Diagnostic services for developmental coordination disorder: Gaps and opportunities identified by parents

BACKGROUND

Affecting one in 20 children, Developmental Coordination Disorder (DCD) is a common neurodevelopmental disorder impacting a child's ability to learn motor skills. Despite its high prevalence, DCD is under-recognized and under-diagnosed, causing unnecessary frustration and stress for families who are seeking help for their child. This study aimed to understand how parents procure diagnostic services and their perspectives on needed supports and services to improve early identification and diagnosis of DCD.

METHODS

Using a multi-pronged recruitment strategy, we circulated the impACT for DCD online questionnaire to parents of children (<18 years) in British Columbia with suspected or diagnosed DCD. Data were analysed descriptively using medians/interquartile ranges for continuous data and frequencies/percentages for categorical data. Open-ended questions were analysed using exploratory content analysis.

RESULTS

A total of 237 respondent data were analysed. Parents identified poor awareness and understanding of health care professionals and educators regarding aetiology, symptomology, and impacts of DCD, affecting timely access to diagnostic services. Long waitlists were also a barrier that often led families with financial means to procure private diagnostic assessments.

CONCLUSION

A standard of care is needed for streamlined diagnostic services, enabling early identification and early intervention. A publicly funded, family-centred, collaborative care approach is critical to assess, diagnose, and treat children with this disorder and to mitigate the secondary physical and mental health consequences associated with DCD.

Assessment and Management of Atopic Dermatitis in Primary Care Settings: A Systematic Review

Atopic dermatitis is a complex, recurrent, chronic inflammatory skin condition. It frequently begins to manifest in early childhood and may last throughout adulthood. The need for clinical practice guidelines that are based on evidence is critical for efficient and secure care. Little is known about how primary care providers (PCPs) should handle pediatric and adult atopic dermatitis cases and whether they should follow national recommendations. Our systemic review aimed to examine management strategies for treating adult and pediatric (family) atopic dermatitis, including topical calcineurin inhibitors (TCIs), topical corticosteroids (TCS), skin emollients, oral antihistamines, and diet. Data sources were PubMed (MEDLINE) and Embase. Our review investigated English-language articles from 2014 to 2023 that studied the management of adult and children atopic dermatitis. Overall, there were 15 articles included. Surveys and analyses of national databases were the most widely used methods (n=7). The use of TCS by PCPs was common, but they also overprescribed nonsedating antihistamines, favored low-potency drugs, and avoided TCIs. Most studies relied on healthcare personnel reporting their typical behaviors rather than looking at specific patient encounters and it is considered a limitation. Finally, there are gaps in knowledge and management of critical topics such as prescribing TCIs and understanding the safety profiles of TCS, when it comes to treating adult and pediatric atopic dermatitis. Future research in this area is urgently needed because the current systemic assessment is mostly restricted to small studies that assess prescribing behaviors with scant information describing nonmedication management.

The Management of Children and Youth With Pediatric Mental and Behavioral Health Emergencies

Mental and behavioral health (MBH) emergencies in children and youth continue to increasingly affect not only the emergency department (ED), but the entire spectrum of emergency medical services for children, from prehospital services to the community. Inadequate community and institutional infrastructure to care for children and youth with MBH conditions makes the ED an essential part of the health care safety net for these patients. As a result, an increasing number of children and youth are referred to the ED for evaluation of a broad spectrum of MBH emergencies, from depression and suicidality to disruptive and aggressive behavior. However, challenges in providing optimal care to these patients include lack of personnel, capacity, and infrastructure, challenges with timely access to a mental health professional, the nature of a busy ED environment, and paucity of outpatient post-ED discharge resources. These factors contribute to prolonged ED stays and boarding, which negatively affects patient care and ED operations. Strategies to improve care for MBH emergencies, including systems level coordination of care, is therefore essential. The goal of this policy statement and its companion technical report is to highlight strategies, resources, and recommendations for improving emergency care delivery for pediatric MBH.

The Management of Children and Youth With Pediatric Mental and Behavioral Health Emergencies

Mental and behavioral health (MBH) emergencies in children and youth continue to increasingly affect not only the emergency department (ED), but the entire spectrum of emergency medical services for children, from prehospital services to the community. Inadequate community and institutional infrastructure to care for children and youth with MBH conditions makes the ED an essential part of the health care safety net for these patients. As a result, an increasing number of children and youth are referred to the ED for evaluation of a broad spectrum of MBH emergencies, from depression and suicidality to disruptive and aggressive behavior. However, challenges in providing optimal care to these patients include lack of personnel, capacity, and infrastructure, challenges with timely access to a mental health professional, the nature of a busy ED environment, and paucity of outpatient post-ED discharge resources. These factors contribute to prolonged ED stays and boarding, which negatively affects patient care and ED operations. Strategies to improve care for MBH emergencies, including systems level coordination of care, is therefore essential. The goal of this policy statement and its companion technical report is to highlight strategies, resources, and recommendations for improving emergency care delivery for pediatric MBH.

Factors Associated with Primary Care Provider's Job Satisfaction and Organizational Commitment in China: A Machine Learning-Based Random Forest Analysis

The objective of the study is to explore the factors that influence the job satisfaction and organizational commitment of primary care providers in China, with a focus on the impact of the COVID-19 pandemic and the rescission of restriction policies. We utilized the 20-item Minnesota Satisfaction Questionnaire (MSQ) and the 25-item organizational commitment survey to assess job satisfaction and organizational commitment. In total, 435 valid responses were included in our analysis. The average scores for job satisfaction and organizational commitment were 80.6 and 90.8. After a two-step tuning process, we built random forest models by machine learning. The results show income change, working years, working years in the current institute, and age were the four most important features associated with job satisfaction, organizational commitment, and most of their dimensions. The number of professional fields engaged, gender, job status, and types of endowment insurance were least associated. During pandemic time, income-related factors remain a core concern for primary care providers, whereas job security may lose its importance. These findings suggest that financial bonuses may be an effective way to boost morale, and age-specific motivation plans may be necessary.

Associations Between General Vaccine Hesitancy and Healthcare Access Among Arkansans

BACKGROUND

Vaccines provide protection against numerous diseases that can cause serious illness and death. However, vaccine hesitancy threatens to undermine progress in reducing preventable diseases and illness. Vaccine hesitancy has been shown to vary by sociodemographic characteristics. However, studies examining associations between healthcare access and vaccine hesitancy are lacking.

