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November/December Annals of Family Medicine 2

November/December Annals of Family Medicine 2

International Group of Research Experts Establish Checklist Detailing Key Consensus Reporting Items for Primary Care Studies  

In an effort to fill the need for primary care–focused guidelines, an international group of top researchers has developed the Consensus Reporting Items for Studies in Primary Care (CRISP) Checklist, which outlines 24 items that describe the research team, patients, study participants, health conditions, clinical encounters, care teams, interventions, study measures, settings of care, and implementation of findings and results in primary care. The CRISP Working Group conducted a scoping review of literature on the state of primary care research reporting as well as several rounds of online surveys to assess the needs of a broad range of primary care researchers, practitioners, journal editors, and patients and other lay research users worldwide. At each stage, the group refined the options for potential reporting items based on survey participants’ responses, thereby moving toward a consensus CRISP Checklist.

Pilot testing of the checklist with a small group of participants across primary care constituencies yielded largely positive feedback. The CRISP Working Group considers the checklist to be a living document that will evolve as more people promote and use it. To that end, they welcome feedback through the CRISP website at The CRISP Checklist appears in the article, and an Explanation & Example report further elaborating on the checklist items is included as an appendix.

What We Know: There are more than 500 medical research reporting guidelines currently recognized by researchers and research journals across the spectrum of medical fields. Although primary care researchers may use some of them as they relate to their particular topics or methods, no published guidelines address primary care’s unique perspectives, approaches, and research concerns.

What This Study Adds: The newly established Consensus Reporting Items for Studies in Primary Care (CRISP) Checklist outlines items that describe the various aspects of research, from the team, patients and study participants to the implementation of study findings and results in primary care. The team considers this a living document and welcomes input from the primary care research community at the following website:

Improving the Reporting of Primary Care Research: Consensus Reporting Items for Studies in Primary Care—the CRISP Statement

William R. Phillips, MD, MPH, et al

Department of Family Medicine, University of Washington, Seattle, Washington

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Dutch Researchers Explore Patient Profiles of Those Who Choose to Stop Eating and Drinking to Hasten Death

Some patients choose to voluntarily stop eating and drinking (VSED) as a way of hastening death. Researchers from the Amsterdam University Medical Centre conducted a study to describe patients’ motives for doing so, how they decide to voluntarily stop eating and drinking, and the way in which they prepare to do so, along with how they involve others. The researchers conducted qualitative interviews with 29 patients living in the Netherlands. Among 29 cases, 24 started VSED and 19 died. Thirteen cases were included before and during VSED and 16 afterwards. Study participants include 17 patients, 18 informal caregivers, and 10 professional caregivers. 

Researchers identified three specific groups of patients who decided to adopt VSED to hasten death. Older people who felt their lives were complete and valued control over the end of their lives were well prepared to carry out VSED and could overlook the need for help and the emotional burden they would have placed on relatives. The second group were older, care-dependent patients with poor quality of life. They often started VSED suddenly and relied heavily on mostly informal caregivers for the preparation and execution of their end-of-life plans. The third group were mostly younger psychiatric patients with a long-lasting, though often fluctuating, wish to control their own deaths. These patients often prepared for VSED in secrecy or initiated VSED unprepared.

What We Know: In the Netherlands, general practitioners usually provide care for a patient who chooses to hasten death by voluntarily stopping eating and drinking.

What This Study Shows: Patients who seek to hasten death by voluntarily stopping food or liquid consumption can be divided into three categories: older patients who seek control over their lives; those who wish to hasten a natural death; and those who want to end their lives through suicide. The researchers explore the background and motive, considerations and expectations; involvement of others, and outcome trajectory for each group.  They conclude that since patients who choose VSED are varied, it is important that professional and patient guidance apply to all patients considering VSED, no matter their reason for choosing to hasten their own deaths.

Patients Who Seek to Hasten Death by Voluntarily Stopping Eating and Drinking: A Qualitative Study

Eva Elizabeth Bolt, MD, PhD et al

Amsterdam University Medical Center, The Netherlands

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Almost Two-Thirds of Residents in U.S. Family Medicine Programs are Training in States that Have Abortion Restrictions

Researchers performed an analysis to assess the proportion of accredited U.S. family medicine residency programs and trainees in states with abortion restrictions. Of 693 accredited family medicine residency programs in the U.S., 201 programs (29%) were in states where abortion was banned or heavily restricted as of August 2, 2023. Fourteen of the 17 states in this category had complete abortion bans.

