A Cross-Sectional Study of Factors Associated With Pediatric Scope of Care in Family Medicine.

PURPOSE: The objective of this study was to identify demographic and practice characteristics associated with family physicians' provision of care to children including a subgroup analysis of those who see pediatric patients younger or older than 5 years of age. METHODS: This cross-sectional study used data from US family physicians taking the American Board of Family Medicine continuous certification examination registration questionnaire in 2017 and 2018. The outcome of interest was self-reported care of pediatric patients in practice. We performed bivariate and multivariate logistic regression examining the association between various demographic and practice characteristics with the outcome of interest. We performed subgroup analyses for physicians seeing patients under 5 years old and from 5 to 18 years old. RESULTS: Among the 11,674 family physicians included in the final analysis, 9744 (83.8%) saw pediatric patients. Physician- and practice-level factors associated with seeing pediatric patients included rural practice, younger age, non-Hispanic White race/ethnicity, independent practice ownership, nonsolo practice, lower pediatrician density, and higher income geographic area. More family physicians saw 5-to-18-year-olds than < 5-year-olds (83.6% vs 68.2%; P < .001), and the factors associated with pediatric care were similar among these age subgroups. CONCLUSIONS: A majority of continuous certification US family physicians see pediatric patients in practice; however, rates of pediatric care vary widely based on various demographic and practice characteristics. Efforts to maintain a broad scope of practice for US family physicians will require exploration of the underlying mechanisms driving these practice patterns.

White Privilege in a White Coat: How Racism Shaped my Medical Education.

In this essay, I reflect on some of the ways racial privilege influenced my experience as a white physician in training. While white Americans often think of "racism" as a social construct primarily affecting people of color, "racism" is a system of both racial disadvantage as well as reciprocal racial advantage. Medical professionals are increasingly aware of how social determinants of health lead to important health disparities, however white physicians seldom ask how their own racial privilege reinforces a white supremacist culture and what effects this may have on our patients' health. Drawing attention to the powerful legacy of racial discrimination in medical institutions, I call on other white physicians to name their privilege in order to dismantle the systems that propagate racism in our profession.

Continuation of long-acting reversible contraceptives among Medicaid patients.

OBJECTIVE: Our objective was to compare continuation and complication rates of subdermal etonogestrel implants and intrauterine devices (IUDs) using Medicaid insurance claims. STUDY DESIGN: We performed a retrospective cohort study using insurance claims data for 15- to 44-year-old subjects receiving implants or IUDs from 2012 to 2015 in a Medicaid managed care organization in Washington, DC, and Maryland. We performed a planned Kaplan-Meier survival analysis for long-acting reversible contraceptive (LARC) continuation, defined as the absence of a claim for LARC removal, during periods of continuous insurance plan enrollment. RESULTS: Three thousand one hundred three subjects received 1335 implants and 1970 IUDs, with implants more common than IUDs among subjects 15-19 years old (rate ratio=2.42), and implants less common than IUDs for subjects 20-44 years old (rate ratio=0.54). Implants had higher continuation rates at 1 year than IUDs (81.0% vs. 76.7%, p=.01). The difference was larger among subjects 25 to 44 years old (84.1% vs. 79.3%, p=.03) compared with subjects 15 to 19 years old (89.5% vs. 86.8%, p=.09) and subjects 20 to 24 years old (75.7% vs. 73.2%, p=.44). Claims for potential complications were similarly uncommon for both implants and IUDs (8.09% vs. 6.95%, p=.65), as were claims for pregnancies prior to LARC removal (0.82% vs. 0.86%, p=.86). CONCLUSION: Among a sample of 15- to 44-year-old Medicaid recipients, both implants and IUDs had high continuation rates and low complication rates; however, implants were slightly more likely than IUDs to remain in use 1 year after insertion. IMPLICATIONS: Among 15- to 44-year-old Medicaid recipients, both etonogestrel implants and IUDs have high continuation rates and low complication rates at 1-year postinsertion; however, implants are slightly more likely than IUDs to remain in use at 1 year.

Revisiting Primary Care's Critical Role in Achieving Health Equity: Pisacano Scholars' Reflections from Starfield Summit II.

