Publications by authors named "Andrew Bazemore"

254 Publications

Practice Patterns of Family Physicians With and Without Addiction Medicine Board Certification.

J Am Board Fam Med 2021 Jul-Aug;34(4):814-819

From the Agency for Healthcare Research and Quality, Rockville, MD (STT); American Board of Family Medicine, Lexington, KY (ZJM, AWB, ARE, LEP); Departments of Family Medicine, and Psychiatry and Behavioral Sciences, Rush University, Chicago, IL (RMF); Department of Family and Community Medicine, College of Medicine, University of Kentucky, Lexington, KY (LEP).

Background: The American Board of Medical Specialties recognized addiction medicine (ADM) as a subspecialty in 2016, which was timely given the recent rise in substance use disorder (SUD). The impact of this dual board opportunity on Family Medicine has not been described. Our study enumerates and characterizes physicians dually certified in Family Medicine and ADM.

Methods: We linked American Board of Medical Specialties data from March 2020 on physicians dually boarded in Family Medicine and ADM to responses on demographic and scope of practice questions in the American Board of Family Medicine (ABFM) National Graduate Survey and Family Medicine Certification Examination Registration Questionnaire.

Results: Of current ABFM Diplomates, 0.53% (492/93,269) are also boarded in ADM. Based on survey responses from a subset of dually certified physicians, those who are dually certified are more likely to practice in federally qualified health centers and to hold a faculty position. Dually certified physicians are more likely to provide HIV/AIDS and hepatitis C management and are as likely as non-dually certified physicians to provide newborn care, obstetric deliveries, inpatient adult medicine care, and intensive care.

Discussion: While only a small proportion of family physicians carry dual ADM board certification, those that do disproportionately serve vulnerable populations while retaining broad scope of care. Further work is needed to examine whether SUD treatment access could be addressed by implementing models that support dually certified physicians in consultative and educational efforts that would amplify their impact across the primary care workforce.
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http://dx.doi.org/10.3122/jabfm.2021.04.200456DOI Listing
August 2020

Mobility and social deprivation on primary care utilisation among paediatric patients with asthma.

Fam Med Community Health 2021 07;9(3)

Department of Family Medicine, Oregon Health & Science University, Portland, Oregon, USA.

Objective: Asthma care is negatively impacted by neighbourhood social and environmental factors, and moving is associated with undesirable asthma outcomes. However, little is known about how movement into and living in areas of high deprivation relate to primary care use. We examined associations between neighbourhood characteristics, mobility and primary care utilisation of children with asthma to explore the relevance of these social factors in a primary care setting.

Design: In this cohort study, we conducted negative binomial regression to examine the rates of primary care visits and annual influenza vaccination and logistic regression to study receipt of pneumococcal vaccination. All models were adjusted for patient-level covariates.

Setting: We used data from community health centres in 15 OCHIN states.

Participants: The sample included 23 773 children with asthma aged 3-17 across neighbourhoods with different levels of social deprivation from 2012 to 2017. We conducted negative binomial regression to examine the rates of primary care visits and annual influenza vaccination and logistic regression to study receipt of pneumococcal vaccination. All models were adjusted for patient-level covariates.

Results: Clinic visit rates were higher among children living in or moving to areas with higher deprivation than those living in areas with low deprivation (rate ratio (RR) 1.09, 95% CI 1.02 to 1.17; RR 1.05, 95% CI 1.00 to 1.11). Children moving across neighbourhoods with similarly high levels of deprivation had increased RRs of influenza vaccination (RR 1.13, 95% CI 1.03 to 1.23) than those who moved but stayed in neighbourhoods of low deprivation.

Conclusions: Movement into and living within areas of high deprivation is associated with more primary care use, and presumably greater opportunity to reduce undesirable asthma outcomes. These results highlight the need to attend to patient movement in primary care visits, and increase neighbourhood-targeted population management to improve equity and care for children with asthma.
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http://dx.doi.org/10.1136/fmch-2021-001085DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8278882PMC
July 2021

The Price of Fear: An Ethical Dilemma Underscored in a Virtual Residency Interview Season.

J Grad Med Educ 2021 Jun 29;13(3):316-320. Epub 2021 Apr 29.

is Director, Robert Graham Center for Policy Studies in Family Medicine and Primary Care.

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http://dx.doi.org/10.4300/JGME-D-20-01411.1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8207909PMC
June 2021

Role of social deprivation on asthma care quality among a cohort of children in US community health centres.

BMJ Open 2021 06 23;11(6):e045131. Epub 2021 Jun 23.

Family Medicine, Oregon Health & Science University, Portland, Oregon, USA.

Objective: Social deprivation is associated with worse asthma outcomes. The Social Deprivation Index is a composite measure of social determinants of health used to identify neighbourhood-level disadvantage in healthcare. Our objective was to determine if higher neighbourhood-level social deprivation is associated with documented asthma care quality measures among children treated at community health centres (CHCs).