OBJECTIVE

Using a statewide random sample of Arkansas adults, we examined the relationship between general vaccine hesitancy and healthcare access.

DESIGN

From July 12 to 30, 2021, participants were contacted by landlines and cellular phones using random digit dialing.

PARTICIPANTS

A total of 1500 Arkansas adults were surveyed. Black/African American and Hispanic/Latinx adults were oversampled to ensure adequate representation. The survey had a cooperation rate of 20%.

MAIN MEASURES

The dependent variable was an ordinal measure of general vaccine hesitancy. Age, gender, race, education, relationship status, and rural/urban residence were included in the model. Healthcare access was measured across four domains: (1) health insurance coverage; (2) having a primary care provider (PCP); (3) forgoing care due to cost; and (4) time since last routine checkup. The relationship between general vaccine hesitancy and healthcare access was modeled using ordinal logistic regression, controlling for sociodemographic characteristics.

KEY RESULTS

Mean age was 48.5 years, 51.1% were women, 28% reported a race other than White, and 36.3% held a bachelor's degree or higher. Those with a PCP and those with health insurance had approximately two-thirds the odds of being more hesitant ([OR=0.63, CI=0.47, 0.84] and [OR=0.68; CI=0.49, 0.94]) than those without a PCP and those without health insurance. Participants reporting a routine checkup in the last 2 years were almost half as likely to be more hesitant than those reporting a checkup more than 2 years prior (OR=0.58; CI=0.43, 0.79).

CONCLUSIONS

Results suggest improving access to health insurance, PCPs, and routine preventative care services may be critical to reducing vaccine hesitancy.

Pediatric Primary Care Providers' Perspectives on Telehealth Platforms to Support Care for Transgender and Gender-Diverse Youths: Exploratory Qualitative Study

BACKGROUND

Access to gender-affirming care services for transgender and gender-diverse youths is limited, in part because this care is currently provided primarily by specialists. Telehealth platforms that enable primary care providers (PCPs) to receive education from and consult specialists may help improve the access to such services. However, little is known about PCPs' preferences regarding receiving this support.

OBJECTIVE

This study aimed to explore pediatric PCPs' perspectives regarding optimal ways to provide telehealth-based support to facilitate gender-affirming care provision in the primary care setting.

METHODS

PCPs who had previously requested support from the Seattle Children's Gender Clinic were recruited to participate in semistructured, 1-hour web-based interviews. Overall, 3 specialist-to-PCP telehealth modalities (tele-education, electronic consultation, and telephonic consultation) were described, and the participants were invited to share their perspectives on the benefits and drawbacks of each modality, which modality would be the most effective, and the most important characteristics or outcomes of a successful platform. Interviews were transcribed and analyzed using a reflexive thematic analysis framework.

RESULTS

The interviews were completed with 15 pediatric PCPs. The benefits of the tele-education platform were developing a network with other PCPs to facilitate shared learning, receiving comprehensive didactic and case-based education, having scheduled education sessions, and increasing provider confidence. The drawbacks were requiring a substantial time commitment and not allowing for real-time, patient-specific consultation. The benefits of the electronic consultation platform were convenient and efficient communication, documentation in the electronic health record, the ability to bill for provider time, and sufficient time to synthesize information. The drawbacks of this platform were electronic health record-related difficulties, text-based communication challenges, inability to receive an answer in real time, forced conversations with patients about billing, and limitations for providers who lack baseline knowledge. With respect to telephonic consultation, the benefits were having a dialogue with a specialist, receiving compensation for PCP's time, and helping with high acuity or complex cases. The drawbacks were challenges associated with using the phone for communication, the limited expertise of the responding providers, and the lack of utility for nonemergent issues. Regarding the most effective platform, the responses were mixed, with 27% (4/15) preferring the electronic consultation, 27% (4/15) preferring tele-education, 20% (3/15) preferring telephonic consultation, and the remaining 27% (4/15) suggesting a hybrid of the 3 models.

CONCLUSIONS

A diverse suite of telehealth-based training and consultation services must be developed to meet the needs of PCPs with different levels of experience and training in gender-affirming care. Beyond the widely used telephonic consultation model, electronic consultation and tele-education may provide important alternative training and consultation opportunities to facilitate greater PCP independence and promote wider access to gender-affirming care.

Assessing Knowledge and Barriers at the Primary Care Provider Level that Contribute to Disparities in Inflammatory Breast Cancer Diagnosis and Treatment

Purpose

The purpose of this study was to evaluate knowledge gaps and barriers related to diagnosis and care of inflammatory breast cancer (IBC), a rare but most lethal breast cancer subtype, amongst Primary Care Providers (PCP) as they are often the first point of contact when patients notice initial symptoms.

Methods

PCP participants within Duke University Health System, federally qualified health center, corporate employee health and community practices, nearby academic medical center, Duke physician assistant, and nurse leadership program alumni were first selected in a convenience sample (n=11) for semi-structured interviews (n=11). Based on these data, an online survey tool was developed and disseminated (n=78) to assess salient measures of IBC diagnosis, health disparity factors, referral and care coordination practices, COVID impact, and continued medical education (CME).

Results

PCP reported access to care and knowledge gaps in symptom recognition (mean = 3.3, range 1-7) as major barriers. Only 31% reported ever suspecting IBC in a patient. PCP (n=49) responded being challenged with referral delays in diagnostic imaging. Additionally, since the COVID-19 pandemic started, 63% reported breast cancer referral delays, and 33% reported diagnosing less breast cancer. PCP stated interest in CME in their practice for improved diagnosis and patient care, which included online (53%), lunch time or other in-service training (33%), patient and provider-facing websites (32%).

Conclusions

Challenges communicating rare cancer information, gaps in confidence in diagnosing IBC, and timely follow-up with patients and specialists underscores the need for developing PCP educational modules to improve guideline-concordant care.

Efficacy of an eConsult service to cure hepatitis C in primary care

In 2016, an eConsult service was developed within a safety net health system to expand access to hepatitis C (HCV) treatment in the primary care setting. The eConsult system provides individualized treatment recommendations from specially trained primary care pharmacists and primary care physicians to primary care providers with less experience in the rapidly changing treatment of HCV. Since its launch, this service has had a large impact in expanding care to a largely homeless and low-income urban population within our health system. We now aim to evaluate its efficacy in curing HCV. In this retrospective cohort study, we describe rates of sustained virologic response 12 weeks after treatment completion (SVR12) for those who received primary care-based HCV treatment through the eConsult system with those who were treated in primary care independent of an eConsult from 2017 to 2019. We found there was no significant difference in the proportion of patients who achieved SVR12 between the two groups. Overall, >90% of patients who received treatment achieved SVR12. Approximately 40% of patients treated for HCV received an eConsult, suggesting utility of the eConsult in expanding access and coordinating treatment for patients within our network.

