January/February 2022 Annals of Family Medicine Media Tip Sheet

January/February 2022 Annals of Family Medicine Media Tip Sheet

Primary Care Medical Practices Struggle to Obtain Advice, Services for Child Behavioral Needs

With behavioral health problems on the rise among children in the United States, primary care practices are often the first stop for families seeking care needed to treat conditions like depression, anxiety and substance abuse disorders. In order to treat these patients, primary care practices must navigate a patchwork of rapidly changing standards of care, siloed human resources and shifting payment models. A new study attempts to quantify how difficult it is for practices to obtain pediatric medication advice, evidence-based psychotherapy and family-based therapy in this context. Researchers determined that more than 85% of the practices included in the study found it difficult to obtain help with evidence-based elements of pediatric behavioral health care. The percent experiencing difficulty was similar between system-owned and independent practices, but was lower for Medicaid Accountable Care Organization practices for medication advice (80% versus 89%) and evidence-based psychotherapy (81% versus 90%). Differences were not significant for family-based treatment (85% versus 91%). The study illustrates that significant barriers exist to pediatric behavioral health treatment across the primary care landscape, regardless of institution size, clinic ownership or payor mix. Policy changes may be necessary to address these barriers.

Difficulty Obtaining Behavioral Health Services for Children: A National Survey of Multiphysician Practices

Alyna T. Chien, MD, MS, et al

Division of General Pediatrics, Department of General Pediatrics, Boston Children’s Hospital and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts


Family Physician Shares “Sam’s Story" to Illustrate Increased Need for Social Support in Primary Care

Family physician Jennifer Karlin, MD, PhD, of the University of California, Davis, calls on fellow primary care physicians to redefine the boundaries of medical interventions to include social determinants of health.

She documents the experiences of her former patient, Sam, who initially sought treatment for hepatitis C, but required additional social support for a substance abuse disorder and insecure housing. Together, Dr. Karlin and Sam developed a care plan, with Sam’s assurances that he would not miss an appointment and would take his medications. Sam remained sober and had kept all his appointments with Dr. Karlin for a year. However, after he was hospitalized for endocarditis requiring an aortic valve replacement, his long-term discharge plan to a rehabilitation center and later permanent housing ran afoul. Sam was denied transitional housing because he was on medically assisted therapy for his substance abuse disorder.

The author describes this short-sighted decision to deny him housing due to his treatment for narcotics addiction as a defect in the social safety net, ultimately leading to Sam’s death. “Medical providers are given the authority to intervene in cases of life or death by providing direct medical services, but can do little about the majority of preventable deaths attributable to social determinants of health,” she writes. She concludes that redefining the boundaries of medical intervention to include structures that support patients’ social needs would not only prevent human and financial losses, it would address barriers to care faced by patients like Sam, who are considered among the most vulnerable patient populations.

Sam’s Story: The Financial and Human Costs of Disjointed Logics of Care

Jennifer Karlin, MD, PhD

University of California, Davis, Sacramento, California


Family Caregivers Find Both Conveniences and Barriers With Telehealth for Older Family Members

Researchers administered an online survey to 90 family caregivers of older adults across the state of Michigan to assess their perceptions of the benefits and barriers of telemedicine. Of those caregivers surveyed who participated in a relative’s telehealth visit, less than half participated from the same audio/video connection. The majority of those caregivers perceived benefits of participating in the visits, but many caregivers were not physically with their relative at the time of the appointment and were unable to provide technical support.

Perceived benefits of telehealth included increasing access to care, continuity of care, limiting risk of exposure to COVID-19 and improving the relationship and rapport between their older relatives and care providers. Perceived barriers included concerns about their older relative’s ability to use telehealth technology independently, a loss of patient-provider rapport, and a decline in quality of care for chronic conditions requiring special types of medical technologies, a doctor’s touch, hands-on assessments or close visual observation.

The researchers argue that policies shaping telehealth should include family caregivers’ input and that the engagement of caregivers in telehealth visits may be critical for enhancing older adults’ ability to age in place.

