Addressing Social Determinants of Health in Family Medicine Practices

Primary care practices are under pressure to address patients' social determinants of health (SDOH). However, the extent to which these practices have this ability remains unknown. The objective of this study was to examine the association between physician, practice, and community characteristics and the ability of family medicine practices to address patients' SDOH. This cross-sectional study used data from the American Board of Family Medicine Continuing Certification Questionnaire from 2017 to 2019, with a 100% response rate. Respondents rated their practice's ability to address SDOH, which was dichotomized as high or low. Sequential multivariate logistic regression determined the association of the reported ability to address SDOH with physician, practice, and community characteristics. Among 19,300 respondents, 55.6% reported a high ability to address patients' SDOH. Across models controlling for different groups of variables, characteristics persistently positively associated with ability to address SDOH included employment at a federally qualified health center (Odds Ratios [OR] = 2.111-3.012), federally funded clinic (OR = 1.999-2.897), managed care organization (OR = 2.038-2.303), and working collaboratively with a social worker (OR = 2.000-2.523) or care coordinator (OR = 1.482-1.681). Characteristics persistently negatively associated with the ability to address SDOH were practicing at an independently owned (OR = 0.726-0.812) or small practice (OR = 0.512-0.863). While results varied across models, these findings are important for developing evidence-based policies and recommendations for resource sharing and allocation in clinics and communities. Ensuring availability and access to allied health professionals and community resources may be key components in Family Medicine clinics addressing SDOH.

Physician-Level Continuity of Care and Patient Outcomes in All-Payer Claims Database

INTRODUCTION

Being one of the few existing measures of primary care functions, physician-level continuity of care (Phy-CoC) is measured by the weighted average of patient continuity scores. Compared with the well-researched patient-level continuity, Phy-CoC is a new instrument with limited evidence from Medicare beneficiaries. This study aimed to expand the patient sample to include patients of all ages and all types of insurance and reassess the associations between full panel-based Phy-CoC scores and patient outcomes.

METHODS

Cross-sectional analysis at patient-level using Virginia All-Payer Claims Database (VA-APCD). Phy-CoC scores were calculated by averaging patient's Bice-Boxerman Index scores and weighted by the total number of visits. Patient outcomes included total cost and preventable hospitalization.

RESULTS

In a sample of 1.6 million Virginians, patients who lived in rural areas or had Medicare as primary insurance were more likely to be attributed to physicians with the highest Phy-CoC scores. Across all adult patient populations, we found that being attributed to physicians with higher Phy-CoC was associated with 7%-11.8% higher total costs, but was not associated with the odds of preventable hospitalization. Results from models with interactions revealed nuanced associations between Phy-CoC and total cost with patient's age and comorbidity, insurance payer, and the specialty of their physician.

CONCLUSIONS

In this comprehensive examination of Phy-CoC using all populations from the VA-APCD, we found an overall positive association of higher full panel-based Phy-CoC with total cost, but a non-significant association with the risk of preventable hospitalization. Achieving higher full panel-based Phy-CoC may have unintended cost implications.

Maternity Access in Rural America: The Role of Family Physicians in Providing Access to Cesarean Sections

INTRODUCTION

As an increasing number of rural hospitals close their maternity care units, many of the approximately 28 million reproductive-age women living in rural America do not have local access to obstetric services. We sought to describe the characteristics and distribution of cesarean section-providing family physicians who may provide critical services in maintaining obstetric access in rural hospitals.

METHODS

Using a cross-sectional study design, we linked data from the 2017 to 2022 American Board of Family Medicine's Continuting Certification Questionnaire on provision of cesarean sections as primary surgeon and practice characteristics to geographic data. Logistic regression determined associations with provision of cesarean sections.

RESULTS

Of 28,526 family physicians, 589 (2.1%) provided cesarean sections as primary surgeon. Those who provided cesarean sections were more likely to be male (odds ratio (OR) = 1.573, 95% confidence limits (CL) 1.246-1.986), and work in rural health clinics (OR = 2.157, CL 1.397-3.330), small rural counties (OR = 4.038, CL 1.887-8.642), and in counties without obstetrician/gynecologists (OR = 2.163, CL 1.440-3.250).