Management of Pediatric Atopic Dermatitis by Primary Care Providers: A Systematic Review

BACKGROUND

Primary care providers (PCPs), including pediatricians and general practitioners, are often the first to see children with eczema/atopic dermatitis (AD). Little is known about management of pediatric AD by PCPs and adherence to national guidelines.

OBJECTIVE

To review existing literature examining management components of pediatric AD (topical corticosteroids [TCS], topical calcineurin inhibitors [TCIs], antihistamines, bathing, emollients, and diet) by PCPs.

DATA SOURCES

PubMed/Medline and Embase.

STUDY ELIGIBILITY CRITERIA

English-language articles dated 2015 to 2020 reporting outcomes addressing management of pediatric AD by PCPs.

STUDY APPRAISAL AND SYNTHESIS METHODS

Two authors independently screened titles/abstracts, reviewed full-text articles, extracted relevant data, and evaluated study quality. Disagreements were resolved by a third author.

RESULTS

Twenty articles were included. Surveys and national database analyses were the most common methodologies (n = 7 each). PCPs commonly prescribed TCS but had a preference for low-potency agents, overprescribed nonsedating antihistamines, and avoided TCIs. PCPs commonly recommended emollients, although this was not universal. Data characterizing nonmedication management were limited.

LIMITATIONS

Most studies did not examine individual patient encounters, but rather relied on providers reporting their general behaviors. Provider behavior may vary based on country of practice.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

Knowledge and management gaps exist among PCPs in treating pediatric AD in key areas including knowledge of TCS safety profiles and prescribing of TCIs. The current literature is largely limited to small studies that evaluate prescribing behaviors with limited data characterizing nonmedication management, highlighting the need for future research in this area.

Use of primary care services among patients with chronic skin disease seen by dermatologists

Background

Skin diseases, such as psoriasis, hidradenitis suppurativa, acne, and alopecia areata, have increasingly been linked to systemic and mental health comorbidities, such as depression. Although identification and management of these comorbidities is typically a part of primary care, some patients might not have an established relationship with a primary care provider and may only be seeing their dermatologist.

Objective

To examine the frequency with which dermatologists are the main contact within a health care system for patients with these chronic skin conditions.

Methods

We performed a retrospective cohort study using Optum's deidentified Clinformatics Data Mart Database. The primary outcome was the proportion of patients who established care with a dermatologist and had no encounters with a primary care provider during the subsequent year after this dermatology encounter.

Results

Across each of the skin diseases evaluated, 21.6%-31.2% of men and 16.9%-26.2% of women had no primary care visits in the subsequent year after establishing care with their dermatologist.

Conclusion and Relevance

For many patients with chronic skin diseases, their dermatologist might be their only source of contact with the health care system. There may be an opportunity for dermatologists to improve the quality of care for our patients by screening for associated comorbidities.

Trends in Positive, Negative, and Neutral Themes of Popular Music From 1998 to 2018: Observational Study

BACKGROUND

Across the United States, the incidence of adolescent depression and suicide cases has risen in the past 10 years. Despite the risk factors and causes being multifactorial, the influence of popular culture on society and adolescents in this media-driven generation cannot be mitigated. Although the impact of social media and its effect on shaping self-identity in adolescents have been observed, the impact of music and its potential for subliminal negative messages to adolescents remains unclear.

OBJECTIVE

This study analyzes the lyrics and music videos of the most popular music of multiple genres to quantify the frequencies of varying music theme trends.

METHODS

The frequencies of themes of 1052 total American and Latin songs were collected from the Nielsen Music and Billboard's top 100 chart performance from 1998 to 2018 for hip hop/rhythm and blues (R&B), pop, Latin, country, and rock/metal genres. Themes from songs were identified, quantified, and categorized with a rubric into negative, neutral, and positive themes by 3 different reviewers. Analysis was performed using 2-tailed t tests and a generalized linear model.

RESULTS

Popular songs were reviewed for positive, negative, and neutral themes in the following 3-year intervals for ease of analysis purposes: 1998 to 2000 (n=148), 2001 to 2003 (n=150), 2004 to 2006 (n=148), 2007 to 2009 (n=156), 2010 to 2012 (n= 150), 2013 to 2015 (n=150), and 2016 to 2018 (n=150). There was a significant 180% increase in the percentage of songs with negative themes between all the interval years and across all genres (P<.001), while there was no significant difference in the frequency of songs with positive (P=.54) or neutral (P=.26) themes by year. There were significant differences in the number of negative themes found across genres (P<.001), with hip hop/R&B having the highest frequency of 130 out of 208 (62.5%) of the negative themes when compared to each of the individual genres (P<.001).

CONCLUSIONS

This study shows there is an increase in the frequency of negative themes over the span of 20 years across all genres, with hip hop/R&B having the highest frequency among the genres. These findings point to the potential impact that music may have in popular culture and on society. Furthermore, these results can help shape discussions between caregivers and their adolescent dependents and between primary care providers and their adolescent patients.

Primary care provider evaluation and management of insomnia

STUDY OBJECTIVES

To evaluate the type and extent of information collected from patients with insomnia during their first office encounter for insomnia and the prescribing therapies of primary care providers during this initial encounter.

METHODS

This study was a retrospective chart review of randomly selected patients who had a primary care provider office visit at any clinic affiliated with a university medical system between March 1, 2013, and March 1, 2016. Demographic and clinical information was abstracted for analysis.

RESULTS

Our sample (n = 200) was primarily female (63.5%), White (69%), middle-aged (ages 44.6 ± 15.1 years) adults. Most (68.5%) encounter notes did not have significant information related to insomnia risk factors and symptoms (< 50% of the notes). When examining comorbidities, we found that younger patients (<45 years old) were more likely to have anxiety linked to insomnia (P = .025), whereas older patients (≥45) were less likely to have any identified comorbidities associated with insomnia (P = .009). Only 5.0% of patients with insomnia were referred for cognitive-behavioral therapy for insomnia, whereas 51.5% of patients were prescribed sleep medications. The younger cohort was statistically more likely to receive sleep hygiene or cognitive-behavioral therapy for insomnia as a treatment option in comparison to the older cohort (P = .01 and P = .04, respectively).