The second Starfield Summit was held in Portland, Oregon, in April 2017. The Summit addressed the role of primary care in advancing health equity by focusing on 4 key domains: social determinants of health in primary care, vulnerable populations, economics and policy, and social accountability. Invited participants represented an interdisciplinary group of primary care clinicians, researchers, educators, policymakers, community leaders, and trainees. The Pisacano Leadership Foundation was one of the Summit sponsors and held its annual leadership symposium in conjunction with the Summit, enabling several Pisacano Scholars to attend the Summit. After the Summit, a small group of current and former Pisacano Scholars formed a writing group to highlight key themes and implications for action discussed at the Summit. The Summit resonated as a call to action for primary care to move beyond identifying existing health inequities and toward the development of interventions that advance health equity, through education, research, and enhanced community partnerships. In doing so, the Summit aimed to build on the foundational work of Dr. Starfield, challenging us to explore the significant role of primary care in truly achieving health equity.

The Association Between Continuity of Care and the Overuse of Medical Procedures.

IMPORTANCE: Both the overuse of unnecessary medical procedures and poor continuity of care are thought to contribute to high health care spending and poor patient outcomes. OBJECTIVE: To investigate the association between care continuity and use of potentially unnecessary procedures. DESIGN, SETTING, AND PARTICIPANTS: Observational retrospective cohort (n = 1,208,250 patients > 65 years) using 5% Medicare fee-for-service claims from 2008. MAIN OUTCOMES AND MEASURES: We evaluated continuity using the Bice-Boxerman continuity of care index. We measured overuse using a previously validated set of 19 potentially overused procedures. RESULTS: Altogether, 14.7% of patients received at least 1 potentially overused procedure during the calendar year. For each 0.1 increase in the continuity score (0.4 SDs), patients had 0.93 times the odds of receiving overused procedures than those with lower scores (95% CI, 0.93-0.94). Higher continuity was significantly associated with lower odds of 9 procedures (Holm-Bonferroni corrected P < .02 was significant: 6 of 13 diagnostic tests [with ORs, 0.84-0.99; P < .001] and 3 therapeutic procedures [with ORs 0.81-0.87; P <.001]). Conversely, higher continuity was significantly associated with increased overuse for 3 procedures (1 diagnostic test [OR, 1.06; P < .001], 1 of 2 screening tests [OR, 1.05; P < .001], and the single monitoring test [OR, 1.03; P < .01]). CONCLUSIONS AND RELEVANCE: Increased continuity was associated with an overall decrease in overuse, suggesting a potential benefit of high-continuity care; however, the strength and direction of the association varied according to the specific procedure.

Perceptions of health system orientation: quality, patient centeredness, and cultural competency.

As part of a pragmatic trial to reduce hypertension disparities, we conducted a baseline organizational assessment to identify aspects of organizational functioning that could affect the success of our interventions. Through qualitative interviewing and the administration of two surveys, we gathered data about health care personnel's perceptions of their organization's orientations toward quality, patient centeredness, and cultural competency. We found that personnel perceived strong orientations toward quality and patient centeredness. The prevalence of these attitudes was significantly higher for these areas than for cultural competency and varied by occupational role and race. Larger percentages of survey respondents perceived barriers to addressing disparities than barriers to improving safety and quality. Health care managers and policy makers should consider how we have built strong quality orientations and apply those lessons to cultural competency.

Federally qualified health centers and private practice performance on ambulatory care measures.