Family Caregivers’ Experiences With Telehealth During COVID-19: Insights From Michigan

Minakshi Raj, PhD, MPH, et al

Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Champaign, Illinois


Integrated Palliative Care in Ambulatory Settings Falls Short of Relieving Symptom Burden but Improves Health Care Utilization

Researchers from Johns Hopkins University conducted a systematic review to evaluate the availability, effectiveness and implementation of models integrating palliative care in ambulatory care settings. They synthesized results from qualitative, mixed methods and quantitative studies analyzing palliative care models for U.S. adults with noncancer-related chronic illness or conditions such as advanced heart failure, advanced COPD and end-stage renal disease.

The authors found that models for integrating palliative care in ambulatory care settings may have little to no effect on reducing overall symptom burden and were not more effective than usual care for improving health-related quality of life or depressive symptom scores. However, the models were more effective for increasing advanced directive documentation. They identified that patient preferences for appropriate timing of palliative care varied. They also identified costs, additional visits and travel as barriers to implementing palliative care models.

The authors write that future research is warranted to advance the science of palliative care by identifying components, characteristics and implementation factors that are critical to models for integrating palliative care in ambulatory care settings that will improve patient-centered outcomes and incorporate patients’ perspectives on care delivery.

Implementation and Effectiveness of Integrating Palliative Care Into Ambulatory Care of Noncancer Serious Chronic Illness: Mixed Method Review and Meta-Analysis

Linda C. Chyr, MPH, et al

Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland


New Diagnoses of Common Chronic Diseases and Cancers Plummeted During COVID-19 Pandemic

New diagnoses of common chronic conditions have dramatically declined during the COVID-19 pandemic, according to a new study. Researchers in Spain analyzed annual incidence rates of the main cardiovascular risk factors, chronic diseases, and some cancers in 2020, compared with data from 2017-2019. They found a reduction in newly reported diagnoses ranging from a 36% decline for high cholesterol diagnoses to a 50% decline in the diagnosis of pulmonary diseases such as chronic bronchitis and emphysema. Additionally, the rate of diagnosis of anxiety disorders increased by 16% while the diagnoses of alcohol use disorder decreased by 46%.

The authors note that the decline is not reflective of improved health outcomes but suggests that people are not receiving appropriate and timely health screenings that would diagnose these conditions early, when there is a greater chance of effective treatment and good health outcomes.

They write that returning to the level of detection and control of chronic diseases before the pandemic will require a substantial increase in primary care physicians and nurses; a return to face-to-face visits; a reorganization of telehealth; and the promotion of proactive care in patients who have the greatest comorbidities.

January/February 2022 Annals of Family Medicine Media Tip Sheet

The Impact of the COVID-19 Pandemic on Primary Health Care Disease Incidence Rates: 2017 to 2020

Antoni Siso-Almirall, MD, PhD, et al

Conscorci d’Atencio Primaria de Salut Barcelona Esquerra (CAPSBE), Barcelona, Spain


COVID-19 has Changed How Primary Care Teams Work,Understanding the Impact is Important

Researchers sought to understand the strategies that clinical and administrative staff at primary care practices use to manage challenges faced by the primary care workforce under strain by an ongoing state of emergency due to the COVID-19 pandemic. Understanding the impact of the pandemic on health care providers could potentially allow health organizations to support workforce well-being, prevent burnout and sustain the quality of patient care.

Researchers conducted short, semi-structured, qualitative interviews among 33 staff members from eight practices within a single health care system. Participants said that they had to adapt every aspect of primary care service delivery for COVID-19 — such as patient scheduling, switching to telehealth visits and increased sanitation responsibilities — which significantly increased their job demands. New skill development opportunities and sense of purpose during this period increased a sense of pride in some staff members, and most teams reported greater support and patience within their practices. Participants also learned to reframe their responsibilities as a necessity during the pandemic. Management support also helped. However, as the pandemic has continued, staff reported that they experienced more feelings of burnout.