CONCLUSIONS

Progress notes from primary care providers tend to have a paucity of information on insomnia symptoms and related comorbidities. Medications are often prescribed as the first-line treatment for insomnia. Cognitive-behavioral therapy for insomnia remains underutilized despite robust evidence suggesting that cognitive-behavioral therapy for insomnia is a safe and effective treatment for insomnia.

Treatment Preferences for Chronic Low Back Pain: Views of Veterans and Their Providers

Purpose

This study was conducted to characterize chronic low back pain (cLBP) and to identify treatment histories and preferences for cLBP management among Veterans and primary care providers within the Veterans Affairs (VA) healthcare system.

Participants and Methods

Veterans with cLBP from five geographically diverse VA medical centers were identified using International Classification of Diseases (ICD) 9 and 10 codes from VA administrative data as were primary care providers at these same sites. From these data, Veterans (200/per site) and providers (160/per site) were selected and mailed surveys. Open-ended interview data were collected from a subset of Veterans and providers.

Results

In total, 235 Veterans and 67 providers returned completed surveys. More than 80% of the Veteran respondents had daily back pain for more than 1 year. Most Veterans had tried several treatments for their pain with medications and physical therapy being the most commonly used. Veterans and providers had similar attitudes towards many cLBP treatments with the exception of psychological therapies that were more favored by providers. Open-ended interview data showed that Veterans and providers emphasized the need for multi-component approaches to treatment.

Conclusion

Among Veterans, cLBP is typically of sustained duration, is relatively severe, and also interferes significantly with normal functioning. Veterans are experienced with respect to treatments and had similar attitudes towards many cLBP treatments as their providers, especially tailored approaches.

Economic Burden and Health Care Access for Patients With Inflammatory Bowel Diseases in China: Web-Based Survey Study

Background

The increasing incidence of inflammatory bowel disease (IBD) has imposed heavy financial burdens for Chinese patients; however, data about their financial status and access to health care are still lacking. This information is important for informing patients with IBD about disease treatment budgets and health care strategies.

Objective

The aim of this study was to evaluate the economic status and medical care access of patients with IBD through the China Crohn’s & Colitis Foundation web-based platform in China.

Methods

Our study was performed in 14 IBD centers in mainland China between 2018 and 2019 through WeChat. Participants were asked to complete a 64-item web-based questionnaire. Data were collected by the Wenjuanxing survey program. We mainly focused on income and insurance status, medical costs, and access to health care providers. Respondents were stratified by income and the associations of income with medical costs and emergency visit times were analyzed.

Results

In this study, 3000 patients with IBD, that is, 1922 patients with Crohn disease, 973 patients with ulcerative colitis, and 105 patients with undetermined colitis were included. During the last 12 months, the mean (SD) direct and indirect costs for per patient with IBD were approximately US $11,668.68 ($7944.44) and US $74.90 ($253.60) in China. The average reimbursement ratios for most outpatient and inpatient costs were less than 50%. However, the income of 85.5% (2565/3000) of the patients was less than ¥10,000 (US $1445) per month. Approximately 96.5% (2894/3000) of the patients were covered by health insurance, but only 24.7% (741/3000) of the patients had private commercial insurance, which has higher imbursement ratios. Nearly 98.0% (2954/3000) of the patients worried about their financial situation. Thus, 79.7% (2392/3000) of the patients with IBD tried to save money for health care and even delayed their medical treatments. About half of the respondents (1282/3000, 42.7%) had no primary care provider, and 52.2% (1567/3000) of the patients had to visit the emergency room 1-4 times per year for the treatment of their IBD. Multivariate analysis revealed that lower income (P=.001) and higher transportation (P=.004) and accommodation costs (P=.001) were significantly associated with the increased number of emergency visits of the patients.

Conclusions

Chinese patients with IBD have enormous financial burdens and difficulties in accessing health care, which have increased their financial anxiety and inevitably influenced their disease outcomes. Early purchase of private insurance, thereby increasing the reimbursement ratio for medical expenses, and developing the use of telemedicine would be effective strategies for saving on health care costs.

Pediatric Asthma Action Plans: National Cross-Sectional Online Survey of Parents' Perceptions

BACKGROUND

Asthma Action Plans (AAPs) are recommended for pediatric patients to help improve asthma control. Studies have shown variable results for unscheduled doctor and emergency room visits. AAPs may have an impact on parental self-efficacy for asthma management as well as on other daily living factors that are valuable for patients and families, such as the number of missed school days and parental workdays, and on school and caregiver management.

OBJECTIVE

The purpose of this study is to understand parent perceptions of AAPs. The goals of this analysis were threefold, including examining (1) the association between pediatric AAPs and parental self-efficacy, (2) parent perceptions of the helpfulness of an AAP for daily living factors, and (3) associations with the type of provider who gave the AAP (a primary care provider or an asthma specialist).

METHODS

A national cross-sectional online survey was completed in October 2018 by parents of children with asthma aged 0-17 years. Survey questions included the presence or absence of a pediatric AAP, the Bursch Parental Self-efficacy for Asthma scale, parental perceptions of the AAP's helpfulness with regard to daily living factors ranked on a 5-point Likert scale, and the provider type who gave the AAP. Survey responses were summarized in terms of percentages or means and standard deviations. A 2-sample t test and analysis of covariance were used to compare self-efficacy for asthma and parental-perception-of-helpfulness scores between subjects with an AAP versus subjects without an AAP. All reported P values were 2-sided.

RESULTS

A total of 704 parents with a child with asthma completed the survey. The parents had a mean age of 37.5 years (SD 10.9), and 82% (577/704) were women and 18% (127/704) were men. Most (564/704, 80%) parents had an AAP for their child; 65% (367/564) were written, 51% (286/564) were online, and 84% (474/564) were available at school. The Bursch Self-efficacy scale was significantly higher for parents with an AAP (mean 57.7, SD 8.6) versus no AAP (mean 55.1, SD 9.9; P<.001). Parents reported that they agreed/strongly agreed that an AAP was helpful for daily living factors, including managing asthma (446/544, 82%), decreased parental missed workdays (367/544, 68%), decreased child missed-school days (396/542, 73%), and for when a child is at school (422/541 78%), with other caregivers (434/543, 80%), doing normal activities (421/540 78%), and leading a normal life (437/540 81%). Parents agreed/strongly agreed that an AAP was helpful from all provider types: a pediatric provider (583/704, 82.8%), a family practice provider (556/704, 79%), and an asthma specialist (594/704, 84.4%). There was no significant difference (P=.53) between the type of provider who gave the AAP.