Methods Setting, Participants, Outcome Measures: We used data from CHCs in 15 states in the Accelerating Data Value Across a National Community Health Center Network (ADVANCE). The sample included 34 266 children with asthma from 2008 to 2017, aged 3-17 living in neighbourhoods with differing levels of social deprivation measured using quartiles of the Social Deprivation Index score. We conducted logistic regression to examine the odds of problem list documentation of asthma and asthma severity, and negative binomial regression for rates of albuterol, inhaled steroid and oral steroid prescription adjusted for patient-level covariates.

Results: Children from the most deprived neighbourhoods had increased rates of albuterol (rate ratio (RR)=1.22, 95% CI 1.13 to 1.32) compared with those in the least deprived neighbourhoods, while the point estimate for inhaled steroids was higher, but fell just short of significance at the alpha=0.05 level (RR=1.16, 95% CI 0.99 to 1.34). We did not observe community-level differences in problem list documentation of asthma or asthma severity.

Conclusions: Higher neighbourhood-level social deprivation was associated with more albuterol and inhaled steroid prescriptions among children with asthma, while problem list documentation of asthma and asthma severity varied little across neighbourhoods with differing deprivation scores. While the homogeneity of the CHC safety net setting studied may mitigate variation in diagnosis and documentation of asthma, enhanced clinician awareness of differences in community risk could help target paediatric patients at risk of lower quality asthma care.
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http://dx.doi.org/10.1136/bmjopen-2020-045131DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8230996PMC
June 2021

Integrating primary care and public health to enhance response to a pandemic.

Prim Health Care Res Dev 2021 06 10;22:e27. Epub 2021 Jun 10.

Department of General Practice & Primary Health Care, University of Auckland, Auckland, New Zealand.

Primary health care (PHC) includes both primary care (PC) and essential public health (PH) functions. While much is written about the need to coordinate these two aspects, successful integration remains elusive in many countries. Furthermore, the current global pandemic has highlighted many gaps in a well-integrated PHC approach. Four key actions have been recognized as important for effective integration.A survey of PC stakeholders (clinicians, researchers, and policy-makers) from 111 countries revealed many of the challenges encountered when facing the pandemic without a coordinated effort between PC and PH functions. Participants' responses to open-ended questions underscored how each of the key actions could have been strengthened in their country and are potential factors to why a strong PC system may not have contributed to reduced mortality.By integrating PC and PH greater capacity to respond to emergencies may be possible if the synergies gained by harmonizing the two are realized.
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http://dx.doi.org/10.1017/S1463423621000311DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8220344PMC
June 2021

Debt of Family Medicine Residents Continues to Grow.

J Am Board Fam Med 2021 May-Jun;34(3):663-664

From the Sparrow-Michigan State University Family Medicine Residency Program, Michigan State University College of Human Medicine, East Lansing (JPP); American Board of Family Medicine, Lexington, KY (ZJM, AWB, LEP); Department of Family and Community Medicine, University of Kentucky, Lexington (ZJM, AWB, LEP).

The proportion of family medicine residents with ≥$250,000 in self-reported educational debt rose from 26% in 2014% to 47% in 2019. Such a rapid rise in high indebtedness is concerning, given known associations with resident distress. Previous research has also shown that highly indebted residents are less likely to choose academics, geriatrics, and service-oriented career paths.
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http://dx.doi.org/10.3122/jabfm.2021.03.200567DOI Listing
October 2020

Academic Achievement, Professionalism, and Burnout in Family Medicine Residents.

Fam Med 2021 Jun;53(6):423-432

American Board of Family Medicine, Lexington, KY.

Background And Objectives: Physician burnout has been shown to have roots in training environments. Whether burnout in residency is associated with the attainment of critical educational milestones has not been studied, and is the subject of this investigation.

Methods: We used data from a cohort of graduating family medicine residents registering for the 2019 American Board of Family Medicine initial certification examination with complete data from registration questionnaire, milestone data, in-training examination (ITE) scores, and residency characteristics. We used bivariate and multilevel multivariate analyses to measure the associations between four professionalism milestones ratings and ITE performance with burnout.

Results: Our sample included 2,509 residents; 36.8% met the criteria for burnout. Multilevel regression modeling showed a correlation between burnout and failure to meet only one of four professionalism milestones, specifically professional conduct and accountability (OR 1.41, 95% CI 1.07-1.87), while no statistically significant relationship was demonstrated between burnout and being in the lowest quartile of ITE scores. Other factors negatively associated with burnout included international medical education (OR 0.60, 95% CI 0.48-0.76) and higher salary compared to cost of housing (OR 0.62, 95% CI 0.46-0.82).

