Publications by authors named "Robert L Phillips"

215 Publications

Revitalizing the U.S. Primary Care Infrastructure.

N Engl J Med 2021 Aug 25. Epub 2021 Aug 25.

From the Center for Excellence in Primary Care, Department of Family and Community Medicine, University of California, San Francisco (K.G., T.B.); the Center for Primary Care Research and Innovation, Department of Family Medicine, Oregon Health and Science University, Portland (D.C.); the Center for Professionalism and Value in Health Care, American Board of Family Medicine Foundation (R.L.P.), and the Robert Graham Center (J.M.W.) - both in Washington, D.C.; and the Center for Community Health Integration, Departments of Family Medicine and Community Health, Population and Quantitative Health Sciences, Oncology, and Sociology, Case Western Reserve University, Cleveland (K.C.S.).

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http://dx.doi.org/10.1056/NEJMp2109700DOI Listing
August 2021

Clinical Quality Measure Exchange is Not Easy.

Ann Fam Med 2021 May-Jun;19(3):207-211. Epub 2021 May 10.

American Board of Family Medicine, Lexington, Kentucky.

Purpose: The Trial of Aggregate Data Exchange for Maintenance of Certification and Raising Quality was a randomized controlled trial which first had to test whether quality reporting could be a by-product of clinical care. We report on the initial descriptive study of the capacity for and quality of exchange of whole-panel, standardized quality measures from health systems.

Methods: Family physicians were recruited from 4 health systems with mature quality measurement programs and agreed to submit standardized, physician-level quality measures for consenting physicians. Identified measure or transfer errors were captured and evaluated for root-cause problems.

Results: The health systems varied considerably by patient demographics and payer mix. From the 4 systems, 256 family physicians elected to participate. Of 19 measures negotiated for use, 5 were used by all systems. There were more than 15 types of identified errors including breaks in data delivery, changes in measures, and nonsensical measure results. Only 1 system had no identified errors.

Conclusions: The secure transfer of standardized, physician-level quality measures from 4 health systems with mature measure processes proved difficult. There were many errors that required human intervention and manual repair, precluding full automation. This study reconfirms an important problem, namely, that despite widespread health information technology adoption and federal meaningful use policies, we remain far from goals to make clinical quality reporting a reliable by-product of care.
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http://dx.doi.org/10.1370/afm.2649DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8118486PMC
May 2021

The Need for Coaches in the Clinical World.

Ann Fam Med 2021 May-Jun;19(3):194-195. Epub 2021 May 10.

American Board of Family Medicine, Lexington, Kentucky

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http://dx.doi.org/10.1370/afm.2700DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8118472PMC
May 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

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

Estimated Effect on Life Expectancy of Alleviating Primary Care Shortages in the United States.

Ann Intern Med 2021 07 23;174(7):920-926. Epub 2021 Mar 23.

Harvard Medical School, Boston, Massachusetts, and American Board of Family Medicine Center for Professionalism and Value in Health Care, Lexington, Kentucky (R.L.P.).

Background: Prior studies have reported that greater numbers of primary care physicians (PCPs) per population are associated with reduced population mortality, but the effect of increasing PCP density in areas of low density is poorly understood.

Objective: To estimate how alleviating PCP shortages might change life expectancy and mortality.

Design: Generalized additive models, mixed-effects models, and generalized estimating equations.

Setting: 3104 U.S. counties from 2010 to 2017.

Participants: Children and adults.

Measurements: Age-adjusted life expectancy; all-cause mortality; and mortality due to cardiovascular disease, cancer, infectious disease, respiratory disease, and substance use or injury.

Results: Persons living in counties with less than 1 physician per 3500 persons in 2017 had a mean life expectancy that was 310.9 days shorter than for persons living in counties above that threshold. In the low-density counties ( = 1218), increasing the density of PCPs above the 1:3500 threshold would be expected to increase mean life expectancy by 22.4 days (median, 19.4 days [95% CI, 0.9 to 45.6 days]), and all such counties would require 17 651 more physicians, or about 14.5 more physicians per shortage county. If counties with less than 1 physician per 1500 persons ( = 2636) were to reach the 1:1500 threshold, life expectancy would be expected to increase by 56.3 days (median, 55.6 days [CI, 4.2 to 105.6 days]), and all such counties would require 95 754 more physicians, or about 36.3 more physicians per shortage county.

Limitation: Some projections are based on extrapolations of the actual data.

Conclusion: In counties with fewer PCPs per population, increases in PCP density would be expected to substantially improve life expectancy.