CONCLUSIONS

Parents who had pediatric AAPs for their children reported increased parental self-efficacy compared to those who did not have AAPs. Parents found AAPs helpful for decreasing missed time from work and school, and for asthma management when at home, school, and with other caregivers. Significant AAP helpfulness was seen regardless of the provider who gave the AAP, the parent's education, and income level. Findings support the usefulness of pediatric AAPs for families and the development of easily sharable electronic AAPs for children.

Utilization of myositis antibody-specific panel for diagnosis, treatment, and evaluation of disease progression

The idiopathic inflammatory myopathies (IIM) are rare sporadic disorders with an overall annual incidence of approximately 1 in 100,000 and with a higher incidence in women. IIM is an autoimmune process leading to muscle inflammation due to a ‘dysfunctional adaptive immune response evidenced by cell-mediated myocytoxicity, a high prevalence of autoantibodies and overexpression of Major Histocompatibility (MHC) I and II molecules on the muscle sarcolemma’. These autoimmune processes can be appreciated as inflammatory infiltrates in muscle biopsies. Common clinical findings in patients diagnosed with IIM include proximal muscle weakness, elevated creatinine kinase levels, circulating autoantibodies, radiological findings of muscular inflammation, and sometimes edema; in some patients, systemic symptoms such as dysphagia can also be present. Currently, there is no specific IIM classification scheme that incorporates all IIM subtypes; however, the four major IIM subtypes include dermatomyositis, polymyositis, inclusion body myositis, and immune-mediated necrotizing myopathy (IMNM). Two clinical cases are presented in this case report to illustrate a smoldering IIM, antisynthetase syndrome, and a more progressive IIM, anti-signal recognition particle IMNM; highlight the utility of the myositis-specific autoantibody panel for early diagnosis, targeted therapy, and prognosis; and offer primary care providers clues to IIM diagnosis.

Electronic Consultation Between Primary Care Providers and Radiologists

OBJECTIVE. The purpose of this study was to assess the use of an electronic consultation platform to connect primary care providers and radiologists and provide opportunities for valuable consultation regarding diagnostic imaging in patients, as well as to identify opportunities for targeted education surrounding high-yield radiology topics. MATERIALS AND METHODS. A retrospective review was performed of consultations conducted using the electronic platform from September 2012 to January 2017. Consultations were classified by subspecialty (neuroradiology, thoracic, abdominal, musculoskeletal, or pediatric radiology), question type (workup, surveillance, education, specialist referral query, discharge, or other), anatomy, and pathology. Feedback surveys were completed by primary care providers after each consultation to evaluate timeliness, value, and impact on patient care. RESULTS. A total of 302 consultations were reviewed. Subspecialty breakdown was as follows: abdominal, 94/302 (31%); neuroradiology, 74/302 (25%); musculoskeletal, 61/302 (20%); thoracic, 56/302 (19%); and pediatric, 17/302 (6%). The majority of consultations pertained to patient workup (112/302 [37%]), surveillance of imaging findings (95/302 [31%]), and provider education (48/302 [16%]). Cystic lesions (38/302 [13%]), pain (24/302 [8%]), and bone lesions (21/302 [7%]) were the most queried conditions. Patient management was altered in 167 cases (55%), and unnecessary testing was avoided in 84 (28%). Providers rated the perceived value of the electronic consultation system as excellent in 227 cases (75%). CONCLUSION. The electronic consultation system allowed primary care providers to easily consult with radiologists, was perceived as high value by primary care providers, resulted in altered patient management, and avoided unnecessary imaging tests. We identified follow-up imaging of cystic lesions and imaging workup of pain in patients as opportunities for continuing medical education for primary care providers.

Primary Care Access to an Online Decision Support Tool is Associated With Improvements in Some Aspects of Pediatric Migraine Care

OBJECTIVE

To evaluate whether primary care provider (PCP) access to an online decision support tool is associated with a change in evidence-based primary care medical management of pediatric migraine.

METHODS

In this prospective observational study, PCPs serving a target community were educated on the availability and use of an online clinical decision support tool that was developed to inform treatment of pediatric migraine. For 9 months before and after implementation of the decision tool, the proportions of children with migraine prescribed evidence-based and contraindicated medications by PCPs in the target region were monitored using electronic medical record query and statistically compared to these same proportions for patients in surrounding (control) regions. Rates of visits to the emergency department for migraine also were tracked pre- and postimplementation as an indirect measure of impact of the decision tool. Provider usage of the decision tool was monitored and summarized using web analytics.

RESULTS

Approximately half (56%) of target region PCPs used the online tool at least once over the project period. Relative to control regions and baseline trends, the proportion of children residing in the target region who were prescribed recommended abortive and preventive medications for treating migraine was statistically significantly higher following implementation of the tool. No significant changes to frequency of emergency care visits for migraine by youth in the target region were observed.

CONCLUSIONS

Availability to PCPs of an online decision support tool for pediatric migraine is associated with a modest change in some aspects of evidence-based medical care.

Use of a Paper Checklist to Increase Clinician Adherence to Mammography Screening Guidelines

OBJECTIVE

To increase clinician adherence to mammography screening guidelines.

DESIGN

Quality improvement initiative.

SETTING/LOCAL PROBLEM

At a nurse practitioner-led primary care practice, a chart audit of adherence to American Cancer Society mammography screening guidelines indicated a 12% adherence rate for clinicians writing mammography orders.

PARTICIPANTS

Nurse practitioners providing care to women ages 40 years and older.

INTERVENTION/MEASUREMENTS

The intervention was a screening checklist that was completed by the woman at registration and given to the clinician during the examination. The pre- and postintervention measurement was the percentage of mammogram orders. A Fisher exact test was used to examine changes from pre- to postintervention rates of adherence.

RESULTS

After the intervention, the percentage of women for whom a mammogram was recommended and ordered was 69.6%, compared to 12% from the original chart audit. This change was statistically significant (p = .01).

CONCLUSION

Clinicians must find efficient approaches to improve processes within their practice settings to ensure that preventive care recommendations are made during visits. Although the screening checklist was deemed useful, improvement in adherence rates is still needed, and a paperless system should be initiated.

