September/October 2020 Annals of Family Medicine tip sheet

The Public Charge Rule: What Physicians Can Do to Support Immigrant Health As the U.S….

September/October 2020 Annals of Family Medicine tip sheet

The Public Charge Rule: What Physicians Can Do to Support Immigrant Health

As the U.S. federal government pursues immigration reform, changes to the federal public charge rule have triggered confusion and concerns among patients who are immigrants. Although federal judges temporarily blocked implementation, a decision by the U.S. Supreme Court in January 2020 allowed the proposed changes to take effect. These policy changes have resulted in many legal immigrants and their family members becoming more reluctant to apply for health insurance, food, housing and other benefits for which they are qualified. Physicians from the University of California, Irvine School of Medicine summarize current knowledge on the public benefits included in the “public charge” rule and offer suggestions for family physicians to support the health of their immigrant patients and families. The authors conclude that “family physicians can effectively respond to patient and immigrant community concerns about these changes by providing outreach education, access to primary health care, and referrals to legal and social services.”

Immigrant Health and Changes to the Public-Charge Rule: Family Physicians’ Response

Cynthia Haq, MD, et al

University of California, Irvine, School of Medicine, Department of Family Medicine

Rural Counties With Access to Obstetrics Have Healthier Infant Birth Outcomes

Rural areas with local access to obstetrical care report better infant health outcomes, including lower infant mortality rates and fewer babies delivered underweight. The retrospective cohort study compared the birth outcomes of rural counties in Alabama with in-county obstetrical care to those without over a 12-year span from 2003 to 2017. Across all four outcome measures–including infant, perinatal, and neonatal mortality rates as well as low birthrate deliveries–counties with access to obstetrical care had significantly better infant birth outcomes. The authors were not able to control for race or other social factors and report that areas with no obstetrical care access were also more likely to have a higher percentage of underrepresented minority residents. This study does not prove a causal link between access to obstetrical care and infant health outcomes, but it does suggest that obstetrical access may play a role in these disparities. These findings have broader implications for the more than half of all rural counties in the United States that do not have access to hospital-based obstetrical care.

Effect of Access to Obstetrical Care in Rural Alabama on Perinatal, Neonatal, and Infant Outcomes: 2003-2017

John B. Waits, MD, et al

Cahaba Medical Care, Centreville, Alabama

Telehealth Supports Collaborative Care Model in Addressing Mental Health Needs of Rural Patients

Traditionally, primary care clinics connect patients who have mental health care needs to specialists like psychiatrists in a collaborative care model. However, rural clinics often lack the workforce capacity to provide collaborative behavioral health services. In a new qualitative study, rural Washington primary care clinics adopted telehealth methods to connect remotely with specialists. The study found that telepsychiatric collaboration prepared primary care physicians and rural clinic staff to deliver high quality mental health care in underserved areas.

Study authors interviewed 17 clinical, support and administrative staff members of three rural primary care clinics. They found that through telepsychiatric consultation, all members of the clinic learned how to better serve the needs of mental health patients. Primary care doctors learned to work proficiently with these patients. Care managers learned to appreciate how medical issues affect mental health and how to diagnose and assess mental health issues, and consulting psychiatrists learned how to coach a primary care team, serve as educators and lead program implementation. The collaborative care model provides important benefits that other rural primary care clinics should consider adopting to help meet the needs of patients with mental health disorders.

Telepsychiatric Consultation as a Training and Workforce Development Strategy for Rural Primary Care

Morhaf Al Achkar, MD, PhD, et al

Department of Family Medicine, University of Washington, Seattle

Delivering Quality Care to Rural Communities

Most of rural North America is medically underserved, with a lack of physicians, nurses, physician assistants and behavioral health clinicians who can meet the needs of people living hundreds of miles from large urban centers. Several papers in the September-October 2020 issue of Annals of Family Medicine address the need for rural primary care and investigate new methods for delivering care to rural communities, including Waits et al’s analysis on benefits of local obstetrical services on birth outcomes across rural Alabama, as well as Al Achkar et al’s paper on the use of telepsychiatric consultations as a means to promote collaborative mental health care in rural primary care clinics.

“Access to health care in rural communities is fragile, too often dependent on individual clinicians, philanthropy, and lucky recruitment,” write John M. Westfall, MD, MPH, and Hoon Byun, DrPH, of the Robert Graham Center. In this editorial, the authors discuss research and make their own suggestions for creating best practices in delivering high quality health care to rural communities.

Editorial: Recruiting, Educating, and Taking Primary Care to Rural Communities.

John M. Westfall, MD, MPH, and Hoon Byun, DrPH

Robert Graham Center, Washington, D.C.