Primary Funding Source: None.
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http://dx.doi.org/10.7326/M20-7381DOI Listing
July 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 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

Quality Changes Among Primary Care Clinicians Participating in the Transforming Clinical Practice Initiative.

J Healthc Qual 2021 Jul-Aug 01;43(4):e64-e69

Abstract: The Transforming Clinical Practice Initiative (TCPI) was designed to provide technical assistance to clinicians and prepare practices to participate in value-based payment arrangements. In this longitudinal cohort study, we assessed whether clinician's participation in TCPI practice transformation networks (PTNs) was associated with changes in quality of care from 2016 to 2018. We extracted quarterly measure performance data from 2016 to 2018 on two NQF-endorsed measures, one for outcome (Controlling High Blood Pressure) and one for process (Use of Imaging Studies for Low Back Pain), from 1,981 primary care clinicians enrolled in the PRIME Registry. Clinicians participating in PTNs were identified and compared with their counterparts who did not participate in PTNs. We found that the performance of PTN clinicians on controlling high blood pressure and use of imaging studies for low back pain was equivalent to that of non-PTN clinicians during the first 3 years of the TCPI. Although PTNs provided assistance to help practices achieve their clinical outcomes, these findings suggest that the changes in quality of care, for the measures studied, among PTN clinicians in the first 3 years of the TCPI were attributable to temporal trends rather than participation in PTNs.
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http://dx.doi.org/10.1097/JHQ.0000000000000287DOI Listing
November 2020

Meaningful Use And Medical Home Functionality In Primary Care Practice.

Health Aff (Millwood) 2020 11;39(11):1977-1983

Robert L. Phillips Jr. is the founding executive director of the American Board of Family Medicine Foundation Center for Professionalism and Value in Health Care, in Washington, D.C.

To improve health care quality and decrease costs, both the public and private sectors continue to make substantial investments in the transformation of primary care. Central to these efforts is the patient-centered medical home model (PCMH) and the adoption and meaningful use of health information technology (IT). We used 2018 national family medicine data to provide a perspective on the implementation of PCMH and health IT elements in a variety of US physician practices. We found that 95 percent of family medicine-affiliated practices used electronic health records (EHRs) in 2018, but there was wide variation in whether those EHRs met meaningful-use criteria. Federally qualified health centers and military clinics were significantly more likely than other settings to have adopted PCMH elements. Adoption of PCMH elements was lowest among independently owned practices, which make up one-third of the primary care delivery system. Our findings suggest that achieving PCMH transformation across all types of practices will require a coordinated approach that aligns strong financial incentives with tailored technical assistance, an approach similar both to that used in federally qualified health centers over the past decade and to that used to drive EHR adoption a decade ago.
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http://dx.doi.org/10.1377/hlthaff.2020.00782DOI Listing
November 2020

The Built Environment for Professionalism.

J Am Board Fam Med 2020 Sep-Oct;33(Suppl):S57-S61

From the Center for Professionalism and Value in Health Care, American Board of Family Medicine Foundation, Washington, DC.

The social contract between the public and health professions is fraying, challenged by changes in the organization and financing of health care, and by a collective failure to meet some of the expectations of society. It is timely for family medicine to acknowledge the social contract, to accept responsibility for its the role in renegotiating this contract, and to partner with other practice communities in doing so. Human behavior is strongly directed by our environment and risk aversion rather than rational decision making and it is possible to design our practice environment to "nudge" clinician behaviors purposefully toward professionalism. Current leveraging of professionalism is a path to burnout and the alternative is to create a built environment for good care that also supports professionalism rather than taking advantage of it. There are good examples to draw on, and further experimentation, partnerships, policy, and facilitation of practice redesign are needed to get there.
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http://dx.doi.org/10.3122/jabfm.2020.S1.190441DOI 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

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

Incorporating machine learning and social determinants of health indicators into prospective risk adjustment for health plan payments.

BMC Public Health 2020 May 1;20(1):608. Epub 2020 May 1.

Center for Primary Care, Harvard Medical School, Boston, USA.

Background: Risk adjustment models are employed to prevent adverse selection, anticipate budgetary reserve needs, and offer care management services to high-risk individuals. We aimed to address two unknowns about risk adjustment: whether machine learning (ML) and inclusion of social determinants of health (SDH) indicators improve prospective risk adjustment for health plan payments.