DISCUSSION

Although few in number, family physicians who provide cesarean sections as primary surgeon disproportionately serve rural communities and counties without obstetrician/gynecologists, suggesting that they provide access to obstetric services in these communities. Policies that support family physician training in cesarean sections and facilitate credentialing of trained family physicians could reverse the trend of closing obstetric units in rural communities and reduce disparities in maternal and infant health outcomes.

A Match Made in Rural: Interpreting Match Rates and Exploring Best Practices

BACKGROUND AND OBJECTIVES

Although rural family medicine residency programs are effective in placing trainees into rural practice, many struggle to recruit students. Lacking other public measures, students may use residency match rates as a proxy for program quality and value. This study documents match rate trends and explores the relationship between match rates and program characteristics, including quality measures and recruitment strategies.

METHODS

Using a published listing of rural programs, 25 years of National Resident Matching Program data, and 11 years of American Osteopathic Association match data, this study (1) documents patterns in initial match rates for rural versus urban residency programs, (2) compares rural residency match rates with program characteristics for match years 2009-2013, (3) examines the association of match rates with program outcomes for graduates in years 2013-2015, and (4) explores recruitment strategies using residency coordinator interviews.

RESULTS

Despite increases in positions offered over 25 years, the fill rates for rural programs have improved relative to urban programs. Small rural programs had lower match rates relative to urban programs, but no other program or community characteristics were predictors of match rate. Match rates were not indicative of any of five measures of program quality nor of any single recruiting strategy.

CONCLUSIONS

Understanding the intricacies of rural residency inputs and outcomes is key to addressing rural workforce gaps. Match rates likely reflect challenges of rural workforce recruitment generally and should not be conflated with program quality.

Challenges Meeting Training Requirements in the Care of Children in Family Medicine Residency Programs: A CERA Study

BACKGROUND AND OBJECTIVE

In 2014, the Accreditation Council for Graduate Medical Education (ACGME) implemented numeric requirements for family medicine (FM) pediatric patient encounters. Impact on residency programs is unclear. We aimed to identify any difficulties faced by FM program directors (PDs) meeting these numeric requirements.

METHODS

Questions about pediatric training in family medicine residencies were included in a survey of PDs conducted by the Council of Academic Family Medicine Educational Research Alliance (CERA). We performed univariate analysis of the demographic and program characteristics. We then used χ2 tests of independence to test for bivariate associations between these characteristics and our primary outcome: the most difficult ACGME pediatric care requirement to meet.

RESULTS

Most programs reported the hospital as the primary location of training (n=131, 46%) and their family medicine practice (FMP) patient population consisted of over 20% pediatric patients (n=153, 56%). Over 80% of program directors reported challenges meeting FM requirements for the care of children. Challenges meeting pediatric requirements were associated with fewer than 20% FMP patients under 19 years of age (P<.0001), fewer than 50% of core FM faculty caring for sick children (P=.0128), and primary location of pediatric training in a family health center (P=.0006).

CONCLUSION

Difficulty meeting ACGME requirements for the care of children in FM residency programs is common, especially for programs with fewer than 20% FMP patients under 19 years of age. Further research is needed to determine how best to assure FM resident competencies in the care of children and adolescents.

Rural Versus Urban Family Medicine Residency Scope of Training and Practice

BACKGROUND AND OBJECTIVES

Little is known about how rural and urban family medicine residencies compare in preparing physicians for practice. This study compared the perceptions of preparation for practice and actual postgraduation scope of practice (SOP) between rural and urban residency program graduates.

METHODS

We analyzed data on 6,483 early-career, board-certified physicians surveyed 2016-2018, 3 years after residency graduation, and 44,325 later-career board-certified physicians surveyed 2014-2018, every 7 to 10 years after initial certification. Bivariate comparisons and multivariate regressions of rural and urban residency graduates examined perceived preparedness and current practice in 30 areas and overall SOP using a validated scale, with separate models for early-career and later-career physicians.

RESULTS

In bivariate analyses, rural program graduates were more likely than urban program graduates to report being prepared for hospital-based care, casting, cardiac stress tests, and other skills, but less likely to be prepared in some gynecologic care and pharmacologic HIV/AIDS management. Both early- and later-career rural program graduates reported broader overall SOPs than their urban-program counterparts in bivariate analyses; in adjusted analyses this difference remained significant only for later-career physicians.