While most (63.8%) family medicine residency programs were in states with at least some abortion restrictions, 251 programs (36.2%) were in states with laws protecting abortion. Of the 13,541 residents in accredited U.S. family medicine programs, 3,930 (29%) were training in states that had banned abortion or where abortion was very restricted and 5,020 residents (37.1%) were in states with protective policies. Most residency programs with abortion training (85%) were in states with protective abortion policies. 

What We Know: There is substantial evidence that abortion training in family medicine residency is safe and appropriate. Additionally, there has been increased appreciation of a family physician’s role in abortion provision, especially because family physicians practice in communities where they may be the only doctor. Though state-level abortion restrictions likely impact family medicine residency training in abortion, post-abortion care, pregnancy options counseling, and early pregnancy loss (EPL) management, the extent of this impact was previously unknown.

What This Study Adds: Nearly one-third of residents in accredited U.S. family medicine programs are training in states that banned abortion or where abortion was very restricted. The overturning of Roe v. Wade will impact family medicine residency training and have long-term effects on family physicians’ ability to provide abortion and follow-up care, manage EPL, and care for patient and community reproductive health needs. The researchers suggest that the Accreditation Council for Graduate Medical Education may be able to mitigate this effect by establishing explicit family medicine requirements for developing skills in comprehensive reproductive health care, regardless of policy environment. They also assert that individual residency program leadership teams, as well as family medicine organizations, must work to optimize training in restrictive states and expand abortion training where possible to promote high-quality, equitable reproductive health care in the context of abortion restrictions.

Implications of Overturning Roe v Wade on Abortion Training in US Family Medicine Residency Programs

Sarah Wulf, MPH, et al

Person-Centered Reproductive Health Program, Department of Family and Community Medicine, University of California, San Francisco, California

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Doctors Whose Psychological Needs are Met is Associated With Greater Well-Being in the New Digital Era 

Canadian researchers examined how the rapid shift to using virtual care during the COVID-19 pandemic has impacted primary care doctors’ well-being at work. They utilized a self-determination theory (SDT) lens to examine how autonomous (vs. controlled) motivation among family physicians impacted their well-being when shifting to virtual care, and whether satisfaction (vs. frustration) of their basic psychological needs at work mediated that relationship. The researchers gathered qualitative data by surveying 156 family physicians in Alberta, Canada. The questionnaire contained validated scales for measuring motivational quality, workplace psychological need fulfillment, and subjective well-being. They performed descriptive, correlational, and mediation analyses. 

The authors found that primary care doctors who felt that they had little choice in using virtual care had decreased well-being, and frustration of their basic psychological needs for autonomy, competence, and relatedness fully mediated that relationship. Conversely, basic psychological need satisfaction at work was associated with higher well-being. The findings suggest that when family physicians’ motivation towards using virtual care is less self-determined, it will lead to poorer well-being, because of psychological need frustration. 

What We Know: The COVID-19 pandemic required medical professionals to adopt telehealth in order to meet the health care needs of patients while keeping them safe from the virus. Prior to this study, the effects that this shift in practice had on primary care physician well-being were largely unknown.

What This Study Adds: Doctors who have higher levels of workplace psychological need satisfaction will likely have higher well-being, regardless of their motivation towards using virtual care. Controlled motivation towards using virtual care, however, seems to predict lower well-being, because of psychological need frustrations in the workplace. Interventions that address these basic psychological needs, and particularly the need for autonomy, may improve physician well-being. 