Conclusions: We found significant association between self-reported burnout and failing to meet expectations for professional conduct and accountability, but no relationship between burnout and medical knowledge as measured by lower ITE performance. Further investigation of how this impacts downstream conduct and accountability behaviors is needed, but educators can use this information to examine program-level interventions that can specifically address burnout and development of physician professionalism.
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http://dx.doi.org/10.22454/FamMed.2021.541354DOI Listing
June 2021

Purposeful Imprinting in Graduate Medical Education: Opportunities for Partnership.

Fam Med 2021 07 10;53(7):574-577. Epub 2021 May 10.

University of Michigan Department of Surgery.

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http://dx.doi.org/10.22454/FamMed.2021.264013DOI Listing
July 2021

Sailing the 7C's: Starfield Revisited as a Foundation of Family Medicine Residency Redesign.

Fam Med 2021 07 6;53(7):506-515. Epub 2021 May 6.

University of Nevada-Reno School of Medicine, Reno, NV.

Amidst a pandemic that has acutely highlighted longstanding failings of the US health care system and the graduate medical education (GME) enterprise that serves it, educators prepare to embark on another revision of the program requirements for family medicine GME. We propose in this article a conceptual framework to guide this endeavor, built on a foundation of the core functions that Barbara Starfield suggested might explain primary care's salutary effects. We first revisit these "4C's"-first Contact, Continuity, Comprehensiveness, and Coordination-and how they might inform design thinking in primary care GME guideline revision. We also propose the addition of Community engagement, patient-Centeredness, and Complexity. Training residents to deliver on these "7C's," functions critical to the delivery of high-performing primary care, is essential if family medicine residency graduates are to serve the clearly articulated, but unrealized, quadruple aim for US health care: improved patient experience and population health at lower costs while preserving clinician well-being. Finally, we highlight and illustrate examples of four critical enablers of these 7C core functions of primary care that must be accommodated in training guidelines and reform, suggesting a need for resident competencies in Team-based, Tool- and Technology-enabled, Tailored ("4T's") care of patients and populations.
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http://dx.doi.org/10.22454/FamMed.2021.383659DOI Listing
July 2021

How Comprehensive Medication Management Contributes to Foundational Elements of Primary Care.

J Am Board Fam Med 2021 Mar-Apr;34(2):420-423

From the University of Minnesota College of Pharmacy, Minneapolis (KAF, LAS, TDS); American Board of Family Medicine, Lexington, KY (AWB); University of North Carolina Eshelman School of Pharmacy, Chapel Hill (MTRM); American Academy of Family Physicians National Research Network, Leawood, KS (JKC); Center for Professionalism & Value in Health Care, Washington, DC (AWB).

Pharmacists are more often being recognized as a critical component of the primary care team. Previous literature has not clearly made the connection to how pharmacists and comprehensive medication management (CMM) contribute to recognized foundational elements of primary care. In this reflection, we examine how the delivery of CMM both supports and aligns with Starfield's 4 Cs of Primary Care. We illustrate how the delivery of CMM supports through increased provider access, through empanelment, by addressing unmet medication needs, and through collaborating with the primary care team and broader team. The provision of CMM addresses critical unmet medication-related needs in primary care and is aligned with the foundational elements of primary care.
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http://dx.doi.org/10.3122/jabfm.2021.02.190318DOI Listing
September 2019

Uniting Public Health and Primary Care for Healthy Communities in the COVID-19 Era and Beyond.

J Am Board Fam Med 2021 Feb;34(Suppl):S203-S209

From the Robert Graham Center for Policy Studies in Primary Care, American Academy of Family Physicians, Washington, DC (JMW); Health Systems and Population Health Sciences, University of Houston, College of Medicine, TX (WL); Department of Family Medicine, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo (KG); Departments of Family Medicine and Community Health, Population and Quantitative Health Sciences, General Medical Sciences and Sociology, and Case Comprehensive Cancer Center Case, Western Reserve University Cleveland, OH (KS); Farley Health Policy Center, University of Colorado School of Medicine Aurora, CO (LAG, LSH); Center for Professionalism and Value in Health Care, American Board of Family Medicine, Washington, DC (RP, AB); Departments of Family & Community Medicine and Population Health Sciences Lozano Long School of Medicine, University of Texas Health, San Antonio (CRJ); Larry A. Green Center for the Advancement of Primary Health Care for the Public Good, Virginia Commonwealth University, Richmond (KS, RSG); Cuyahoga County Board of Health, Parma, OH (HG); Department of Family Medicine, Oregon Health and Science University, Portland (JD); American Board of Family Medicine (JCP); Center for Community Health Integration, Case Western Reserve University, Cleveland, OH (KS, RSG).