CONCLUSIONS

Compared with urban program graduates, rural graduates more often rated themselves prepared in several hospital care measures and less often in certain women's health measures. Controlling for multiple characteristics, only rurally trained, later-career physicians reported a broader SOP than their urban program counterparts. This study demonstrates the value of rural training and provides a baseline for research exploring longitudinal benefits of this training to rural communities and population health.

Academic Achievement and Competency in Rural and Urban Family Medicine Residents

BACKGROUND AND OBJECTIVES

The quality of training in rural family medicine (FM) residencies has been questioned. Our objective was to assess differences in academic performance between rural and urban FM residencies.

METHODS

We used American Board of Family Medicine (ABFM) data from 2016-2018 residency graduates. Medical knowledge was measured by the ABFM in-training examination (ITE) and Family Medicine Certification Examination (FMCE). The milestones included 22 items across six core competencies. We measured whether residents met expectations on each milestone at each assessment. Multilevel regression models determined associations between resident and residency characteristics milestones met at graduation, FMCE score, and failure.

RESULTS

Our final sample was 11,790 graduates. First-year ITE scores were similar between rural and urban residents. Rural residents passed their initial FMCE at a lower rate than urban residents (96.2% vs 98.9%) with the gap closing upon later attempts (98.8% vs 99.8%). Being in a rural program was not associated with a difference in FMCE score but was associated with higher odds of failure. Interactions between program type and year were not significant, indicating equal growth in knowledge. The proportions of rural vs urban residents who met all milestones and each of six core competencies were similar early in residency but diverged over time with fewer rural residents meeting all expectations.

CONCLUSIONS

We found small, but persistent differences in measures of academic performance between rural- and urban-trained FM residents. The implications of these findings in judging the quality of rural programs are much less clear and warrant further study, including their impact on rural patient outcomes and community health.

Characteristics of Family Physicians Practicing Collaboratively With Behavioral Health Professionals

Integrating behavioral health into primary care can improve access to behavioral health and patient health outcomes. We used 2017-2021 American Board of Family Medicine continuing certificate examination registration questionnaire responses to determine the characteristics of family physicians who work collaboratively with behavioral health professionals. With a 100% response rate, 38.8% of 25,222 family physicians reported working collaboratively with behavioral health professionals, with those working in independently owned practices and in the South having substantially lower rates. Future research exploring these differences could help develop strategies to support family physicians implement integrated behavioral health to improve care for patients in these communities.

Colorectal Cancer Screening in Rural and Urban Primary Care Practices Amid Implementation of the Medicare Access and CHIP Reauthorization Act

PURPOSE

The Medicare Access and CHIP Reauthorization Act (MACRA) incentivized primary care practices to improve colorectal cancer screening rates. This study examined if colorectal screening rates improved among rural and urban primary care practices amid implementation of MACRA.

METHODS

Colorectal cancer screening data are from a national registry of 139 primary care practices. Repeated measures regression tested for rural/urban differences and changes in screening rates between 2016 and 2020, adjusting for county demographic factors and social deprivation.

RESULTS

Screening rates were 64% in both rural and urban practices in the first quarter of 2016 and increased to 80% and 83% in rural and urban practices, respectively, in the last quarter of 2020. In adjusted analyses, screening rates increased by 4% per year and there were no rural/urban differences. Lower screening rates were associated with higher county proportions of persons who were 45 to 74 years of age and Hispanic. Higher screening rates were associated with higher county proportions of persons who were White, Black, and Asian and higher social deprivation.

CONCLUSIONS

Colorectal screening rates improved among rural and urban primary care practices during implementation of MACRA, but disparities persist among practices serving county populations that are relatively older, more Hispanic, and have higher social deprivation.