Methods: We employed a 2-by-2 factorial design comparing: (i) linear regression versus ML (gradient boosting) and (ii) demographics and diagnostic codes alone, versus additional ZIP code-level SDH indicators. Healthcare claims from privately-insured US adults (2016-2017), and Census data were used for analysis. Data from 1.02 million adults were used for derivation, and data from 0.26 million to assess performance. Model performance was measured using coefficient of determination (R), discrimination (C-statistic), and mean absolute error (MAE) for the overall population, and predictive ratio and net compensation for vulnerable subgroups. We provide 95% confidence intervals (CI) around each performance measure.

Results: Linear regression without SDH indicators achieved moderate determination (R 0.327, 95% CI: 0.300, 0.353), error ($6992; 95% CI: $6889, $7094), and discrimination (C-statistic 0.703; 95% CI: 0.701, 0.705). ML without SDH indicators improved all metrics (R 0.388; 95% CI: 0.357, 0.420; error $6637; 95% CI: $6539, $6735; C-statistic 0.717; 95% CI: 0.715, 0.718), reducing misestimation of cost by $3.5 M per 10,000 members. Among people living in areas with high poverty, high wealth inequality, or high prevalence of uninsured, SDH indicators reduced underestimation of cost, improving the predictive ratio by 3% (~$200/person/year).

Conclusions: ML improved risk adjustment models and the incorporation of SDH indicators reduced underpayment in several vulnerable populations.
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http://dx.doi.org/10.1186/s12889-020-08735-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7195714PMC
May 2020

Maternity Care and Buprenorphine Prescribing in New Family Physicians.

Ann Fam Med 2020 03;18(2):156-158

American Board of Family Medicine, Lexington, Kentucky.

The American Board of Family Medicine routinely surveys its Diplomates in each national graduating cohort 3 years out of training. These data were used to characterize early career family physicians whose services include management of pregnancy and prescribing buprenorphine. A total of 261 (5.1%) respondents both provide maternity care and prescribe buprenorphine. Family physicians who care for pregnant women and also prescribe buprenorphine represented 50.4% of all buprenorphine prescribers. The family physicians in this group were trained in a small number of residency programs, with only 15 programs producing at least 25% of graduates who do this work.
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http://dx.doi.org/10.1370/afm.2504DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7062488PMC
March 2020

In Reply to Fyfe and Douglass.

Acad Med 2020 03;95(3):328-329

Attending physician, assistant professor, Department of Emergency Medicine, and assistant medical director, Tisch Observation/Short Stay Unit, NYU Langone Health, New York, New York. At the time of writing, she was health policy fellow, Robert Graham Center, Washington, DC; Professor and associate chair research director, Department of Family Medicine, McGill University, Montreal, Quebec. Executive director, Center for Professionalism and Value in Health Care, Washington, DC.

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http://dx.doi.org/10.1097/ACM.0000000000003130DOI Listing
March 2020

Payment Structures That Support Social Care Integration With Clinical Care: Social Deprivation Indices and Novel Payment Models.

Am J Prev Med 2019 12;57(6 Suppl 1):S82-S88

American Board of Family Medicine, Lexington, Kentucky.

The U.S. lags behind other developed countries in the use of indices and novel reimbursement models to adjust for social determinants of health (SDH) in medicine. This may be due in part to the inadequate body of research regarding outcomes after implementation of healthcare payments designed to address SDH. This perspective article focuses on four models employed both internationally and domestically to outline the implementation, successes, limitations, and research needed to support national application of SDH models. A brief history of prior models is introduced as a primer to the current U.S. system. Internationally, the United Kingdom and New Zealand employ small area indices to adjust healthcare dollar allocation based on increased social need in an area. Despite published evidence of disparate health outcomes based on SDH, research is limited on the association of SDH indices, subsequent increased reimbursement, and improved healthcare equity. In the U.S., the Massachusetts Managed Care Organization assesses and addresses social needs within communities served by Medicaid. Unsurprisingly, there is evidence of overlap between those with worse health outcomes and those with high social need. However, implementation in Massachusetts is too recent to demonstrate reduced healthcare disparities. Within Minnesota, Hennepin Healthcare System initiated a novel Medicaid waiver that provides extended services to high-need patients under a partial capitation reimbursement program. These services, including increased access to primary care, have promising results in financial improvement of the system, but have not yet demonstrated patient-oriented outcomes. The association between high social risk and poor medical outcomes has been established globally; however, healthcare payment policies designed to respond to this relationship generally lack evidence of affecting outcomes. U.S. policymakers are demonstrating increasing interest in requiring capture of SDH in health care, creating accountability for addressing SDH, paying differentially for patients with increased social risk, or all three. In countries with a legacy of adjusting healthcare payments for social risk, more robust evaluation of associated effects could be helpful. Payers, states, or health systems making similar resource commitments should build in robust longitudinal evaluations of outcomes to inform evolution of their payment policies. SUPPLEMENT INFORMATION: This article is part of a supplement entitled Identifying and Intervening on Social Needs in Clinical Settings: Evidence and Evidence Gaps, which is sponsored by the Agency for Healthcare Research and Quality of the U.S. Department of Health and Human Services, Kaiser Permanente, and the Robert Wood Johnson Foundation.
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http://dx.doi.org/10.1016/j.amepre.2019.07.011DOI Listing
December 2019

