked the highest for research. Providing financial support to students from minority or low-socioeconomic backgrounds, commitment from undergraduate and medical school leadership for educational equity, providing opportunities for students from minority or low-socioeconomic backgrounds to prepare for standardized tests, and equitable primary and secondary school funding were ranked highest for diversity. CONCLUSIONS: The AAFP and other medical specialty societies have an important opportunity to advance health equity. They should develop a health equity policy agenda, equip physicians and other stakeholders, use their connections with practice-based research networks to identify and translate practical solutions to address the SDoH, and advocate for a more diverse medical workforce. TRIAL REGISTRATION: Not applicable.

Assessment and management patterns for chronic musculoskeletal pain in the family practice setting.

BACKGROUND: Chronic pain affects 11% of the US population. Most patients who experience pain, particularly chronic musculoskeletal pain, seek care in primary care settings. Assessment of the patient pain experience is the cornerstone to optimal pain management; however, pain assessment remains a challenge for medical professionals. It is unknown to what extent the assessment of pain intensity is considered in context of function and quality of life. OBJECTIVE: To understand common practices related to assessment of pain and function in patients with chronic musculoskeletal disorders. DESIGN: Cross-sectional survey. METHODS: A 42-item electronic survey was developed with self-reported numeric ratings and responses related to knowledge, beliefs, and current practices. All physicians and non-physician clinicians affiliated with the AAFP NRN and 2000 AAFP physician members were invited to participate. RESULTS/FINDINGS: Primary care clinicians report that chronic joint pain assessment should be comprehensive, citing assessment elements that align with the comprehensive pain assessment models. Pain intensity remains the primary focus of pain assessment in chronic joint pain and the most important factor in guiding treatment decisions, despite well-known limitations. Clinicians also report that patients with osteoarthritis should be treated by Family Medicine. CONCLUSIONS: Pain assessment is primarily limited to pain intensity scales which may contribute to worse patient outcomes. Given that most respondents believe primary care/family medicine should be primary responsible for the care of patients with osteoarthritis, awareness of and comfort with existing guidelines, validated assessment instruments and the comprehensive pain assessment models could contribute to delivery of more comprehensive care.

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.

A randomized, parallel group, pragmatic comparative-effectiveness trial comparing medication-assisted treatment induction methods in primary care practices: The HOMER study protocol.

Opioid use disorder (OUD) represents a public health crisis in the United States. Medication for opioid use disorder (MOUD) with buprenorphine in primary care is a proven OUD treatment strategy. MOUD induction is when patients begin withdrawal and receive the first doses of buprenorphine. Differences between induction methods might influence short-term stabilization, long-term maintenance, and quality of life. This paper describes the protocol for a study designed to: (1) compare short-term stabilization and long-term maintenance treatment engagement in MOUD in patients receiving office, home, or telehealth induction and (2) identify clinically-relevant practice and patient characteristics associated with successful long-term treatment. The study design is a randomized, parallel group, pragmatic comparative effectiveness trial of three care models of MOUD induction in 100 primary care practices in the United States. Eligible patients are at least 16 years old, have been identified by their clinician as having opioid dependence and would benefit from MOUD. Patients will be randomized to one of three induction comparators: office, home, or telehealth induction. Primary outcomes are buprenorphine medication-taking and illicit opioid use at 30, 90, and 270 days post-induction. Secondary outcomes include quality of life and potential mediators of treatment maintenance (intentions, planning, automaticity). Potential moderators include social determinants of health, substance use history and appeal, and executive function. An intent to treat analysis will assess effects of the interventions on long-term treatment, using general/generalized linear mixed models, adjusted for covariates, for the outcomes analysis. Analysis includes practice- and patient-level random effects for hierarchical/longitudinal data. No large-scale, randomized comparative effectiveness research has compared home induction to office or telehealth MOUD induction on long-term outcomes for patients with OUD seen in primary care settings. The results of this study will offer primary care providers evidence and guidance in selecting the most beneficial induction method(s) for specific patients.

Essential integrated behavioral health care skills for primary care providers: A Delphi study.

INTRODUCTION: Workforce development is a vital process for advancing the field of integrated behavioral health in primary care (IBHPC) and depends on the development of job-specific skills that meet the needs of patients and other team members. Job-specific skills guide both university- and worksite-based training programs in preparing future cohorts of health care professionals in IBHPC; however, there are no extant training criteria for nontrainee primary care providers. METHOD: A multiround survey using a modified Delphi technique was conducted. Participants were recruited from a large national research network, university alumni and community health center partners. Participants included allopathic and osteopathic physicians, physician assistants and nurse practitioners serving as primary care providers in a variety of IBHPC settings. In the survey, participants were instructed to categorize 22 skills as "Essential," "Compatible," or "Irrelevant" for IBHPC practice. Categorized responses were analyzed using descriptive statistics and comments were analyzed using a modified thematic analysis method. RESULTS: Fifty-four participants were recruited for the study, with 43 participating in round 1, 38 participating in round 2, and 36 participating in round 3. After 3 rounds, 19 skills received at least 80% consensus as "Essential" and 22 received at least 50% consensus as "Essential." Comment themes revealed participants were overall agreeable with skills, but had concerns about role, training, and time constraints. DISCUSSION: Primary care providers can prepare for and enhance IBHPC practice by developing skills identified as essential. Employers can adapt this skill list for efforts related to recruiting, hiring, and onboarding. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Stimulant Prescribing Error Assessment Rubric Development.

OBJECTIVE: Stimulant medications are used to treat attention-deficit/hyperactivity disorder (ADHD) in adults. However, stimulants are among the most frequently prescribed medications that have a potential to be used nonmedically. We sought to define types of errors associated with treatment of ADHD in adults and to describe a classification rubric for stimulant-related prescribing faults. METHODS: An expert panel conducted a scoping review of the literature and rubric development. The literature search including relevant English language publications indexed in Medline (1990-present, human) and Embase (1990-present, human). In addition, we reviewed relevant documentation such as medication labels and guides containing information related to medications used for the treatment of adult ADHD. The initial version draft rubric was developed by adapting an existing framework for prescribing errors. The expert panel further defined a classification rubric and developed error subcategories, classifications, and descriptions. RESULTS: Two error categories were identified. Category 1 errors are errors resulting from prescribing faults, which further included errors in decision making/judgment; errors related to monitoring for potential harm of stimulants; possible errors: events that should generally be avoided or be used with caution; and suboptimal prescribing. Category 2 errors result from prescription writing, further defined as failure to communicate essential information and transcription errors. CONCLUSIONS: This study provides a comprehensive description of medication errors associated with stimulant and related medications. Our findings have the potential to assist decision making and to tailor delivery programs, recommendations, guidelines, and clinical decision support health information technology on stimulant prescribing and monitoring.

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.