Family Physician Motivation and Well-Being in the Digital Era

Adam Neufeld, MSc, MD, CCFP, et al

Department of Family Medicine, Cumming School of Medicine, University of Calgary,

Calgary, Alberta, Canada 

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Medical Student Contemplates the Healing Power of Open-Ended Questions in Patient Medical Encounters

Medical student Samantha Gogola writes about the power of open-ended questions in interactions with various patients. From the woman who has lived with pain for decades to the physically wounded man in the wheelchair who is also experiencing homelessness, Gogola writes about the common thread that emerges in each of her medical encounters with these patients, specifically the profound impact that a simple personal question can have on clinical encounters. She writes that oftentimes, patients will respond, “No one’s ever asked me that before,” when she has asked them open-ended questions. To Gogola, their responses echo with a sense of longing and unmet needs. She writes that this left her thinking of the ways elicitation of personal narratives can foster the expression of fears and struggles, aiding in both emotional and physical recovery. “I contemplate a future where compassion flourishes alongside medical expertise, nurtured through a greater incorporation of patient-centered care,” she added.

The Seven Words That Changed My Perspective on Patient Care

Samantha Gogola, BS 

Florida International University Herbert Wertheim College of Medicine, Miami, Florida

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Survey Finds Patients’ Coping Styles Changed During COVID-19 and That Stable Coping Styles Can Reduce Anxiety and Depression 

Researchers assessed Veterans Affairs participants’ patterns of coping strategies, as well as the stability and change in strategies, at three timepoints (December 2020-March 2021) when COVID-19 vaccines became widely available. Two thousand and eighty-five participants completed surveys at any time point during the specified time frame and 930 participants completed all three surveys. Researchers identified three distinct coping styles: Adaptive, Distressed, and Disengaged. They then assessed stability and change over time in these strategies and found that the majority of the sample (71%) changed their coping style at least once during the study period. Participants who used stable coping styles across all three points reported lower levels of anxiety and depression.

Researchers report that their results do not support patterns of change in coping style in a particular direction (e.g., a trend toward an increase in use of adaptive strategies) but point to potential advantages of stability in coping style. Potentially, less adaptive styles that are more stable may be advantageous for mental health. 

What We Know: Family practice has long been an environment in which patients

can learn about positive coping strategies. Understanding how coping strategies work together in stressful contexts is important for enhancing opportunities for doctors to support the resilience of patients. Military veterans and individuals with existing health problems have been identified as a potentially high-risk subgroup that may be particularly vulnerable to COVID-19 stressors.

What This Study Adds: Over the four months of a rapidly changing context for the COVID-19 pandemic, changes in coping style were common. The malleability of coping styles points to practical applications for supporting individuals in developing and engaging in adaptive strategies. Study results suggest that coping styles are not necessarily evolving in a direction of growth, resilience, or adaptation, making it important to understand how a change in coping styles over time may impact well-being and to support patients during coping with stress.

Veterans and Non-Veterans Coping With Stress During 4 months of Covid-19

Jorie M. Butler, PhD, et al 

Department of Biomedical Informatics, Spencer Fox Eccles School of Medicine at the University of Utah; Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System; Geriatrics Research, Education, and Clinical Center (GRECC), VA Salt Lake City Health Care System, all of Salt Lake City, Utah

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Annals Editorialists Applaud New Primary Care Research Checklist, Encourage Colleagues to Contribute Feedback

Drs. José Rodriguez, Sherri Sheinfeld Gorin, and Vincent Van Vugt, primary care researchers and Annals of Family Medicine associate editors, compose this issue’s editorial about the new Consensus Reporting Items for Studies in Primary Care (CRISP) Statement and Checklist. The checklist was created by an international team of primary care researchers to address the field’s unique perspectives, approaches, and research concerns. While the editorialists applaud the team’s efforts at creating the checklist, they encourage primary care researchers to use race/ethnicity and gender when describing patients as a means to promote health equity. They also encourage their fellow scientists to involve more patients in the research process, considering that primary care strives to be patient-focused. They note that the checklist is a dynamic tool for change and encourage the primary care research community to review the CRISP guidelines and offer input on what they feel may or may not work. Input can be provided here: ​​ Rodriguez et al argue that by working together, the primary care research community can make these guidelines more meaningful for the growing community of family medicine researchers. 