Post-Parkland Shooting: Development and Assessment of Experiential Training in Adolescent Depression and Post-Traumatic Stress Disorder for Primary Care Providers

Primary care pediatric providers (PCPs) could facilitate early intervention for youth impacted by trauma, yet lack appropriate training. Experiential training for PCPs following a school shooting helped improve PCP confidence and practices in caring for youth with depression and post-traumatic stress disorder.

Transition of care to prevent recurrence after acute coronary syndrome: the critical role of the primary care provider and pharmacist

Despite therapeutic advances, patients with acute coronary syndrome (ACS) are at an increased long-term risk of recurrent cardiovascular events. This risk continues to rise as the number of associated comorbidities, often observed in patients presenting with ACS, increases. Such a level of clinical complexity can lead to gaps in care and subsequently worse outcomes. Guidelines recommend providing an evidence-based post-discharge plan to prevent readmission and recurrent ACS, including cardiac rehabilitation, medication, patient/caregiver education, and ongoing follow-up. A patient-centric multidisciplinary approach is critical for the effective management of the transition of care from acute care in the hospital setting to the outpatient care setting in patients with ACS. Ongoing communication between in-hospital and outpatient healthcare providers ensures that the transition is smooth. Primary care providers and pharmacists have a pivotal role to play in the effective management of transitions of care in patients with ACS. Guideline recommendations regarding the post-discharge care of patients with ACS and the role of the primary care provider and the pharmacist in the management of transitions of care will be reviewed.

Racial/ethnic differences in treatment quality among youth with primary care provider-initiated versus mental health specialist-initiated care for major depressive disorders

OBJECTIVES

To compare the racial/ethnic differences in treatment quality among youth with primary care provider-initiated versus mental health specialist-initiated care for major depressive disorders (MDD).

METHODS

A retrospective cohort study was conducted using the 2005-2007 Medicaid claims data from Texas. Youth aged 10-20 during the study period were identified if they had two consecutive MDD diagnoses and received either medications for MDD or psychotherapy. Patients who received ≥84 days of medications and/or ≥4 sessions of psychotherapy for MDD treatment during 4 months of follow-up were considered meeting the minimum adequacy of treatment.

RESULTS

The generalized linear multilevel model (MLM) analysis revealed that both Hispanics and Blacks were approximately 30% less likely to receive adequate treatment (Hispanics - OR: 0.67; 95% CI: 0.6-0.8) (Blacks - OR: 0.66; 95% CI: 0.6-0.8) and Hispanic children were 50% more likely to undergo MH-related hospitalization (OR: 1.53; 95% CI: 1.1-2.2) compared to their White counterparts. The odds of meeting the minimum MDD treatment adequacy were comparable between pediatric MDD cases first identified by primary care providers (PCP-I) and psychiatrists (PSY-I) (PCP-I vs. PSY-I: OR: 0.97; 95% CI: 0.8-1.2), and slightly lower in those first identified by social workers/psychologists (SWP-I) as compared to PSY-I (SWP-I vs. PSY-I: OR: 0.81; 95% CI: 0.7-0.9). In all models, the interaction between race/ethnicity and type of provider who initiated MDD care was not statistically significant.

CONCLUSIONS

Minority youths received less adequate MDD treatment compared to Whites. Hispanic children had the highest risk of having mental health-related hospitalization. The specialty of provider who initiated MDD care had limited impact on treatment quality and was not associated with the racial/ethnic variations in treatment completion and mental health-related hospitalizations.

Childhood Bullying: Screening and Intervening Practices of Pediatric Primary Care Providers

INTRODUCTION

Many adverse outcomes related to childhood bullying are treated in primary care, although little is known about how often providers are screening for, and intervening in, bullying.

METHODS

A descriptive survey on the practices, attitudes, self-confidence, and knowledge of health care providers was sent to pediatric primary care providers in the state of Ohio.

RESULTS

One hundred and two health care providers responded to the survey. More than half of the providers reported screening their patients for bullying. Interventions frequently used were providing counseling to the patient, referring patients to mental health, and documenting bullying in the chart. Providers with stronger attitudes and self-efficacy scores were more likely to screen for bullying, whereas knowledge was not related to screening for bullying.

DISCUSSION

Despite national calls to screen for bullying, many providers do not routinely carry out screening. When bullying is suspected, many interventions are used in lieu of a paucity of evidence-based interventions.

Primary care provider-reported involvement in breast cancer treatment decisions

BACKGROUND

Treatment decisions for patients with early-stage breast cancer often involve discussions with multiple oncology providers. However, the extent to which primary care providers (PCPs) are involved in initial treatment decisions remains unknown.

METHODS

A stratified random sample of PCPs identified by newly diagnosed patients with early-stage breast cancer from the Georgia and Los Angeles Surveillance, Epidemiology, and End Results registries were surveyed (n = 517; a 61% response rate). PCPs were asked how frequently they discussed surgery, radiation, and chemotherapy options with patients; how comfortable they were with these discussions; whether they had the necessary knowledge to participate in decision making; and what their confidence was in their ability to help (on 5-item Likert-type scales). Multivariate logistic regression was used to identify PCP-reported attitudes associated with more PCP participation in each treatment decision.

RESULTS

In this sample, 34% of PCPs reported that they discussed surgery, 23% discussed radiation, and 22% discussed chemotherapy options with their patients. Of those who reported more involvement in surgical decisions, 22% reported that they were not comfortable having a discussion, and 17% did not feel that they had the necessary knowledge to participate in treatment decision making. PCPs who positively appraised their ability to participate were more likely to participate in all 3 decisions (odds ratio [OR] for surgery, 6.01; 95% confidence interval [CI], 4.16-8.68; OR for radiation, 8.37; 95% CI, 5.16-13.58; OR for chemotherapy, 6.56; 95% CI, 4.23-10.17).

CONCLUSIONS

A third of PCPs reported participating in breast cancer treatment decisions, yet gaps in their knowledge about decision making and in their confidence in their ability to help exist. Efforts to increase PCPs' knowledge about breast cancer treatment options may be warranted.

A Study Protocol for the "Practitioner Training in Child and Adolescent Psychiatry" Cluster-randomized Pilot Study

BACKGROUND

Primary care providers (PCPs) are increasingly called upon to assist in meeting the growing demand for paediatric mental health care in Canada, yet they report inadequate training and confidence to do so. The Practitioner Training in Child and Adolescent Psychiatry (PTCAP) program was designed to fill this gap by teaching PCPs the skills needed to provide frontline care themselves, particularly in rural/remote regions where specialist resources are limited. This innovative educational intervention may improve paediatric mental health care capacity, but a pilot study is needed.