Study Shows Synthetic Medication and Desiccated Thyroid to be Equally Effective in Treating Hypothyroidism

A study by researchers at Kaiser Permanente in Denver, Colorado evaluated the stability of thyroid stimulating hormone (TSH) in patients using synthetic medication versus those using desiccated thyroid products to treat hypothyroidism. The results showed no difference in TSH stability over a three-year period between patients taking desiccated thyroid products and those on synthetic levothyroxine, an unanticipated finding given concerns about variability among batches of desiccated thyroid, which is prescribed much less frequently than synthetic levothyroxine.

In an accompanying editorial, Jill Schneiderhan and Suzanna Zick argue in favor of a patient-centered approach as opposed to relying primarily on laboratory results when determining the best way to manage hyperthyroidism. Emerging evidence shows that for many patients taking levothyroxine, symptoms persist despite lab results indicating normal TSH values. Further, these patients may feel invalidated and not in control of their treatment decisions. Schneiderhan and Zick conclude, “[k]eeping desiccated thyroid medications as an option in our tool kit will allow for improved shared decision making, while allowing for patient preference, and offer an option for those patients who remain symptomatic on levothyroxine monotherapy.”

Thyroid Stimulating Hormone Stability in Patients Prescribed Synthetic or Desiccated Thyroid Products: A Retrospective Study

Catherine S. Riggs, PharmD, et al

Kaiser Permanente Colorado, Denver

Editorial: Returning to a Patient-Centered Approach in the Management of Hypothyroidism

Jill Schneiderhan, MD, and Suzanna Zick, ND, MPH

University of Michigan Medical School, Ann Arbor

Risk of Peritonsillar Abscess Following Respiratory Tract Infection is Low Whether or Not Antibiotics are Prescribed

While widespread unnecessary use of antibiotics can diminish their effectiveness, reducing antibiotic prescribing may increase the risk of serious bacterial infections. This study quantifies the benefits of prescribing antibiotics for respiratory tract infections in terms of reduction in risk of peritonsillar abscess. Researchers used a large sample of 11,000 anonymized electronic health records in the United Kingdom from 2002 through 2017 to estimate the probability of peritonsillar abscess within 30 days of a consultation for a respiratory tract infection, and compared rates between people prescribed or not prescribed antibiotics. Overall, the risk of peritonsillar abscess was low, and in two-thirds of cases, patients did not consult their primary care physician prior to developing an abscess. The study concludes that antibiotics may only prevent one case of peritonsillar abscess for every 1,000 antibiotic prescriptions, and authors suggest that reducing antibiotic prescribing may not have a significant impact on incidence of peritonsillar abscess.

Peritonsillar Abscess and Antibiotic Prescribing for Respiratory Infection in Primary Care: A Population-Based Cohort Study and Decision-Analytic Model

Martin C. Gulliford, MA, FRCP, et al

King’s College London, School of Population Health and Environmental Sciences and NIHR Biomedical Research Centre at Guy’s and St Thomas’ Hospitals London, United Kingdom

Canadian Researchers Identify Four Barriers to Successfully Rolling Out ‘Gold-Standard’ Abortion Pill

Canada is the first country to facilitate provision of medical abortion in primary care settings through evidence-based deregulation of mifepristone, which is considered the ‘gold standard’ for medical abortion. A Canadian study investigated the factors that influence successful initiation and ongoing provision of medical abortion services among Canadian health professionals and how these factors relate to abortion policies, systems and service access throughout the country.

Results suggest that Health Canada’s initial restrictions discouraged physicians from prescribing mifepristone and were inconsistent with provincial licensing standards, thereby limiting patient access. During, and after removal of, these restrictions, researchers identified four barriers to utilizing/prescribing the drug, including the initial federal restrictions which made mifepristone “more complicated than it needs to be”; navigating the “huge bureaucratic process” of organizational implementation; challenges with diffusion and dissemination of policy information; and adoption by physicians as “a process rather than an event.”

This study, the authors write, is relevant to other nations experiencing challenges to accessing family planning services. Amidst the COVID-19 pandemic, U.S. policies restricting access to mifepristone have reached the Supreme Court after a federal district court judge temporarily suspended strict FDA regulations that require patients to visit a hospital or clinic in-person to obtain mifepristone. In Canada, ongoing implementation of mifepristone will require organizations to create tailored solutions to barriers, which may include creating new medical billing codes, provincial policy advocacy efforts, specifically in Quebec, which added its own restriction requiring accredited training in surgical abortion for any mifepristone provider, and conducting physician engagement to raise awareness to access barriers.

Perspectives Among Canadian Physicians on Factors Influencing Implementation of Mifepristone Medical Abortion: A National Qualitative Study

Sarah Munro, PhD, et al

University of British Columbia, Department of Obstetrics and Gynaecology, Vancouver, British Columbia, Canada

In, But Out of Touch: What Does the Loss of Touch Mean in the Clinical Setting?