The Coronavirus disease 2019 (COVID-19) pandemic has laid bare the dis-integrated health care system in the United States. Decades of inattention and dwindling support for public health, coupled with declining access to primary care medical services have left many vulnerable communities without adequate COVID-19 response and recovery capacity. "Health is a Community Affair" is a 1966 effort to build and deploy local communities of solution that align public health, primary care, and community organizations to identify health care problem sheds, and activate local asset sheds. After decades of independent effort, the COVID-19 pandemic offers an opportunity to reunite and align the shared goals of public health and primary care. Imagine how different things might look if we had widely implemented the recommendations from the 1966 report? The ideas and concepts laid out in "Health is a Community Affair" still offer a COVID-19 response and recovery approach. By bringing public health and primary care together in community now, a future that includes a shared vision and combined effort may emerge.
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http://dx.doi.org/10.3122/jabfm.2021.S1.200458DOI Listing
February 2021

Primary Care in the COVID-19 Pandemic: Essential, and Inspiring.

J Am Board Fam Med 2021 02;34(Suppl):S1-S6

From the Department of Family Medicine, Oregon Health & Science University, Portland, (JED); American Board of Family Medicine and Center for Professionalism & Value in Health Care, Washington D.C. (AB).

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http://dx.doi.org/10.3122/jabfm.2021.S1.200631DOI Listing
February 2021

Developing measures to capture the true value of primary care.

BJGP Open 2021 Apr 26;5(2). Epub 2021 Apr 26.

Department of General Practice & Primary Health Care, University of Auckland, Auckland, New Zealand.

Primary care (PC) is an essential building block for any high quality healthcare system, and has a particularly positive impact on vulnerable patients. It contributes to the overall performance of health systems, and countries that reorient their health system towards PC are better prepared to achieve universal health coverage. Monitoring the actual performance of PC in health systems is essential health policy to support PC. However, current indicators are often too narrowly defined to account for quality of care in the complex populations with which PC deals. This article reviews a number of conceptual frameworks developed to capture PC values in robust measures and indicators that can inform policy and practice performance. Each have benefits and limitations. Further work is needed to develop meaningful primary health care (PHC) and PC measures to inform strategic action by policymakers and governments for improved overall performance of health systems.
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http://dx.doi.org/10.3399/BJGPO.2020.0152DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8170610PMC
April 2021

Primary care perspectives on pandemic politics.

Glob Public Health 2021 Jan 24:1-16. Epub 2021 Jan 24.

Mast Analytics, Cape Town, South Africa.

While the COVID-19 pandemic now affects the entire world, countries have had diverse responses. Some responded faster than others, with considerable variations in strategy. After securing border control, primary health care approaches (public health and primary care) attempt to mitigate spread through public education to reduce person-to-person contact (hygiene and physical distancing measures, lockdown procedures), triaging of cases by severity, COVID-19 testing, and contact-tracing. An international survey of primary care experts' perspectives about their country's national responseswas conducted April to early May 2020. This mixed method paper reports on whether they perceived that their country's decision-making and pandemic response was primarily driven by medical facts, economic models, or political ideals; initially intended to develop herd immunity or flatten the curve, and the level of decision-making authority (federal, state, regional). Correlations with country-level death rates and implications of political forces and processes in shaping a country's pandemic response are presented and discussed, informed by our data and by the literature. The intersection of political decision-making, public health/primary care policies and economic strategies is analysed to explore implications of COVID-19's impact on countries with different levels of social and economic development.
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http://dx.doi.org/10.1080/17441692.2021.1876751DOI Listing
January 2021

Primary Care Physicians and Spending on Low-Value Care.

Ann Intern Med 2021 06 19;174(6):875-878. Epub 2021 Jan 19.

Center for Professionalism and Value in Health Care, Washington, DC.

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http://dx.doi.org/10.7326/M20-6257DOI Listing
June 2021

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

J Am Board Fam Med 2021 Jan-Feb;34(1):196-207

From the Robert Graham Center: Policy Studies in Family Medicine and Primary Care, Washington, DC (AJ, MJR, YJ, SP, AB); Johns Hopkins Bloomberg School of Public Health General Preventive Medicine Residency, Baltimore, MD (MJR); American Board of Family Medicine, Lexington, KY (AB).

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%;  < .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.
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http://dx.doi.org/10.3122/jabfm.2021.01.200300DOI Listing
June 2020

The Essential Role of Family Physicians in Providing Cesarean Sections in Rural Communities.

J Am Board Fam Med 2021 Jan-Feb;34(1):10-11

From the Agency for Healthcare Research and Quality, Rockville, MD (STT); American Board of Family Medicine, Lexington, KY (ARE, ZJM, AWB, LEP); Department of Family and Community Medicine, College of Medicine, University of Kentucky, Lexington, KY (LEP).