Participants’ perceptions of the pandemic’s effect on their jobs, demands of those jobs, sense of control over their responsibilities and support they received are factors other health care system officials can examine to improve staff engagement and wellness.

Burnout and Commitment to Primary Care: Lessons From the Early Impacts of COVID-19 on the Workplace Stress of Primary Care Practice Teams

Erin Kelly, PhD, et al

Department of Family and Community Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania


Chat Box Usage Supports Primary Care Medical Staff Needs for Information, Resources and Peer Support During COVID-19 Crisis

As COVID-19 swept across the country in 2020, primary care medical staff were forced to make dramatic changes to their practices with little to no assistance and inconsistent guidance from the federal government. Researchers from Oregon Health & Science University created an 11-session COVID-19 Extension for Community Outcomes (ECHO) program, which served as a telementoring education model for clinicians involved in the ongoing pandemic crisis. They encouraged interactions between the participants via a chat box. Researchers used the text extracted from chat box interactions to assess how communications within the statewide program identified and fulfilled some of the clinicians’ needs during the pandemic.

Researchers conducted a qualitative analysis of 11 chat box transcripts and explored the context of clinicians’ needs, as conceptualized by Maslow’s hierarchy of needs, which include physiological and self-actualization needs, in addition to safety, love, belonging and esteem. Steeves-Reece et al identified three key content themes from clinicians using the chat box: 1) answers and trustworthy information; 2) practical resources; and 3) affirmation and peer support.

Participants were able to create a community through chat box use where colleagues provided connection and validation, as well as a forum for discussing their fears, concerns and grievances. Researchers also saw many participants taking on an advocacy role, another demonstration of self-actualization. Additionally, participants advocated within the chat box for their marginalized and underserved patients and for those with special health needs. The chat box supported many clinicians’ needs, including the ability to ask questions and provide comments during this rapidly changing health care environment. The researchers write that identifying and meeting clinicians’ needs during a pandemic — or any public health crisis — is critical for primary care as a discipline to reach its full potential. While interactive virtual education programs may be helpful, greater investments in both public health and primary care are fundamental for supporting clinicians’ ability to respond in a crisis.

Clinicians’ Core Needs in a Pandemic: Qualitative Findings From the Chat Box in a Statewide COVID-19 ECHO Program

Anna L. Steeves-Reece, PhD candidate, MPH, MA, et al

Oregon Rural Practice-based Research Network, Oregon Health & Science University, Portland, Oregon


Decision-Making Tools Proved Ineffective in Reducing Prescription Rates for Antibiotics

Antibiotics are one of the great advances in modern medicine, but their over prescription has led to resistant bacteria that are becoming more difficult to treat. The problem is particularly concerning in Australia, which has high rates of antibiotic prescribing, the majority of which are written in the primary care setting. In this clustered, randomized trial, researchers from Bond University and the University of Sydney, New South Wales, in Australia, piloted and evaluated a series of work aids to allow doctors to more easily talk with their patients about the benefits and risks of different antibiotic prescriptions. The aids consisted of a double-sided document presenting the options of managing the condition with and without antibiotics, and the evidence-based benefits and harms of each option, as well as a 15-minute video-delivered training.

The researchers found that the shared decision-making tools, provided to 122 general practitioners from 27 practices, did not reduce acute respiratory infection-related antibiotic dispensing more than usual care. However, general practitioners’ knowledge of relevant benefit-harm evidence increased significantly after the intervention.

A Brief Shared Decision-Making Intervention for Acute Respiratory Infections on Antibiotic Dispensing Rates in Primary Care: A Cluster Randomized Trial

Tammy C. Hoffmann, PhD, et al

Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Queensland, Australia


Female Family Medicine Researchers Submitted Fewer Manuscripts Compared to their Male Counterparts in 2020, Which May Reflect Larger Disparity

Researchers from Northwestern University’s Feinberg School of Medicine and Rush University conducted a bibliometric analysis of the Annals of Family Medicine to explore how the COVID-19 pandemic has impacted submission rates based on gender. Examining submission rates from January 1, 2015 to July 15, 2020, the study authors found that women represented 46.33% of all manuscript submissions. They found that the overall volume of submissions increased during COVID-19 as compared to pre-pandemic months, though submissions increased by 122% for men and 101% for women.