Touch connects doctors and patients physically and emotionally as human beings, forming an intimate bond. The ability to touch has been hindered because of COVID-19. Touch, however, is central to the practice of medicine, including the physical examination that guides diagnoses and informs health care management.

In this narrative essay, authors Martina Ann Kelly of the University of Calgary in Alberta, Canada, and Gerard Gormley, of Queens University in Belfast, Northern Ireland, reflect on the meaning of touch in clinical practice and how virtual care is transforming this aspect of care. They write that touch is a ‘silent language’ that fulfills a deeper symbolic function, enabling doctors to acknowledge their patients’ concerns in a tangible way.

With the current COVID-19 global pandemic, doctors’ acumen now relies more on verbal histories supported by visual images, including videos or photographs. Kelly and Gormley express a sense of emotional inadequacy in sight and words, which they deem as lacking when treating patients. Though doctors have never been more connected with utilization of video conferencing for medical discussion, learning and providing patient care, the authors believe fellow family physicians should also pause to consider any unintended consequences.

In, But Out of Touch: Connecting With Patients During the Virtual Visit

Martina Ann Kelly, MB, BCh, BAO, MA, PhD, FRCGP, CCFP and Gerard J. Gormley, MB, BCh, BAO, MD, FRCGP, FHEA

University of Calgary, Cumming School of Medicine, Department of Family Medicine, Alberta, Canada and Queens University Belfast, Centre for Medical Education, Northern Ireland, United Kingdom

Out-of-Pocket and Total Visit Expenditures for Primary Care Physician Visits May Affect How Primary Care Is Delivered

This study looks at trends in out-of-pocket and total visit expenditures for visits to primary care physicians. Using the 2002-2017 Medical Expenditure Panel Survey (MEPS), the authors described changes in out-of-pocket and total visit expenditures for primary care visits for Medicare, Medicaid and private insurance. Between 2002 and 2017, the proportion of primary care visits associated with private insurance or no insurance decreased, while Medicare- and Medicaid-associated visits increased. Total expenditure per visit increased for private insurance and Medicare visits. Out-of-pocket expenditures rose primarily from increases in private insurance visits with higher out-of-pocket expenditures, while Medicare and Medicaid changed minimally. If these current trends continue, the authors would expect increasing difficulty with primary care physician access, particularly for Medicaid patients.

Trends in Total and Out-of-Pocket Expenditures for Visits to Primary Care Physicians, by Insurance Type, 2002-2017

Michael E. Johansen, MD, MS and Jonathan Doo Young Yun, MD, MPH

OhioHealth, Columbus, Ohio, and Heritage College of Osteopathic Medicine at Ohio University, Dublin and Heritage College of Osteopathic Medicine at Ohio University, Dublin

Improved Physician-Patient Relationships are Associated With Improved Health

This study found an association between improved physician-patient relationships and improved patient-reported health status. Researchers at Case Western Reserve University found over a one-year period that while consistent access to a provider is important, the quality of each clinical encounter is equally as important in shaping a patient’s reported overall health outcomes, as measured by the SF-12 quality of life questionnaire.

The authors also found some evidence that adults with five or more diagnosed conditions experience physician-patient relationships that are significantly lower in quality than those reported by adults without multimorbidity. This discrepancy may reflect unmet physician-patient relationship needs among adults bearing multimorbidity burdens and indicate another opportunity for intervention. The study findings can potentially inform health care strategies and health policy aimed at improving patient-centered health outcomes.

Assessing the Longitudinal Impact of Physician-Patient Relationship on Functional Health

R. Henry Olaisen, MPH, PhD, et al

Case Western Reserve University, Department of Population and Quantitative Health Sciences, Cleveland, Ohio

Patient Access to After-Hours Primary Care Could Prevent Some Less Urgent ER Visits

Patients who receive in-home nursing care have lower emergency room utilization if they have access to after-hours primary care. Previous research found that home nursing patients in Ontario, Canada, have an increased risk of visiting the ER after normal clinic hours on the same day they receive a home nursing visit. These ER visits may be linked to the visiting nurse identifying a health issue they are unable to appropriately address during the visit.

This study analyzed almost 12,000 patients who visited the ER after 5pm. The authors found that patients with after-hours primary care access had a smaller increased risk of an ER visit on the day a nurse came to their home compared to patients with no after-hours primary care access. These findings suggest increasing access to after-hours primary care could prevent some less-urgent ER visits.

Effect of Access to After-Hours Primary Care on the Association Between Home Nursing Visits and Same-Day Emergency Department Use

Aaron Jones, PhD, et al

McMaster University, Department of Health Research Methods, Evidence, and Impact, Hamilton, Ontario, Canada.