METHODS

We designed a cluster randomized, controlled pilot of PTCAP. Random assignment to intervention or control (treatment-as-usual) will occur at the practice level. Participating PCPs (N=61) at sites randomized to intervention will receive eight hours of training in the use of practice guidelines and brief counseling techniques (i.e., common skills/elements) for addressing diagnosable conditions and more general, transdiagnostic concerns. Mental health care capacity at one-week post-intervention will be the primary outcome, assessed through self-report questionnaires of mental health care confidence, and through a more objective, observational assessment of trained skills. We will also examine retention of these skills at one-month follow-up. We expect use of trained common skills/elements to be associated with better child mental health outcomes on the Strengths and Difficulties Questionnaire (N = 250).

DISCUSSION

As one of the first RCTs of its kind in Canada, this study will provide unique, preliminary evidence in regards to the feasibility and efficacy of the PTCAP intervention for enhancing rural, paediatric mental health care capacity.

Home Oxygen Therapy for Bronchiolitis: An Evaluation of the Primary Care Providers' Experience at Sea Level

Despite 90% of primary care providers at altitude reporting experience with home oxygen therapy for hypoxemic, otherwise well infants, its use at sea level is not well described. Our objective was to understand experience with home oxygen at sea level and determine potential barriers and benefits of its use. We surveyed all pediatricians and family medicine providers within a 30-mile radius of our pediatric hospital from May 2016 to December 2016. Forty-three percent of providers responded. Few (8%) had any experience with home oxygen therapy for bronchiolitis. When all responders were asked about potential benefits and barriers, they reported less disruption of family routines and reduced cost as the largest potential benefits, and lack of parental comfort the largest barrier. Despite their concerns, 53% of providers felt that home oxygen use would not substantially affect their practice. Our results identify a need for education before using this alternative to admission in our center.

Having a Regular Primary Care Provider Is Associated With Improved Markers of Well-Being Among Children With Attention-Deficit Hyperactivity Disorder

We examined the association between having a regular primary care physician (PCP) and measures of flourishing and academic success in children with attention-deficit hyperactivity disorder (ADHD). We performed a cross-sectional study using data from the 2011-2012 National Survey of Children's Health. Children aged 6 to 17 years with a diagnosis of ADHD were included in the study (n = 8173). The exposure was whether the guardian identified a regular PCP for their child. The outcomes were parental-reported measures of child well-being and academic performance. Among the study population, 8.9% reported no regular PCP. These children were found to be significantly less likely to finish assigned tasks (adjusted odds ratio [OR] = 0.52, 95% confidence interval [CI] = 0.35-0.79), care about school (adjusted OR = 0.62, 95% CI = 0.38-0.92), and finish homework (adjusted OR = 0.58, 95% CI = 0.36-0.88). There were no differences in other examined outcomes. Enhancing longitudinal care for this population may optimize their academic performance.

Unexplained Practice Variation in Primary Care Providers' Concern for Pediatric Obstructive Sleep Apnea

OBJECTIVE

To examine primary care provider (PCP) screening practice for obstructive sleep apnea (OSA) and predictive factors for screening habits. A secondary objective was to describe the polysomnography completion proportion and outcome. We hypothesized that both provider and child health factors would predict PCP suspicion of OSA.

METHODS

A computer decision support system that automated screening for snoring was implemented in 5 urban primary care clinics in Indianapolis, Indiana. We studied 1086 snoring children aged 1 to 11 years seen by 26 PCPs. We used logistic regression to examine the association between PCP suspicion of OSA and child demographics, child health characteristics, provider characteristics, and clinic site.

RESULTS

PCPs suspected OSA in 20% of snoring children. Factors predicting PCP concern for OSA included clinic site (P < .01; odds ratio [OR] = 0.13), Spanish language (P < .01; OR = 0.53), provider training (P = .01; OR = 10.19), number of training years (P = .01; OR = 4.26) and child age (P < .01), with the youngest children least likely to elicit PCP concern for OSA (OR = 0.20). No patient health factors (eg, obesity) were significantly predictive. Proportions of OSA suspicion were variable between clinic sites (range, 6-28%) and between specific providers (range, 0-63%). Of children referred for polysomnography (n = 100), 61% completed the study. Of these, 67% had OSA.

CONCLUSIONS

Results suggest unexplained small area practice variation in PCP concern for OSA among snoring children. It is likely that many children at risk for OSA remain unidentified. An important next step is to evaluate interventions to support PCPs in evidence-based OSA identification.

Understanding the drivers of interprofessional collaborative practice among HIV primary care providers and case managers in HIV care programmes

Care coordination programmes are an important aspect of HIV management whose success depends largely on HIV primary care provider (PCP) and case manager collaboration. Factors influencing collaboration among HIV PCPs and case managers remain to be studied. The study objective was to test an existing theoretical model of interprofessional collaborative practice and determine which factors play the most important role in facilitating collaboration. A self-administered, anonymous mail survey was sent to HIV PCPs and case managers in New York City. An adapted survey instrument elicited information on demographic, contextual, and perceived social exchange (trustworthiness, role specification, and relationship initiation) characteristics. The dependent variable, perceived interprofessional practice, was constructed from a validated scale. A sequential block wise regression model specifying variable entry order examined the relative importance of each group of factors and of individual variables. The analysis showed that social exchange factors were the dominant drivers of collaboration. Relationship initiation was the most important predictor of interprofessional collaboration. Additional influential factors included organisational leadership support of collaboration, practice settings, and frequency of interprofessional meetings. Addressing factors influencing collaboration among providers will help public health programmes optimally design their structural, hiring, and training strategies to foster effective social exchanges and promote collaborative working relationships.

"Connecting the Dots": A Qualitative Study of Home Health Nurse Perspectives on Coordinating Care for Recently Discharged Patients

BACKGROUND

In 2012, nearly one-third of adults 65 years or older with Medicare discharged to home after hospitalization were referred for home health care (HHC) services. Care coordination between the hospital and HHC is frequently inadequate and may contribute to medication errors and readmissions. Insights from HHC nurses could inform improvements to care coordination.

OBJECTIVE

To describe HHC nurse perspectives about challenges and solutions to coordinating care for recently discharged patients.

DESIGN/PARTICIPANTS

We conducted a descriptive qualitative study with six focus groups of HHC nurses and staff (n = 56) recruited from six agencies in Colorado. Focus groups were recorded, transcribed, and analyzed using a mixed deductive/inductive approach to theme analysis with a team-based iterative method.