Commentary on the CRISP Statement

José E. Rodríguez, MD, FAAFP, et al 

University of Utah; Sherri Sheinfeld Gorin, Ph.D., University of Michigan, Ann Arbor, Michigan; and Vincent Van Vugt, MD, Ph.D, University of Amsterdam Medical Center, Amsterdam, the Netherlands

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Knowledge Translation Materials Can Promote Discussions Between Asian Men With Diabetes and Their Physicians About Erectile Dysfunction

Researchers studied communication about erectile dysfunction (ED) between doctors and 120 Asian male patients with diabetes in a primary care clinic in Kedah, Malaysia. At the outset of the study, all participating physicians received a brief introduction to the fundamentals of ED treatment. Prior to a regular consultation, 60 men (the intervention group) were given a simple prompt sheet on which they could indicate whether they wanted to discuss, or were already discussing, ED with their doctor; physicians in the intervention group were provided with a knowledge translation flipchart developed by the researchers to assist with ED discussion. The flipchart featured concise, plain-language text and colorful illustrations, presented on paired patient- and physician-facing panels. Neither patients nor doctors in the control group received materials to facilitate discussion. Following consultation, all 120 men in the study completed a survey providing demographic information, an ED diagnostic sheet (the 5-item International Index of Erectile Function, or IIEF-5), and questions about any discussion of ED with their physician.

About two-thirds of the intervention group discussed ED-related issues with their physician, compared with 8.3% of the control group. ED medications were prescribed to 57.5% of subjects in the intervention group, but to none in the control group. Physicians used the flipchart in 82.5% of intervention group consultations, and all patients with whom the flipchart was used reported that they were satisfied with their consultations.

What We Know: ED is a common sexual dysfunction worldwide and often affects men with other serious health issues, including type 2 diabetes mellitus (T2DM). Nevertheless, ED is frequently underdiagnosed and undertreated due to communication barriers between patients, who might face embarrassment about discussing sexual health, and physicians, who might not be knowledgeable about ED. Further, Asian men tend to be more conservative about sexuality—and, by extension, addressing sexual health with their doctors—than European men, despite experiencing higher rates of sexual dysfunction.

What This Study Adds: This study suggests that, for Asian men who view ED as a taboo subject, the use of both doctor- and patient-oriented materials may encourage conversations about and treatment of ED. Usage of the flipchart created for this study may improve patients’ overall satisfaction with ED consultation in this cultural context. This type of intervention could improve diagnosis and treatment of ED elsewhere if the knowledge translation tools are adapted to respond to diverse cultures’ attitudes toward ED and sexual health more broadly.

Improving Erectile Dysfunction Management Among Asian Men With Diabetes Using the Knowledge Translation Intervention

Saharuddin Ahmad, MD, MMed, et al

Department of Family Medicine, Faculty of Medicine, National University of Malaysia, Kuala Lumpur, Malaysia

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An AI-Aided Stethoscope can Improve Home Monitoring of Asthma in Very Young Children 

Adults and older children with asthma can take objective measures of symptoms such as peak expiratory flow (PEF), the volume of airflow in one forced exhalation, at home. This provides a more complete picture of their disease and helps them detect asthma exacerbations or negative changes to their condition at the onset. However, a 2022 report by the Global Initiative for Asthma (GINA) identifies continuous respiratory sounds such as wheezes, rhonchi, as the best indicators of asthma exacerbation, especially in children under 5 years of age. Assessment of these symptoms, still primarily done by doctors using stethoscopes in face-to-face visits, can be largely subjective, especially when judged by those who are not medical professionals. There is no objective tool currently recommended for parents to monitor their young children’s symptoms at home.

Researchers conducted a six-month observational study on 149 home-monitored asthma patients of various ages in Poland. They investigated which symptoms are crucial to measure in detecting exacerbation. To what extent could an AI-aided home stethoscope support detection, especially in young children? Standard certified medical devices were used to take objective measures of certain asthma symptoms (pulse oximeters for peripheral capillary oxygen saturation, and peak flow meters for expiratory flow) in study participants over five years old but not for participants under 5 years old. For more subjective, auditory symptoms, a Conformité Européenne-certified StethoMe, an AI-based home stethoscope, recorded auscultatory sounds from standard chest points of all study participants and transferred the sound files to a cell phone app. 

The recordings were automatically analyzed by an AI module and the generated results (pathological auscultatory sound intensities, heart rate, respiratory rate, inspiration-to-expiration duration ratio) were displayed in the app. All data were analyzed by physicians via an online platform to identify exacerbation occurrences. Ultimately, results suggest that, while taking multiple measures is preferable, AI analysis of home stethoscope recordings alone can efficiently detect asthma exacerbation in patients of all ages, including children under 5 years old.