Primary Care Clinicians Drove Increasing Use of Medicare’s Chronic Care Management Codes

To address the problem of care fragmentation for Medicare recipients with multiple chronic conditions, Medicare introduced Chronic Care Management (CCM) in 2015 to reimburse clinicians for care management and coordination. The authors of this study analyzed publicly available Medicare data on all CCM claims submitted nationwide from 2015 through 2018. They compared CCM code usage and paid and denied services across a broad range of medical specialties. The study showed that CCM use increased over this four-year period, driven largely by primary care physicians. Most claims were billed to the original general CCM code, with newer codes for more complex services accounting for a small portion of overall code usage. The percentage of denied services remained consistent at around 5 percent during this period. The authors note that a limited number of clinicians currently deliver CCM services and that future work evaluating facilitators and barriers to patients’ and providers’ usage of CCM will be needed.

Use of Chronic Care Management Among Primary Care Clinicians

Ashok Reddy, MD, MSc, et al

University of Washington, Department of Medicine, Seattle

Processes Supportive of Patient Engagement are Boosted by Full Staffing, Daily Huddles, Responsible Leadership and Performance Improvement Discussions

VA researchers whose aim was to identify organizational and contextual factors associated with greater use of patient engagement processes found that high performing clinics were more likely to have fully-staffed primary care teams, clearly defined roles for team members, leadership responsible for implementing team-based care, and team meetings to discuss performance improvement, compared to clinics that performed poorly with regard to use of patient engagement processes.

Previous research has found that patients who are actively engaged in their own care are more likely to adhere to treatment, perform regular self-monitoring, have better intermediate health outcomes, and report better mental health and physical functioning. for engaging patients in self-management include involving patients in long-term planning and goal setting, training providers in motivational interviewing, and promoting the use of shared medical appointments, group visits, peer support, and home telehealth. Improving organizational functioning of primary care teams may enhance patient engagement in care.

Care Practices to Promote Patient Engagement in VA Primary Care: Factors Associated With High Performance

David A. Katz, MD, MSc, et al

Iowa City VA Medical Center and the University of Iowa, Departments of Medicine and Epidemiology, Iowa City

Innovations in Primary Care

Innovations in Primary Care are brief one-page articles that describe novel innovations from health care’s front lines. In this issue:

  • Wellness Wheel Mobile Outreach Clinic: A Community-Led Care Model Improving Access to Care in Indigenous Communities–Wellness Wheel is a roving primary care outreach clinic that serves rural Indigenous communities in Saskatchewan, providing community-informed health care services that are grounded in Indigenous knowledge and harm reduction, with a goal of building capacity and increasing access to testing and care for HIV, hepatitis C and other chronic disease in areas that have faced systematic exclusion.
  • Development and Implementation of a COVID-19 Respiratory Diagnostic Center–The University of North Carolina Health System shares components of their drive-through COVID-19 screening and testing clinic, testing 1,074 patients in its first 10 days.
  • Begin the Turn: A Mobile Recovery Program for a Targeted Urban Population– Begin the Turn, a multidisciplinary, mobile recovery program, can deliver street-side, community-mobilized treatment to address the opioid overdose crisis among urban populations struggling with homelessness and substance use disorder.
  • Enhanced Care Team Nurse Process to Improve Diabetes Care–A team of primary care physicians, registered nurses, pharmacists and clinical nurse specialists affiliated with the Mayo Clinic developed a nurse-led collaborative practice model for diabetes management whereby nurses engage directly with adult patients, clinicians and other health care team members to facilitate proactive, patient-centered care and support patient self-management
  • Innovative Family Medicine and Behavioral Health Co-Precepting via Telemedicine–With the onset of the COVID-19 pandemic, faculty at Rowan University School of Osteopathic Medicine transformed their Family Medicine/Behavioral Health co-preceptorship model to allow residents to gain valuable experience in telehealth and in team-based interaction in a virtual environment.


Annals of Family Medicine is a peer-reviewed, indexed research journal that provides a cross-disciplinary forum for new, evidence-based information affecting the primary care disciplines. Launched in May 2003, Annals is sponsored by seven family medical organizations, including the American Academy of Family Physicians, the American Board of Family Medicine, the Society of Teachers of Family Medicine, the Association of Departments of Family Medicine, the Association of Family Medicine Residency Directors, the North American Primary Care Research Group, and The College of Family Physicians of Canada. Annals is published six times each year and contains original research from the clinical, biomedical, social and health services areas, as well as contributions on methodology and theory, selected reviews, essays and editorials. Complete editorial content and interactive discussion groups for each published article can be accessed free of charge on the journal’s website,

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