Facilitating Practice Transformation in Frontline Health Care.

Ann Fam Med 2019 08;17(Suppl 1):S2-S5

Division of General Medicine and Clinical Epidemiology, School of Medicine, University of North Carolina, Chapel Hill, North Carolina.

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http://dx.doi.org/10.1370/afm.2439DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6827672PMC
August 2019

Residency Program Characteristics and Individual Physician Practice Characteristics Associated With Family Physician Scope of Practice.

Acad Med 2019 10;94(10):1561-1566

A.J. Coutinho was, when this research occurred, a third-year family medicine resident, Santa Rosa Family Medicine Residency Program, Santa Rosa, California. Z. Levin was, when this research occurred, research assistant, Robert Graham Center, Washington, DC. S. Petterson is research director, Robert Graham Center, Washington, DC. R.L. Phillips Jr is executive director, Center for Professionalism and Value in Health Care, Washington, DC. L.E. Peterson is vice president of research, American Board of Family Medicine, Lexington, Kentucky.

Purpose: A family physician's ability to provide continuous, comprehensive care begins in residency. Previous studies show that patterns developed during residency may be imprinted upon physicians, guiding future practice. The objective was to determine family medicine residency characteristics associated with graduates' scope of practice (SCoP).

Method: The authors used (1) residency program data from the 2012 Accreditation Council for Graduate Medicine Education Accreditation Data System and (2) self-reported data supplied by family physicians when they registered for the first recertification examination with the American Board of Family Medicine (2013-2016)-7 to 10 years after completing residency. The authors used linear regression analyses to examine the relationship between individual physician SCoP (measured by the SCoP for primary care [SP4PC] score [scale of 0-30; low = small scope]) and individual, practice, and residency program characteristics.

Results: The authors sampled 8,261 physicians from 423 residencies. The average SP4PC score was 15.4 (standard deviation, 3.2). Models showed that SCoP broadened with increasing rurality. Physicians from unopposed (single) programs had higher SCoP (0.26 increase in SP4PC); those from major teaching hospitals had lower SCoP (0.18 decrease in SP4PC).

Conclusions: Residency program characteristics may influence family physicians' SCoP, although less than individual characteristics do. Broad SCoP may imply more comprehensive care, which is the foundation of a strong primary care system to increase quality, decrease cost, and reduce physician burnout. Some residency program characteristics can be altered so that programs graduate physicians with broader SCoP, thereby meeting patient needs and improving the health system.
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http://dx.doi.org/10.1097/ACM.0000000000002838DOI Listing
October 2019

Family Medicine Residents' Debt and Certification Examination Performance.

PRiMER 2019 27;3. Epub 2019 Feb 27.

American Board of Family Medicine, Lexington, KY.

Introduction: Previous studies have found that medical students and internal medicine residents with high educational debt perform less well on examinations. The purpose of this study was to examine the relationship between educational debt and family medicine residents' performance on initial in-training and board certification examinations.

Methods: Our study was a cross-sectional secondary analysis of American Board of Family Medicine (ABFM) data collected from residents (N=5,828) who registered for the Family Medicine Certification Examination (FMCE) in 2014 and 2015, representing 85.8% of graduating family medicine residents in the United States in those years. Multivariable linear and logistic regression modeling was used to examine the relationship between debt level and examination scores, and also to explore the relationship between debt level and passing the initial FMCE.

Results: After controlling for demographic variables, residents with high debt ($150,000 to $249,999) and very high debt (more than $250,000) performed significantly worse than those with no debt on the initial in-training examination (score differences of 14.2 [CI 8.6, 19.8] and 15.8 [CI 10.3, 21.4] points, respectively) and FMCE (score differences of 19.3 points [CI 13.4, 25.3] and 30.4 points [CI 24.6, 36.3], respectively). Additionally, those with debt above $250,000 had half the odds of passing their initial FMCE (OR 0.45; CI 0.27-0.75).