What We Know: Asthma is the most common chronic childhood disease and is prevalent in adults as well. Although asthma can be controlled with medication, the disease can worsen, and timely identification of asthma exacerbation is essential for proper management and symptom relief. One way to identify exacerbation is by measuring peak expiratory flow (PEF). Home monitoring tests for PEF are available for adults and school-aged children, though none are currently recommended for children under five years of age. Assessing more subjective, auditory symptoms such as coughing and wheezing, while recommended, is less reliable when done at home.

What This Study Adds: The results of this study indicate that, while combining multiple measurements of asthma is ideal, the parameters measured by the StethoMe AI-aided home stethoscope can help detect asthma exacerbation more effectively than peak expiratory flow measurements. It can be a useful tool for optimizing patient-doctor collaboration via telemedicine. For children under 5, an AI-aided home stethoscope could significantly facilitate asthma monitoring by their parents and caregivers. 

Home Monitoring of Asthma Exacerbations in Children and Adults With Use of an AI-Aided Stethoscope

Kamil Janeczek, MD, PhD et al

Medical University of Lublin, Department of Paediatric Pulmonology and Rheumatology, Lublin, Poland

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Family Physician Describes Clinic That Provides Welcoming, Holistic Care for Survivors of Sexual Violence, Abuse and Exploitation  

Survivors of interpersonal trauma—including people who have experienced human trafficking, intimate partner violence, and sexual assault—may avoid health care due to fear of stigmatization and potential re-traumatization in health care settings. A family medicine physician founded a clinic within a federally qualified health center in New York City to provide health care, as well as referrals to social and mental health services, to survivors of sexual violence, abuse, and exploitation. During its 3.5 years, the program received nearly 700 referrals from 75 community partners, with 287 patients ultimately connecting for care (62% had repeat visits, ranging from 2 to 43 visits). Survivors (and their children) received routine primary care, including reproductive, HIV, LGBTQ+, and preventative health care, regardless of age, documentation, or insurance status. The author concluded that system-wide trauma-informed care training, and team-based care involving both primary care and mental health departments, are necessary to longitudinally engage trauma survivors.

PurpLE Clinic: A Primary Care Pilot for Survivors of Sexual Violence, Abuse, and Exploitation

Anita Ravi, MD, MPH, MSHP, FAAFP

President, CEO, co-founder and founding board member of the PurpLE Health Foundation

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Practice Facilitation Programs Can Help Primary Care Clinics Adopt Best Practices for Providing COVID-19 Vaccinations

In Ontario, Canada, most COVID-19 vaccinations were administered by public health organizations and pharmacies rather than by family physicians. Researchers devised a practice facilitation intervention program to help family physicians proactively engage with their patients who were not yet vaccinated for COVID‐19.

Six trained practice facilitators helped 90 family physicians identify unvaccinated patients and offered resources to address COVID‐19 vaccine hesitancy, scripts and email templates for patient outreach, and connections to trained medical student volunteers to work as physician‐delegates by conducting patient telephone outreach and motivational interviewing. At the end of the four-month intervention, the researchers interviewed both the practice facilitators and the physicians participating in the study about their experiences. They also analyzed quantitative data capturing the amount of time facilitators spent working with participating clinics and the percentage of physicians requesting each type of available support. The results suggest that the most useful service provided by the facilitators was helping physicians identify unvaccinated patients; medical students who shared a language or cultural background with patients were also appreciated. Barriers to implementing practice facilitation included resistance by physicians and/or staff and time required for onboarding and training. The most popular types of support, such as robocalls to patients, required minimal engagement and time commitments from physicians and clinic staff.

What We Know: Family physicians play an essential role in educating their patients about vaccinations, encouraging vaccine uptake, addressing hesitancies, and debunking misinformation. However, as with other types of care, they may face barriers such as time constraints, tight budgets, and staffing issues to following best practices for providing vaccinations. COVID-19 brought significant changes to the practice of family medicine, adding to physicians’ feelings of burnout and limiting their time and resources to discuss evolving vaccination information with their patients.