In the early months of the pandemic, 244 submissions were authored by men (58.5%) versus 173 submissions authored by women (41.5%). Throughout the pandemic, men submitted more original research articles and research briefs compared to women.

The study authors write that since the beginning of shelter-in-place orders, women scientists have experienced a significant decrease in work productivity in comparison to men. This may mean that in the future, they are less likely to be promoted within their field. The authors recommend that academic medical centers reevaluate promotion and tenure considerations to reflect the shift in education and clinical needs in response to COVID-19. They also suggest more supportive policies around parental leave, childcare and tenure extensions, which may help mitigate challenges faced by women researchers during the pandemic.

COVID-19 and Gender Differences in Family Medicine Scholarship

Katherine M. Wright, PhD, MPH, et al

Department of Family and Community Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois


Team-based Primary Care, Coupled With Payment Reform, May Reduce Emergency Department Use

Team-based care is a critical component of effective primary care that may reduce emergency department use by patients. In addition, sharing care responsibilities within an interprofessional primary care team, coupled with payment reform, may improve patient care while also reducing family physician burnout.

In a new study, researchers in Canada sought to compare annual ED visit rates of approximately 2.5 million patients before and after their physician transitioned from an enhanced fee-for-service to either a team-based or a non-team-based blended capitation model. Specifically, they compared ED visit rates in big cities, small towns and rural areas following the transition, which began around the year 2000.

While the analysis showed an overall increase in ED visits, the rate of increase was lower among patients who transitioned to a team-based, capitated primary care practice than those who transitioned to a capitated practice without an inter-professional team. The authors note that their findings are consistent with evidence supporting the role of extended health care teams in improving service delivery. Adoption of team-based primary care may reduce emergency department use. However, further research is needed to understand optimal team composition and roles.

Impact of Team-Based Care on Emergency Department Use

Tara Kiran, MD, MSc, et al

Department of Family and Community Medicine and the MAP Centre for Urban Health Solutions, St. Michael’s Hospital, a site of Unity Health Toronto, Toronto, Ontario;Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario;

Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario; and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario


Multi-Level Program Enhances Primary Care Treatment for Opioid Use Disorder in Rural Colorado

Researchers studied the implementation of a multilevel program called Implementing Technology and Medication Assisted Treatment Team Training in Rural Colorado (IT MATTRs). The program included a practice-focused intervention to improve the awareness, adoption and use of buprenorphine to treat opioid dependence and opioid use disorder. Four hundred and forty-one team members from 42 practices in Colorado received team training and support. Treatment components that support team-based care, as well as clinicians’ obtaining the Drug Enforcement Agency waiver needed to prescribe buprenorphine for OUD, were assessed before and after training implementation.

Prior to training, practices reported having an average of 4.7 treatment-related components, such as patient consent forms or a urine drug testing protocol in place. Practices reported an average of 13 components at 12 months post-intervention. The proportion of participating practices providing or referring patients for treatment increased from 18.8% to 74.4%, and the number of people with a prescription for buprenorphine in the rural Colorado study region was significantly greater over a four-year period (87%) compared to the rest of the state (65%). IT MATTRS training for primary care teams in OUD treatment with buprenorphine addresses elements beyond the required clinician waiver training to make implementation a reality. It effectively increased implementation and treatment delivery in Colorado.

Increasing Capacity for Treatment for Opioid Use Disorder in Rural Primary Care Practices

Linda Zittleman, MSPH, et al

University of Colorado School of Medicine, Department of Family Medicine, Aurora, Colorado


Study Examining Technology-Facilitated Abuse Among Young Men Calls for Primary Care Doctors to Create Interventions

Results from a nationally representative sample of young men 18-35 in the U.S. indicate that technology-facilitated abuse is common, with 38% of young men surveyed indicating that they either delivered, received, or both delivered and received technology-facilitated abuse in the last year. The majority of young men who reported experiences with technology-facilitated abuse both delivered and received abuse, highlighting the complexity of identifying and responding to technology-facilitated abuse among men. This pattern is similar to patterns seen in non-technology-facilitated abuse male intimate partner violence. Furthermore, the study found that men who reported ever having mental health care visits, those who owned smartphones and those who self-reported substance misuse were more likely to both deliver and receive technology-facilitated abuse. Depression, education level and employment status were not found to correlate with technology-facilitated abuse.