Conclusions: High educational debt is associated with lower examination performance among family medicine residents. This may be because residents with more debt have more stress or fewer day-to-day financial resources. However, confounding factors may also contribute to this association.
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http://dx.doi.org/10.22454/PRiMER.2019.568241DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7205089PMC
February 2019

Association of Primary Care Physician Supply With Population Mortality in the United States, 2005-2015.

JAMA Intern Med 2019 04;179(4):506-514

Center for Primary Care, Harvard Medical School, Boston, Massachusetts.

Importance: Recent US health care reforms incentivize improved population health outcomes and primary care functions. It remains unclear how much improving primary care physician supply can improve population health, independent of other health care and socioeconomic factors.

Objectives: To identify primary care physician supply changes across US counties from 2005-2015 and associations between such changes and population mortality.

Design, Setting, And Participants: This epidemiological study evaluated US population data and individual-level claims data linked to mortality from 2005 to 2015 against changes in primary care and specialist physician supply from 2005 to 2015. Data from 3142 US counties, 7144 primary care service areas, and 306 hospital referral regions were used to investigate the association of primary care physician supply with changes in life expectancy and cause-specific mortality after adjustment for health care, demographic, socioeconomic, and behavioral covariates. Analysis was performed from March to July 2018.

Main Outcomes And Measures: Age-standardized life expectancy, cause-specific mortality, and restricted mean survival time.

Results: Primary care physician supply increased from 196 014 physicians in 2005 to 204 419 in 2015. Owing to disproportionate losses of primary care physicians in some counties and population increases, the mean (SD) density of primary care physicians relative to population size decreased from 46.6 per 100 000 population (95% CI, 0.0-114.6 per 100 000 population) to 41.4 per 100 000 population (95% CI, 0.0-108.6 per 100 000 population), with greater losses in rural areas. In adjusted mixed-effects regressions, every 10 additional primary care physicians per 100 000 population was associated with a 51.5-day increase in life expectancy (95% CI, 29.5-73.5 days; 0.2% increase), whereas an increase in 10 specialist physicians per 100 000 population corresponded to a 19.2-day increase (95% CI, 7.0-31.3 days). A total of 10 additional primary care physicians per 100 000 population was associated with reduced cardiovascular, cancer, and respiratory mortality by 0.9% to 1.4%. Analyses at different geographic levels, using instrumental variable regressions, or at the individual level found similar benefits associated with primary care supply.

Conclusions And Relevance: Greater primary care physician supply was associated with lower mortality, but per capita supply decreased between 2005 and 2015. Programs to explicitly direct more resources to primary care physician supply may be important for population health.
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http://dx.doi.org/10.1001/jamainternmed.2018.7624DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6450307PMC
April 2019

Experience of Family Physicians in Practice Transformation Networks.

J Ambul Care Manage 2019 Apr/Jun;42(2):92-104

Department of Research & Policy, American Board of Family Medicine, Lexington, Kentucky (Ms Hansen and Drs Eden, Peterson, and Bishop); Department of Family and Community Medicine, University of Kentucky, Lexington (Dr Peterson); and Center for Professionalism and Value in Health Care, Washington, District of Columbia (Dr Phillips).

To help health care practices transition away from fee-for-service reimbursement and toward value-based payment, the Transforming Clinical Practice Initiative was launched in October 2015. It was designed to provide clinicians support through peer-based Practice Transformation Networks (PTNs). A group of American Board of Family Medicine board-certified family physicians enrolled in PTNs described their expectations of and experiences with PTN participation; we analyzed open-text comments. Physicians expected and experienced PTN support in informatics and data, team building, and workflow and care coordination; however, expectations regarding patient care and engagement, costs and payment reform, and population and panel health were described less frequently.
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http://dx.doi.org/10.1097/JAC.0000000000000269DOI Listing
June 2020

Recruiting and Training a Health Professions Workforce to Meet the Needs of Tomorrow's Health Care System.

Acad Med 2019 05;94(5):651-655

M. Raffoul is assistant professor, Department of Emergency Medicine, and assistant medical director, Tisch Observation/Short Stay Unit, NYU Langone Health, New York, New York. G. Bartlett-Esquilant is professor, associate chair, and research and graduate program director, Department of Family Medicine, McGill University, Montreal, Quebec, Canada. R.L. Phillips Jr is executive director, Center for Professionalism and Value in Health Care, American Board of Family Medicine, Lexington, Kentucky, and professor, Department of Family Medicine, Georgetown University, Washington, DC.