What This Study Adds: Practice facilitation can help primary care clinics adopt best practices for patient care, including providing vaccinations. Being unable to identify patients who had not received COVID-19 vaccinations posed a problem and receiving technical help in identifying those patients was the most important resource for primary care doctors. Additionally, researchers found that programs should be tailored to the needs of individual clinics and the populations they serve. They should provide new services and resources without significantly increasing the workloads of physicians and clinic staff; among the most popular supports used in this study were the assistance of medical student volunteers and robocalls to patients about the COVID-19 vaccine. 

Practice Facilitation to Support Family Physicians in Encouraging COVID‐19 Vaccine Uptake: A Multi‐Method Process Evaluation 

Jennifer Shuldiner, PhD, et al

Women’s College Hospital Institute for Health Systems Solutions and Virtual Care, Toronto, Ontario, Canada

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Practice Interventions to Enhance Integrated Behavioral Health Care may Have Minimal Effect on Patient Outcomes

Researchers from around the United States collaborated on a clinical trial to test the effectiveness of a practice intervention for improving outcomes for patients with both physical and mental health problems by enhancing integrated behavioral health (IBH) activities. The research team recruited 42 primary care practice sites in 13 states, including internal medicine, family medicine, small and large groups, for-profit, academic, and safety-net clinics. Each site had a co-located behavioral health provider (a psychologist, social worker, or licensed counselor in the same building) working at least 0.5 FTE and a Practice Integration Profile (PIP) score (a measure of staff perception of IBH activities) below 75 out of 100. Electronic health records were used to identify eligible adult patients with multiple chronic medical and behavioral conditions at these practices, of whom 2,426 agreed to participate in the study.

Twenty practices randomly assigned to the active group were required to assemble an intervention team with a facilitator. They had access to an intervention toolkit with workbooks to guide quality improvement (QI) strategies within the practice and in care management; online education tailored to clinic roles; and remote coaching for the facilitator and intervention team. The 22 practices randomly assigned to the control group did not implement the intervention. At the start, midpoint, and two-year mark of the study, staff at all participating practices completed the PIP survey, while all patient participants (967 in the active group, 1,459 in the control group) completed the Patient-Reported Outcomes Measurement Information System (PROMIS-29) survey. The research team measured changes in the level of practice integration as indicated by the six domains of the PIP survey (Workflow, Clinical Services, Workspace, Integration of Providers, Patient Identification, and Patient Engagement) and changes in the eight PROMIS-29 domain scores (Physical Function, Anxiety, Depression, Fatigue, Sleep Disturbance, Social Functioning, Pain Intensity, and Pain Interference). 

Total PIP scores improved minimally for both active and control practices. Though there was no significant difference between their overall levels of improvement, the active group’s Workflow scores had a nearly 10-point increase, while the control group showed marginal improvement. Overall, the PROMIS-29 scores revealed no significant difference in the amount of change reported by patients at the active practices compared with patients at the control practices; patient outcomes also tended to be higher at practices that started with a higher level of IBH. However, patient outcomes showed greater improvement at the 13 active practices that followed the intervention workbook to completion.

What We Know: Mental health conditions such as depression and substance use disorder are often concurrent with a range of physical health concerns. For patients with both chronic physical and behavioral conditions, outcomes may improve with the use of integrative behavioral health (IBH) interventions, or the systematic collaboration between primary care and behavioral health providers on patient care. IBH interventions can range from simply working with a behavioral health provider in the same building to sharing patient records and scheduling. However, barriers such as the complexity of a health system can make it difficult to improve on existing IBH interventions or implement new ones.

What This Study Adds: The study intervention appeared to have no significant effect on patient-reported outcomes or practices’ overall PIP scores. However, the results showed a greater increase in PIP Workflow scores of practices in the intervention group than those in the control group. Researchers also found improved patient outcomes based on PROMIS-29 scores at active practices that completed the intervention and at practices that had a higher level of IBH per the PIP survey at the outset of the study. Further research is needed to determine how best to reach patients by enhancing IBH.

A Cluster Randomized Trial of Primary Care Practice Redesign to Integrate Behavioral Health for Those Who Need It Most: Patients With Multiple Chronic Conditions

Benjamin Littenberg, MD, et al, Division of General Internal Medicine Research, Department of Medicine, Robert Larner MD College of Medicine at the University of Vermont, Burlington, Vermont

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