Of family physicians who perform cesarean sections, more than half do so in rural communities and 38.6% provide cesarean sections in counties without any obstetrician/gynecologists. As policymakers in the United States struggle with a widening landscape of 'obstetrical deserts,' efforts to adequately train a family physician workforce prepared to provide cesarean sections could help maintain access to local obstetric services in rural communities and reduce perinatal morbidity and mortality.
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http://dx.doi.org/10.3122/jabfm.2021.01.200132DOI Listing
April 2020

Rural Workforce Years: Quantifying the Rural Workforce Contribution of Family Medicine Residency Graduates.

J Grad Med Educ 2020 Dec 4;12(6):717-726. Epub 2020 Dec 4.

Senior Vice President of Research and Policy, American Board of Family Medicine, and Co-Director, Center for Professionalism & Value in Healthcare.

Background: Rural regions of the United States continue to experience a disproportionate shortage of physicians compared to urban regions despite decades of state and federal investments in workforce initiatives. The graduate medical education system effectively controls the size of the physician workforce but lacks effective mechanisms to equitably distribute those physicians.

Objective: We created a measurement tool called a "rural workforce year" to better understand the rural primary care workforce. It quantifies the rural workforce contributions of rurally trained family medicine residency program graduates and compares them to contributions of a geographically matched cohort of non-rurally trained graduates.

Methods: We identified graduates in both cohorts and tracked their practice locations from 2008-2018. We compared the average number of rural workforce years in 3 cross sections: 5, 8, and 10 years in practice after residency graduation.

Results: Rurally trained graduates practicing for contributed a higher number of rural workforce years in total and on average per graduate compared to a matched cohort of non-rural/rural training tack (RTT) graduates in the same practice intervals ( < .001 in all 3 comparison groups). In order to replace the rural workforce years produced by 1 graduate from the rural/RTT cohort, it would take 2.89 graduates from non-rural/RTT programs.

Conclusions: These findings suggest that rural/RTT-trained physicians devote substantially more service to rural communities than a matched cohort of non-rural/RTT graduates and highlight the importance of rural/RTT programs as a major contributor to the rural primary care workforce in the United States.
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http://dx.doi.org/10.4300/JGME-D-20-00122.1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7771603PMC
December 2020

Distribution of Physician Specialties by Rurality.

J Rural Health 2020 Dec 4. Epub 2020 Dec 4.

American Board of Family Medicine, Lexington, Kentucky.

Purpose: Physicians of all specialties are more likely to live and work in urban areas than in rural areas. Physician availability affects the health and economy of rural communities. This study aimed to measure and update the availability of physician specialties in rural counties.

Methods: This analysis included all counties with a Rural-Urban Continuum Code (RUCC) between 4 and 9. Geographically identified physician data from the 2019 American Medical Association Masterfile was merged with 2019 County Health Rankings, the Census Bureau's 2010 county-level population data, and 2010 Topologically Integrated Geographic Encoding and Referencing shapefiles. Multivariate logistic regression was performed to assess the availability of physicians by specialty in rural counties.

Findings: Of the 1,947 rural counties in our sample, 1,825 had at least 1 physician. Specialties including emergency medicine, cardiology, psychiatry, diagnostic radiology, general surgery, anesthesiology, and OB/GYN were less available than primary care physicians (PCPs) in all rural counties. The probability of a rural county having a PCP was the highest in RUCC 4 (1.0) and lowest in RUCC 8 (0.93). Of all primary care specialties, family medicine was the most evenly distributed across the rural continuum, with a probability of 1.0 in RUCC 4 and 0.88 in RUCC 9.

Conclusions: Family medicine is the physician specialty most likely to be present in rural counties. Policy efforts should focus on maintaining the training and scope of practice of family physicians to serve the health care needs of rural communities where other specialties are less likely to practice.
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http://dx.doi.org/10.1111/jrh.12548DOI Listing
December 2020

Taking a Closer Look at Mental Health Treatment Differences: Effectiveness of Mental Health Treatment by Provider Type in Racial and Ethnic Minorities.

J Prim Care Community Health 2020 Jan-Dec;11:2150132720966403

American Board of Family Medicine, Washington, DC, USA.

Objectives: To estimate racial/ethnic differences in the extent to which mental health treatment is obtained from mental health providers, primary care physicians (PCPs), or both and to examine the effects of provider type on change in mental component scores (MCS) of the SF-12 on different race/ethnic groups.

Methods: Secondary data analysis of 2008 to 2015 Medical Expenditure Panel Survey (MEPS). Non-institutionalized civilian US population, aged 18 to 64 (N = 62 558). Based on counts of all mental health visits in a calendar year, we identified patients who obtained care from PCPs, mental health provider, PCP and mental health providers and other providers and examined changes in MCS by type of care.