Racial/Ethnic Group Trajectory Differences in Exam Performance Among US Family Medicine Residents

Background and Objectives: Racial/ethnic score disparities on standardized tests are well documented. Such differences on the American Board of Family Medicine (ABFM) certification examination have not been previously reported. If such differences exist, it could be due to differences in knowledge at the beginning of residency or due to variations in the rate of knowledge acquisition during residency. Our objective was to examine the residents’ mean initial scores and score trajectories using the In-Training Examination (ITE) and certification examination. Methods: A total of 17,275 certification candidates from 2014 to 2019 were included in this study. Annual ITE scores and certification examination scores are reported on the same scale and serve as the outcome. We conducted multilevel longitudinal regression to determine initial knowledge and growth in knowledge acquisition during residency by race/ethnicity categories. Results: The mean postgraduate year 1 (PGY-1) ITE score was 393.3, with minority residents scoring 16.2 to 36.0 points lower compared to White residents. The mean increase per year in exam performance from PGY-1 ITE to the certification exam was 39.9 points (95% CI, 38.7, 41.1) with additional change among race/ethnicity categories per year of -3.2 to 1.9 points. Conclusions: This study found that there were initial score disparities across race/ethnicity groups in PGY-1, and these disparities continued at the same rate throughout residency training, suggesting equality in acquisition of knowledge during family medicine residency training but with a persistent gap throughout training.

rmc-discord: reverse Monte Carlo refinement of diffuse scattering and correlated disorder from single crystals

A user-friendly Python-based program has been developed to analyze diffuse scattering from single crystals with the reverse Monte Carlo method. The approach allows for refinement of correlated disorder from atomistic supercells with magnetic or structural (occupational and/or displacive) disorder.

A user-friendly program has been developed to analyze diffuse scattering from single crystals with the reverse Monte Carlo method. The approach allows for refinement of correlated disorder from atomistic supercells with magnetic or structural (occupational and/or displacive) disorder. The program is written in Python and optimized for performance and efficiency. Refinements of two user cases obtained with legacy neutron-scattering data demonstrate the effectiveness of the approach and the developed program. It is shown with bixbyite, a naturally occurring magnetic mineral, that the calculated three-dimensional spin-pair correlations are resolved with finer real-space resolution compared with the pair distribution function calculated directly from the reciprocal-space pattern. With the triangular lattice Ba₃Co₂O₆(CO₃)_0.7, refinements of occupational and displacive disorder are combined to extract the one-dimensional intra-chain correlations of carbonate molecules that move toward neighboring vacant sites to accommodate strain induced by electrostatic interactions. The program is packaged with a graphical user interface and extensible to serve the needs of single-crystal diffractometer instruments that collect diffuse-scattering data.

HIV Care by Early-Career Family Physicians

BACKGROUND AND OBJECTIVES

Antiretroviral treatment has transformed human immunodeficiency virus (HIV) infection into a chronic disease. Prior research demonstrated a discrepancy between preparation to provide HIV care and current provision among recent residency graduates. Our study aimed to describe characteristics related to preparedness and provision of HIV care, and to identify the associations between physician and practice characteristics with current provision of HIV care among those prepared.

METHODS

We obtained data from the 2016 through 2019 American Board of Family Medicine (ABFM) National Family Medicine Graduate Survey. Our main outcome was self-reported provision of HIV care. Bivariate statistics compared differences in personal and practice characteristics with self-reported preparation for HIV care, then among those prepared, provision of HIV care. We used logistic regression to determine associations between HIV care, among those prepared, with practice and personal characteristics.

RESULTS

The response rate was 68.7% and our final sample size was 6,740 respondents. Only 25% of respondents reported preparedness in residency, and 44% of them reported current provision. Among those prepared, female gender (OR=0.604; 95% CI, 0.494-0.739) was associated with lower odds of practicing HIV care. Those working in high HIV prevalence areas (OR=1.718; 95% CI, 1.259-2.344) and in Northeast census region (OR=1.557; 95% CI, 1.137-2.132) had higher odds of providing HIV care.

CONCLUSIONS

Fewer than half of those prepared in residency reported currently providing HIV care. Working in a high HIV prevalence area was associated with higher odds of providing HIV care, which suggests early-career family physicians are responding to community needs.

Academic Achievement, Professionalism, and Burnout in Family Medicine Residents

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.