With increased focus on screening for intimate partner violence in primary and emergency care settings, the authors argue for the expansion of intimate partner violence screening questions among male patients in the clinical setting to include technology-facilitated abuse. Providers can consider adapting intimate partner violence screening tools that have been validated among women, including the Partner Violence Screen and Index of Spousal Abuse, for assessment of intimate partner violence and technology-facilitated abuse among male patients.

Technology-Facilitated Abuse Prevalence and Associations Among a Nationally Representative Sample of Young Men

Laura Seewald, MD, et al

Department of Emergency Medicine, Medical School, University of Michigan, Ann Arbor, Michigan


Preventive Medicine Use for Gastrointestinal Bleeding Varies by Specialty, Indicating Need for Improved Prescribing Guidelines

Proton pump inhibitors are common and effective medications for the treatment of stomach acid-related diseases including peptic ulcers that can lead to gastrointestinal bleeding. While proton pump inhibitors are commonly prescribed, for patients at high risk of a gastrointestinal bleed they may be underutilized. Researchers explored the prescribing practices and barriers doctors face when deciding whether to implement gastroprotection. They interviewed five primary care physicians, four cardiologists, three gastroenterologists, and three vascular surgeons within a single institution to produce qualitative results for this study.

Most primary care physicians, gastroenterologists and vascular surgeons seldom prescribed gastroprotection. Cardiologists varied most in their use of proton pump inhibitor gastroprotection. Other health care professionals never prescribed proton pump inhibitors. Barriers revolved around knowledge, decision processes and professional roles in prescribing proton pump inhibitors. Knowledge about prescribing guidelines was greatest among cardiologists and gastroenterologists and low among primary care physicians and vascular surgeons. Barriers operated differently across specialties. Multi-component interventions will likely be necessary to improve guidelines-based use of proton pump inhibitors to prevent upper gastrointestinal bleeding.

Barriers to Guideline-Based Use of Proton Pump Inhibitors to Prevent Upper Gastrointestinal Bleeding

Jacob E. Kurlander, MD, MS, et al

Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan


Survey Says Youth Need More Education on Adequate Protection and Enhanced Safety When Engaging in Oral Sex

Researchers assessed more than 900 youths’ knowledge of the risks of oral sex and barriers to using protection through the use of MyVoice, a national text message–based poll.

Barriers to using protection when engaging in oral sex included a lack of knowledge of the risks, limited access to and dissatisfaction with protection methods, and cultural norms. Many respondents knew that some STIs can be transmitted through unprotected oral sex, but many youths also underestimated the severity of risk associated with the act: “You can’t really get anything super harmful from it.” Participants also reported a lack of information about adequate protection methods as barriers to their engaging in safe oral sex. Some respondents expressed a lesser concern for sexually transmitted infections as compared to pregnancy.

Youths suggested that greater sex education, frank discussions about oral sex versus saying ‘don’t have oral sex,’ and normalized mentions in the media would increase their use of protection. Researchers concluded that programs tailored to decrease rates of sexually transmitted infections among youths should include education on the use of sexual protective devices in oral sex.