Results: 9.9% of Non-Hispanic Whites obtained mental health treatment, compared to 5.0% for Hispanics, 5.3% for Blacks and 5.5% for Other Races ( < .001). Non-Hispanic Blacks and non-Hispanic "Other" were more likely than other groups to obtain care from mental health providers only ( = .017). All obtaining care solely from PCP had better mental health (mean (se)) MCS: 43.2(0.28)) than those obtaining care solely from mental health provider (39.8 (0.48)), which in turn was higher than for those obtaining care from both PC and MH providers (38.5 (0.31), ( < .001).

Conclusion: Even when diagnosed with a mental health disorder, Hispanics and Blacks were less likely to seek mental health treatment than Whites, highlighting the continuing disparity. Future research should focus on understanding how and what aspects of integrated care models and other mental health delivery models that reduce disparities and provide greater accessibility.
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http://dx.doi.org/10.1177/2150132720966403DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7585881PMC
June 2021

Asthma Care Quality, Language, and Ethnicity in a Multi-State Network of Low-Income Children.

J Am Board Fam Med 2020 Sep-Oct;33(5):707-715

From the Department of Family Medicine, Oregon Health & Science University, Portland (JH, JK, JL, DEH, MM); OCHIN Inc., Portland, OR (JH, JP, SG); Emory University, Atlanta, GA (SS); American Board of Family Medicine, Lexington, KY (AB); Boston Medical College, Boston, MA (AG).

Introduction: Prior research has documented disparities in asthma outcomes between Latino children and non-Hispanic whites, but little research directly examines the care provided to Latino children over time in clinical settings.

Methods: We utilized an electronic health record-based dataset to study basic asthma care utilization (timely diagnosis documentation and medication prescription) between Latino (Spanish preferring and English preferring) and Non-Hispanic white children over a 13-year study period.

Results: In our study population (n = 37,614), Latino children were more likely to have Medicaid, be low income, and be obese than non-Hispanic white children. Latinos (Spanish preferring and English preferring) had lower odds than non-Hispanic whites of having their asthma recorded on their problem list on the first day the diagnosis was noted (odds ratio [OR] = 0.83; 95% CI, 0.77 to 0.89 Spanish preferring; OR = 0.93; 95% CI, 0.87 to 0.99 English preferring). Spanish-preferring Latinos had higher odds of ever receiving a prescription for albuterol (OR = 1.96; 95% CI, 1.52 to 2.52), inhaled corticosteroids (OR = 1.45; 95% CI, 1.01 to 2.09), or oral steroids (OR = 1.48; 95% CI, 1.07 to 2.04) than non-Hispanic whites. Among those with any prescription, Spanish-preferring Latinos had higher rates of albuterol prescriptions compared with non-Hispanic whites (adjusted rate ratio [aRR] = 1.0; 95% CI, 1.01 to 1.13).

Conclusions: In a multi-state network of clinics, Latino children were less likely to have their asthma entered on their problem list the first day it was noted than non-Hispanic white children, but otherwise did not receive inferior care to non-Hispanic white children in other measures. Further research can examine other parts of the asthma care continuum to better understand asthma disparities.
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http://dx.doi.org/10.3122/jabfm.2020.05.190468DOI Listing
July 2021

Relationship between the perceived strength of countries' primary care system and COVID-19 mortality: an international survey study.

BJGP Open 2020 Oct 27;4(4). Epub 2020 Oct 27.

American Board of Family Medicine, Washington, DC, US.

Background: Strong primary health care (PHC) is the cornerstone for universal health coverage and a country's health emergency response. PHC includes public health and first-contact primary care (PC). Internationally, the spread of COVID-19 and mortality rates vary widely. The authors hypothesised that countries perceived to have strong PHC have lower COVID-19 mortality rates.

Aim: To compare perceptions of PC experts on PC system strength, pandemic preparedness, and response with COVID-19 mortality rates in countries globally.

Design & Setting: A convenience sample of international PHC experts (clinicians, researchers, and policymakers) completed an online survey (in English or Spanish) on country-level PC attributes and pandemic responses.

Method: Analyses of perceived PC strength, pandemic plan use, border controls, movement restriction, and testing against COVID-19 mortality were undertaken for 38 countries with ≥5 responses.

Results: In total, 1035 responses were received from 111 countries, with 1 to 163 responders per country. The 38 countries with ≥5 responses were included in the analyses. All world regions and economic tiers were represented. No correlation was found between PC strength and mortality. Country-level mortality negatively correlated with perceived stringent border control, movement restriction, and testing regimes.

Conclusion: Countries perceived by expert participants as having a prepared pandemic plan and a strong PC system did not necessarily experience lower COVID-19 mortality rates. What appears to make a difference to containment is if and when the plan is implemented, and how PHC is mobilised to respond. Many factors contribute to spread and outcomes. Important responses are first to limit COVID-19 entry across borders, then to mobilise PHC, integrating the public health and PC sectors to mitigate spread and reduce burden on hospitals through hygiene, physical distancing, testing, triaging, and contract-tracing measures.
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http://dx.doi.org/10.3399/bjgpopen20X101129DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7606144PMC
October 2020

The Impact of Social and Clinical Complexity on Diabetes Control Measures.