The quality of any health care system depends on the caliber, enthusiasm, and diversity of the workforce. Yet, workforce research often focuses on the number and type of health professionals needed and anticipated shortages compared with anticipated needs. These projections do not address whether the workforce will have the requisite social, intellectual, cultural, and emotional capital needed to deliver care in an increasingly complex health care system.Building a workforce that can deliver care in such a system begins by recruiting individuals with the requisite knowledge, skills, and attributes. To address this and other workforce needs, the authors argue that health professions education programs must make purposeful changes to their admissions criteria, such as focusing on emotional intelligence and diversity and recruiting students from the communities where they will return to work; partner with communities; ensure that accreditation systems support these goals of fostering diversity; recruit students who can bridge the gap between public health and health care; and invest in health professions education research.In this article, they contemplate how health professions education programs can recruit and educate talented health professionals to create a high-performing workforce that is capable of serving in the complex health care system of tomorrow. They provide examples of successful programs to highlight the potential effects of their recommendations.
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http://dx.doi.org/10.1097/ACM.0000000000002606DOI Listing
May 2019

Primary Care Research Priorities in Low-and Middle-Income Countries.

Ann Fam Med 2019 01;17(1):31-35

Department of Primary and Community Care, Radboud Institute of Health Sciences, Nijmegen, The Netherlands.

Purpose: To identify and prioritize the needs for new research evidence for primary health care (PHC) in low-and middle-income countries (LMICs) about organization, models of care, and financing of PHC.

Methods: Three-round expert panel consultation of LMIC PHC practitioners and academics sampled from global networks, via web-based surveys. Iterative literature review conducted in parallel. Round 1 (pre-Delphi survey) elicited possible research questions to address knowledge gaps about organization and models of care and about financing. Round 2 invited panelists to rate the importance of each question, and in round 3 panelists provided priority ranking.

Results: One hundred forty-one practitioners and academics from 50 LMICs from all global regions participated and identified 744 knowledge gaps critical to improving PHC organization and 479 for financing. Four priority areas emerged: effective transition of primary and secondary services, horizontal integration within a multidisciplinary team and intersectoral referral, integration of private and public sectors, and ways to support successfully functioning PHC professionals. Financial evidence priorities were mechanisms to drive investment into PHC, redress inequities, increase service quality, and determine the minimum necessary budget for good PHC.

Conclusions: This novel approach toward PHC needs in LMICs, informed by local academics and professionals, created an expansive and prioritized list of critical knowledge gaps in PHC organization and financing. It resulted in research questions, offering valuable guidance to global supporters of primary care evaluation and implementation. Its source and context specificity, informed by LMIC practitioners and academics, should increase the likelihood of local relevance and eventual success in implementing research findings.
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http://dx.doi.org/10.1370/afm.2329DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6342597PMC
January 2019

The American Board of Family Medicine's Data Collection Method for Tracking Their Specialty.

J Am Board Fam Med 2019 Jan-Feb;32(1):89-95

From the American Board of Family Medicine, Lexington, KY.

Background: Medical certifying boards' core mission is assuring the public that Diplomates have the requisite knowledge, skills, and professional character to provide high-quality medical care. By understanding their Diplomates' workforce and practice environments, Boards ensure that certification is relevant to the profession and accountable to the public. Current and reliable data are key to meeting this function. The objective of this article was to describe American Board of Family Medicine (ABFM) data collection procedures and demonstrate the capacity to compare cohorts by examination year.

Methods: We used data from ABFM examination application practice demographic questionnaires from 2013 to 2016. Descriptive and bivariate statistics assessed variation in Diplomate and certification candidate characteristics across examination cohorts.

Results: From 2013 to 2016, 55,532 family physicians applied for either initial certification (n = 15,388) or to continue their certification (n = 40,144). Diplomate characteristics varied slightly from year to year with more International Medical Graduates and fewer men in later cohorts but, these differences were not large between cohorts. Initial certification candidates were more likely to be women, and racial or ethnic minorities than Diplomates seeking to continue their certification, and each year's cohort was characterized by increasing numbers of female and US medical graduates.

Discussion: Data collected from Diplomates as part of examination registration have proved invaluable to serving the mission of the ABFM and advancing knowledge about the specialty of family medicine. Continued refinement of data collection to enhance data reliability and usefulness, while reducing collection burden, will continue.
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http://dx.doi.org/10.3122/jabfm.2019.01.180138DOI Listing
March 2020
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