Abortion Provision Among Recently Graduated Family Physicians

BACKGROUND AND OBJECTIVES

Family physicians (FPs) are well positioned to increase abortion access given their broad scope and diverse geographic practice regions. Previously published studies focus on physicians who received formal abortion training but do not include the full landscape of FPs performing abortions in the United States. This secondary data analysis presents a unique opportunity to examine characteristics of early-career FPs who provide abortions, including practice locations and if they received abortion training during residency.

METHODS

We analyzed data from the 2016-2018 Family Medicine National Graduate Survey to generate descriptive statistics about respondents who report providing pregnancy termination, uterine aspiration/dilation and curettage, or both. We evaluated associations between physician and/or practice characteristics and providing pregnancy termination using bivariate statistics.

RESULTS

Of the 6,319 survey respondents, 3% reported providing pregnancy termination. Nearly three-quarters of this subset reported graduating residency feeling prepared to provide pregnancy termination. Most respondents completed residency in the West or Northeast US geographic regions, and 3 years later were practicing in the West or South regions. Additional characteristics associated with providing pregnancy termination include female gender, providing continuity care, and practicing in either an academic medical center or a federally qualified health center.

CONCLUSIONS

FPs are well positioned to address gaps in abortion access, and those who provide pregnancy termination practice in various US geographic regions. This is the first discussion of its kind about the scope of family physicians providing abortion care. Future research should continue to characterize FPs who provide abortions to determine where they train and practice and what type of abortions they provide.

The Declining Scope of Practice of Family Physicians Is Limited to Urban Areas

PURPOSE

Scope of practice of family physicians (FPs) has been decreasing overall. Our objective was to determine if the distribution of declining scope occurs across urban and rural settings.

METHODS

We used secondary data from practicing FPs collected on the American Board of Family Medicine examination registration demographic questionnaire from 2014 to 2016 on scope of practice merged with county-level data from the Area Health Resources File. Rurality was assigned using 4 population-based groupings from the Rural Urban Continuum Codes. Outcome measures were scope of practice score (0-30, higher score reflecting broader scope) and provision of specific types of care/procedures. Bivariate statistics assessed changes in scope of practice over time. Adjusted regression models tested associations between time, physician, practice, and county characteristics with scope of practice score.

FINDINGS

Our sample was 27,343 practicing FPs. Overall, the scope score decreased from 15.5 to 15.0 (P value < .05) but was significant only for urban settings. Regression analysis found that scope decreased each year (β = -0.15), broader scope for rural FPs, and no interaction between year and rural.

CONCLUSIONS

The decrease in FP scope of practice is largely an urban phenomenon. FPs in rural areas have a broad scope of practice, which may ensure access to care in rural areas that rely on FPs to provide a large portion of health care services. However, county characteristics like persistent poverty and the presence of nurse practitioners, physician assistants, and other physicians were associated with changes in scope that may modify the gains associated with rurality.

Family Physician Burnout Does Not Differ With Rurality

PURPOSE

Burnout affects about half of family physicians (FPs). Minimal research exists which examines the impact of urban and rural practice settings on FP burnout. In this study, we examined whether rural practice is associated with FP burnout.

METHODS

Data from the 2017 and 2018 American Board of Family Medicine Family Medicine Certification examination registration questionnaire were used. We limited our sample to FPs in continuity care in the United States. The questionnaire is a mandatory component of registration, resulting in a 100% response rate. Burnout was measured via 2 questions validated against the Maslach Burnout Inventory. We used logistic regression to determine associations between burnout and rural location, controlling for practice and personal characteristics.

FINDINGS

Of the FPs surveyed, 2,740 met our inclusion criteria. Rural FPs were older, more likely to be male, and had a broader scope of practice than urban FPs. Rural FPs had a nonsignificantly higher burnout rate than urban FPs (45.1% vs 43.0%). Burnout was more common in younger and female FPs. We found no rural/urban differences between job satisfaction, practice environment, workload, and job stress; however, all of these characteristics were associated with burnout. In adjusted analyses, rural location was not associated with burnout (odds ratio = 1.15, 95% CI: 0.87-1.52).

CONCLUSION

In a large national sample, we found no difference in burnout between rural and urban FPs. This suggests there is nothing unique about rural practice that predisposes to burnout and that a common pathway to reduce burnout may exist.

Maternity Care and Buprenorphine Prescribing in New Family Physicians

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.