J Am Board Fam Med 2020 Jul-Aug;33(4):600-610

From OCHIN, Inc, Portland, OR (EKC, JPO, KD, MAH, AS); Department of Family Medicine. Oregon Health and Science University, Portland (EKC, JPO, BP, JED); University of Florida, Gainesville (HX, EAS); Cornell University School of Medicine, Ithaca, NY (MC); American Board of Family Medicine, Lexington, KY (AB).

Purpose: In an age of value-based payment, primary care providers are increasingly scrutinized on performance metrics that assess quality of care, including the outcomes of their patient population in key areas such as diabetes control. Although such measures often adjust for patient clinical risk factors or clinical complexity, most do not account for the social complexity of patient populations, despite research demonstrating the strong association between social factors and health.

Methods: Using patient electronic health record data from 2 large community health center networks serving safety net patients, we assessed the effect of both clinical and social risk factors on poor glucose control among diabetics. Logistic regression results were used to estimate the impact of adjusting for both clinical and social complexity on provider performance metrics. Clinical complexity was measured at the patient-level using the Charlson Comorbidity Index. Social complexity was measured at the community-level using the Social Deprivation Index.

Results: Clinical complexity alone was not consistently associated with poor diabetes control (ie, HbA1c > 9%) in diabetic patients with HbA1c testing during the study period. However, increasing social complexity was significantly associated with higher rates of poor diabetic control in both cohorts. After adding adjustment for social complexity down to the national median score, our models suggest that approximately 25% of providers would have 1 to 2% improvement in the assessment of their diabetes control measures, with 45% showing a 2 to 5% improvement, and 5% showing more than a 5% improvement.

Conclusions: Providers caring for patients with greater social risk factors may benefit from having their performance metrics adjusted for the social complexity of their patient populations.
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http://dx.doi.org/10.3122/jabfm.2020.04.190367DOI Listing
October 2019

The Evolving Family Medicine Team.

J Am Board Fam Med 2020 Jul-Aug;33(4):499-501

From the Robert Graham Center for Policy Studies in Primary Care, Washington, DC (TJ, AJ); The American Board of Family Medicine, Lexington, KY (MD, MM, AB); University of Utah School of Medicine, Salt Lake City (MM); Center for Professionalism and Value in Healthcare, Washington, DC (AB).

A decade of practice transformation, consolidation, and payment experimentation have highlighted the need for team-based primary care, but little is known about how team composition is changing over time. Surveys of Family Physicians (FPs) from 2014-18 reveal they continue to work alongside inter-professional team members and suggest slow but steady growth in the proportion of FPs working with nurses, behaviorists, clinical pharmacists, and social workers.
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http://dx.doi.org/10.3122/jabfm.2020.04.190397DOI Listing
October 2019

Trends in the Gender Ratio of Authorship at the Robert Graham Center.

Ann Fam Med 2020 07;18(4):341-344

Robert Graham Center for Policy Studies in Family Medicine and Primary Care, Washington, DC.

Gender disparities in medical publication have been demonstrated in several specialties. This descriptive bibliometric analysis aims to determine the gender ratio of scholarly authorship at the Robert Graham Center (RGC) over an 11-year period. We examined publications by RGC researchers and assessed first, second, and last author gender. Of 229 publications, 65.5% had a male first author and 34.5% had a female first author. Of the 217 publications with a last author, 13.4% had a female last author. This study aims to inform the broader discussion about authorship gender parity in academic medicine using a one-site case-study approach.
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http://dx.doi.org/10.1370/afm.2552DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7358020PMC
July 2020

Using Machine Learning to Predict Primary Care and Advance Workforce Research.

Ann Fam Med 2020 07;18(4):334-340

Robert Graham Center, Washington, DC.

Purpose: To develop and test a machine-learning-based model to predict primary care and other specialties using Medicare claims data.

Methods: We used 2014-2016 prescription and procedure Medicare data to train 3 sets of random forest classifiers (prescription only, procedure only, and combined) to predict specialty. Self-reported specialties were condensed to 27 categories. Physicians were assigned to testing and training cohorts, and random forest models were trained and then applied to 2014-2016 data sets for the testing cohort to generate a series of specialty predictions. Comparing the predicted specialty to self-report, we assessed performance with F1 scores and area under the receiver operating characteristic curve (AUROC) values.

Results: A total of 564,986 physicians were included. The combined model had a greater aggregate (macro) F1 score (0.876) than the prescription-only (0.745; <.01) or procedure-only (0.821; <.01) model. Mean F1 scores across specialties in the combined model ranged from 0.533 to 0.987. The mean F1 score was 0.920 for primary care. The mean AUROC value for the combined model was 0.992, with values ranging from 0.982 to 0.999. The AUROC value for primary care was 0.982.