Youths’ Knowledge and Perceptions of Health Risks Associated With Unprotected Oral Sex

Tammy Chang, MD, MPH, MS, et al

Department of Family Medicine and National Clinician Scholars Program at the Institute for Health Policy & Innovation, University of Michigan, Ann Arbor, Michigan


COVID-19 Pandemic Demands Adaptation by Those who Practice Family Medicine and Those who Receive Care

The January/February edition of Annals of Family Medicine presents a research package highlighting the massive impact that COVID-19 has had on the family medicine landscape. It includes original research papers on the alarming reduction in diagnoses of common chronic conditions such as diabetes and hypertension in Spain, as compared to the number of diagnoses three years prior to the pandemic (Siso-Almarill et al); a family medicine residency team that collaborated to increase vaccination rates among low-vaccine use communities (Ha et al); and the development of a virtual extension program to support primary care teams in the community (Steeves-Reece et al). Additionally, this edition of Annals features research exploring the impact of the telehealth transition on caregivers (Raj et al) and the troubling decline in manuscript submissions by female researchers as compared to their male counterparts in Annals of Family Medicine after the onset of COVID (Wright et al). “This collection of COVID-19 impact articles presents some concerning data about the impact of COVID-19 on primary care above and beyond the direct impact of the virus on the health of patients and health care teams,” writes Annals Editor-in-Chief Caroline Richardson, MD, this edition’s editorialist. “Research, innovation and evaluation efforts will play a critical role in guiding policy and practice as we navigate a world with COVID-19.”

The Pandemic’s Agenda

Caroline Richardson, MD

Editor-in-Chief, Annals of Family Medicine


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:

The Effect of a Shared Decision-Making Process on Acceptance of Colorectal Cancer Screening — Using data from OptumLabs, researchers implemented a shared decision making process to educate patients on risks, harms and benefits of three options for colorectal cancer screening, whether it is in the clinic or by using a non-invasive screening test. The study found that in-office shared decision-making processes for colorectal cancer screening, facilitated by information and guidance for clinicians, helps patients select the best screening test for themselves. The majority of patients selected less invasive, non-colonoscopy alternatives to colorectal cancer screening. The shared decision-making approach significantly increased screening rates.

Ethan M. Berke, MD, MPH, et al

UnitedHealth Group, Minnetonka, Minnesota


Targeted Advanced Home Care for Patients With Moderate or Severe COVID-19 — Primary care doctors in Japan collaborated with public health and emergency response officials to organize rapid response measures to triage and treat at-home patients with COVID-19. Primary care physicians and visiting nurses provided home visits and implemented home oxygen therapy and dexamethasone administration in individuals with severe COVID-19 cases. The team provided home visits for 17 patients during May 2021, when coronavirus cases soared in Sapporo, Japan. They hope their experience helps worldwide primary care teams to treat moderate and severe COVID-19 patients at home.

Koki Kato, MD, MPH, et al

Madoka Family Clinic, Ogori city, Fukuoka, Japan and Hokkaido Centre for Family Medicine, Sappoo city, Hokkaido, Japan


Addressing COVID-19 Immunization Disparities Through Targeted Primary Care Outreach — Members of the Stanford-O’Connor Family Medicine Residency developed an outreach process in collaboration with a community health clinic in San Jose, California, to distribute COVID-19 vaccinations in January 2021. They identified communities with low vaccination rates and patients in those communities who were not vaccinated. They attempted to contact 36 patients and successfully reached 20 patients. Fourteen of 15 referred unvaccinated patients received at least one dose of the vaccine through the clinic. Due to this successful innovation, an institutional, staff-based outreach program has been initiated in the larger clinic population.

Emmeline Ha, MD, et al

Stanford-O’Connor Family Medicine Residency, San Jose, California


A Multidisciplinary Precision Medicine Service in Primary Care — In July 2019, the University of Pennsylvania Medical Center Health System launched the Primary Care Precision Medicine clinic to deliver genomic testing and services in the primary care setting. A multidisciplinary primary care team focused on how precision medicine can expand patient access to genetic services. Since the program’s launch, staff have received 99 referrals from other primary care clinicians. Of these referrals, 61 were for genetic cancer risk assessment; 29 for pharmacogenomic testing; and nine for validation and interpretation of direct-to-consumer testing. Their program provides what they feel is an innovative and accessible approach to offering intermediate genetic services care for primary care patients.

Mylynda Massart, MD, PhD, et al

University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania


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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, www.AnnFamMed.org.

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