BACKGROUND: The 2010 Affordable Care Act relies on Federally Qualified Health Centers (FQHCs) and FQHC look-alikes (look-alikes) to provide care for newly insured patients, but ties increased funding to demonstrated quality and efficiency. PURPOSE: To compare FQHC and look-alike physician performance with private practice primary care physicians (PCPs) on ambulatory care quality measures. METHODS: The study was a cross-sectional analysis of visits in the 2006-2008 National Ambulatory Medical Care Survey. Performance of FQHCs and look-alikes on 18 quality measures was compared with private practice PCPs. Data analysis was completed in 2011. RESULTS: Compared to private practice PCPs, FQHCs and look-alikes performed better on six measures (p<0.05); worse on diet counseling in at-risk adolescents (26% vs 36%, p=0.05); and no differently on 11 measures. Higher performance occurred in ACE inhibitors use for congestive heart failure (51% vs 37%, p=0.004); aspirin use in coronary artery disease (CAD; 57% vs 44%, p=0.004); ß-blocker use for CAD (59% vs 47%, p=0.01); no use of benzodiazepines in depression (91% vs 84%, p=0.008); blood pressure screening (90% vs 86%, p<0.001); and screening electrocardiogram (EKG) avoidance in low-risk patients (99% vs 93%, p<0.001). Adjusting for patient characteristics yielded similar results, except that private practice PCPs no longer performed better on any measures. CONCLUSIONS: FQHCs and look-alikes demonstrated equal or better performance than private practice PCPs on select quality measures despite serving patients who have more chronic disease and socioeconomic complexity. These findings can provide policymakers with some reassurance as to the quality of chronic disease and preventive care at Federally Qualified Health Centers and look-alikes, as they plan to use these health centers to serve 20 million newly insured individuals.

Is the three-foot bicycle passing law working in Baltimore, Maryland?

Maryland (MD) recently became one of fourteen states in the United States to enact a traffic law requiring motor vehicles to pass bicyclists at a distance of greater than three feet. To our knowledge, motorist compliance with the law has never been assessed. This study measured the distance between overtaking motor vehicles and cyclists [e.g. vehicle passing distance (VPD)], to develop baseline metrics for tracking implementation of the three-foot passing law in Baltimore, MD and to assess risk factors for dangerous passes. During September and October 2011, cyclists (n=5) measured VPD using a previously published video technique (Parkin and Meyers, 2010). Cyclists logged a total of 10.8h of video footage and 586 vehicle passes on 34 bicycle commuting trips. The average trip lasted 19.5±4.9 min and cyclists were passed on average 17.2±11.8 times per trip. VPDs of three feet or less were common when cycling in standard lanes (17%; 78 of 451 passes) and lanes with a shared lane marking (e.g. sharrows) (23%; 11 of 47 passes). No passes of three feet or less occurred in bicycle lanes (0 of 88 passes). A multiple linear regression model was created, which explained 26% of the variability in VPD. Significant model variables were lane width, bicycle infrastructure, cyclist identity, and street identity. Interventions, such as driver education, signage, enforcement, and bicycle infrastructure changes are needed to influence driving behavior in Baltimore to increase motorist compliance with the three-foot law.

Electronic health records and clinical decision support systems: impact on national ambulatory care quality.

BACKGROUND: Electronic health records (EHRs) are increasingly used by US outpatient physicians. They could improve clinical care via clinical decision support (CDS) and electronic guideline-based reminders and alerts. Using nationally representative data, we tested the hypothesis that a higher quality of care would be associated with EHRs and CDS. METHODS: We analyzed physician survey data on 255,402 ambulatory patient visits in nonfederal offices and hospitals from the 2005-2007 National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey. Based on 20 previously developed quality indicators, we assessed the relationship of EHRs and CDS to the provision of guideline-concordant care using multivariable logistic regression. RESULTS: Electronic health records were used in 30% of an estimated 1.1 billion annual US patient visits. Clinical decision support was present in 57% of these EHR visits (17% of all visits). The use of EHRs and CDS was more likely in the West and in multiphysician settings than in solo practices. In only 1 of 20 indicators was quality greater in EHR visits than in non-EHR visits (diet counseling in high-risk adults, adjusted odds ratio, 1.65; 95% confidence interval, 1.21-2.26). Among the EHR visits, only 1 of 20 quality indicators showed significantly better performance in visits with CDS compared with EHR visits without CDS (lack of routine electrocardiographic ordering in low-risk patients, adjusted odds ratio, 2.88; 95% confidence interval, 1.69-4.90). There were no other significant quality differences. CONCLUSIONS: Our findings indicate no consistent association between EHRs and CDS and better quality. These results raise concerns about the ability of health information technology to fundamentally alter outpatient care quality.