Conclusions: This novel approach showed high performance and provides a near real-time assessment of current primary care practice. These findings have important implications for primary care workforce research in the absence of accurate data.
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http://dx.doi.org/10.1370/afm.2550DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7358033PMC
July 2020

Advancing bibliometric assessment of research productivity: an analysis of US Departments of Family Medicine.

J Prim Health Care 2020 Jun;12(2):149-158

Royal New Zealand College of General Practitioners, Wellington, New Zealand.

INTRODUCTION Measurement of family medicine research productivity has lacked the replicable methodology needed to document progress. AIM In this study, we compared three methods: (1) faculty-to-publications; (2) publications-to-faculty; and (3) department-reported publications. METHODS In this cross-sectional analysis, publications in peer-reviewed, indexed journals for faculty in 13 US family medicine departments in 2015 were assessed. In the faculty-to-publications method, department websites to identify faculty and Web of Science to identify publications were used. For the publications-to-faculty method, PubMed's author affiliation field were used to identify publications, which were linked to faculty members. In the department-reported method, chairs provided lists of faculty and their publications. For each method, descriptive statistics to compare faculty and publication counts were calculated. RESULTS Overall, 750 faculty members with 1052 unique publications, using all three methods combined as the reference standard, were identified. The department-reported method revealed 878 publications (84%), compared to 616 (59%) for the faculty-to-publications method and 412 (39%) for the publication-to-faculty method. Across all departments, 32% of faculty had any publications, and the mean number of publications per faculty was 1.4 (mean of 4.4 per faculty among those who had published). Assistant Professors, Associate Professors, Professors and Chairs accounted for 92% of all publications. DISCUSSION Online searches capture a fraction of publications, but also capture publications missed through self-report. The ideal methodology includes all three. Tracking publications is important for quantifying the return on our discipline's research investment.
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http://dx.doi.org/10.1071/HC19098DOI Listing
June 2020

Integrating Community and Clinical Data to Assess Patient Risks with A Population Health Assessment Engine (PHATE).

J Am Board Fam Med 2020 May-Jun;33(3):463-467

From Long School of Medicine, University of Texas Health San Antonio, San Antonio (PGB); Department of Health Systems and Population Health Sciences, University of Houston College of Medicine (WL); American Board of Family Medicine, Lexington, KY (RLP, AB).

Clinicians are concerned about their patients' social determinants of health (SDH); yet, they are unsure how to effectively gather patient-level SDH data and intervene without adding to current administrative burdens. Designed properly, clinical registries offer solutions to integrate neighborhood SDH data with clinical data from electronic health records, enabling the understanding of community factors to guide patient care. Federal and state interest in adjusting reimbursements based on SDH further underscores the need for strategies that integrate SDH and clinical data. The Population Health Assessment Engine (PHATE) exemplifies a registry-based SDH data integration solution that adjusts payments, contributes to public health surveillance, organizes care around hot spots (gaps in quality or uncontrolled disease), assesses patient risk, and connects with community organizations. PHATE also permits residency training to meet community health competency milestones by incorporating the PHATE curriculum. These functions enhance value, and their utility in education and care delivery would benefit from further investigation.
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http://dx.doi.org/10.3122/jabfm.2020.03.190206DOI Listing
July 2021

Gender Differences in Personal and Organizational Mechanisms to Address Burnout Among Family Physicians.

J Am Board Fam Med 2020 May-Jun;33(3):446-451

From American Board of Family Medicine, Lexington, KY (ARE, ZJM, MD, AB); Robert Graham Center for Policy Studies, Washington, DC (YJ, MC).

Background: Few studies have examined how interventions designed to address physician burnout might impact female and male physicians differently. Our aim was to test whether there are gender differences in individual approaches to address burnout and/or in organizational support aimed at physician well-being.

Methods: An online survey was administered in 2019 to family physicians in California and Illinois who are either board certified by the American Board of Family Medicine, a member of their state Academy of Family Physicians, or both. Descriptive statistics and bivariate independence tests were performed for each personal step and organizational support to determine whether there was any gender difference.

Results: A total of 2176 family physicians (58% female and 42% male) responded to the survey. A total of 55% of female and 50% of male physicians were burned out. Female physicians were more likely to reduce work hours/go part time and to use domestic help; males were more likely to spend more time on hobbies. Only 8% reported taking no personal steps to address burnout. Male and female physicians reported similar types of organizational support aimed at physician wellness; yet, 20% reported that their organization did not provide any type of well-being support.

Conclusions: We identified gendered differences in physician responses to burnout. Effectively mitigating burnout may require different individual-level approaches and different organizational support mechanisms for female and male physicians.
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http://dx.doi.org/10.3122/jabfm.2020.03.190344DOI Listing
July 2021
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