KEY RESULTS

HHC nurses described challenges and solutions within domains of Accountability, Communication, Assessing Needs & Goals, and Medication Management. One additional domain of Safety, for both patients and HHC nurses, emerged from the analysis. Within each domain, solutions for improving care coordination included the following: 1) Accountability-hospital physicians willing to manage HHC orders until primary care follow-up, potential legislation allowing physician assistants and nurse practitioners to write HHC orders; 2) Communication-enhanced access to hospital records and direct telephone lines for HHC; 3) Assessing Needs & Goals-liaisons from HHC agencies meeting with patients in hospital; 4) Medication Management-HHC coordinating directly with clinician or pharmacist to resolve discrepancies; and 5) Safety-HHC nurses contributing non-reimbursable services for patients, and ensuring that cognitive and behavioral health information is shared with HHC.

CONCLUSIONS

In an era of shared accountability for patient outcomes across settings, solutions for improving care coordination with HHC are needed. Efforts to improve care coordination with HHC should focus on clearly defining accountability for orders, enhanced communication, improved alignment of expectations for HHC between clinicians and patients, a focus on reducing medication discrepancies, and prioritizing safety for both patients and HHC nurses.

The provider perspective: investigating the effect of the Electronic Patient-Reported Outcome (ePRO) mobile application and portal on primary care provider workflow

Aim

This qualitative study investigates how the Electronic Patient-Reported Outcome (ePRO) mobile application and portal system, designed to capture patient-reported measures to support self-management, affected primary care provider workflows.

Background

The Canadian health system is facing an ageing population that is living with chronic disease. Disruptive innovations like mobile health technologies can help to support health system transformation needed to better meet the multifaceted needs of the complex care patient. However, there are challenges with implementing these technologies in primary care settings, in particular the effect on primary care provider workflows.

Methods

Over a six-week period interdisciplinary primary care providers (n=6) and their complex care patients (n=12), used the ePRO mobile application and portal to collaboratively goal-set, manage care plans, and support self-management using patient-reported measures. Secondary thematic analysis of focus groups, training sessions, and issue tracker reports captured user experiences at a Toronto area Family Health Team from October 2014 to January 2015.

Findings

Key issues raised by providers included: liability concerns associated with remote monitoring, increased documentation activities due to a lack of interoperability between the app and the electronic patient record, increased provider anxiety with regard to the potential for the app to disrupt and infringe upon appointment time, and increased demands for patient engagement. Primary care providers reported the app helped to focus care plans and to begin a collaborative conversation on goal-setting. However, throughout our investigation we found a high level of provider resistance evidenced by consistent attempts to shift the app towards fitting with existing workflows rather than adapting much of their behaviour. As health systems seek innovative and disruptive models to better serve this complex patient population, provider change resistance will need to be addressed. New models and technologies cannot be disruptive in an environment that is resisting change.

Do Avoidable Hospitalization Rates among Older Adults Differ by Geographic Access to Primary Care Physicians?

OBJECTIVE

To investigate the association between older adults' potentially avoidable hospitalization rates and both a geographic measure of primary care physician (PCP) access and a standard bounded-area measure of PCP access.

DATA SOURCES

State physician licensure data from the Virginia Board of Medicine. Patient-level hospital discharge data from Virginia Health Information. Area-level data from the American Community Survey and the Area Health Resources Files. Virginia Information Technologies Agency road network data. US Census Bureau TIGER/Line boundary files.

STUDY DESIGN

We use enhanced two-step floating catchment area methods to calculate geographic PCP accessibility for each ZIP Code Tabulation Area in Virginia. We use spatial regression techniques to model potentially avoidable hospitalization rates.

DATA COLLECTION/EXTRACTION

Geographic accessibility was calculated using ArcGIS. Physician locations were geocoded using TAMU GeoServices and ArcGIS.

PRINCIPAL FINDINGS

Increased geographic access to PCPs is associated with lower rates of potentially avoidable hospitalization among older adults. This association is robust, allowing for spatial spillovers in spatial lag models.

CONCLUSIONS

Compared to bounded-area density measures, unbounded geographic accessibility measures provide more robust evidence that avoidable hospitalization rates are lower in areas with more PCPs per person. Results from our spatial lag models reveal the presence of positive spatial spillovers.

Testing the Effectiveness of a Primary Care Intervention to Improve Uptake of Colorectal Cancer Screening: A Randomized Controlled Trial Protocol

BACKGROUND

Screening for colorectal cancer (CRC) significantly reduces mortality associated with this disease. In Australia, the National Bowel Cancer Screening Program provides regular fecal occult blood tests (FOBT) for those aged 50 to 74 years, however, participation rates in the program have plateaued at 36%. Given low uptake in the National Bowel Cancer Screening Program, it is necessary to explore alternate methods to increase CRC screening rates. Primary care is a promising adjunct setting to test methods to increase CRC screening participation. Primary care guidelines support the recommendation and provision of CRC screening to primary care patients. Those in the National Bowel Cancer Screening Program target age range frequently present to their primary care provider.

OBJECTIVE

This study tests the effect that a multicomponent primary care-based intervention has on CRC screening uptake when compared to usual care.

METHODS

Primary care patients presenting for an appointment with their primary care provider complete a touchscreen survey to determine eligibility for the trial. Those aged 50 to 74 years, at average risk of CRC, with no history of CRC or inflammatory bowel disease, who have not had an FOBT in the past 2 years or a colonoscopy in the past 5 years are eligible to participate in the trial. Trial participants are randomized to the intervention or usual care group by day of attendance at the practice. The intervention consists of provision of an FOBT, printed information sheet, and primary care provider endorsement to complete the FOBT. The usual care group receives no additional care.

RESULTS

The primary outcome is completion of CRC screening 6 weeks after recruitment. The proportion of patients completing CRC screening will be compared between trial groups using a logistic regression model.

CONCLUSIONS

CRC screening rates in Australia are suboptimal and interventions to increase screening participation are urgently required. This protocol describes the process of implementing a multicomponent intervention designed to increase CRC screening uptake in a primary care setting.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12616001299493; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=371136&isReview=true (Archived by WebCite at http://www.webcitation.org/6pL0VYIj6). Universal Trial Number U1111-1185-6120.

Quality Improvement in Concussion Care: Influence of Guideline-Based Education

OBJECTIVE

To evaluate the potential impact of a concussion management education program on community-practicing pediatricians.

STUDY DESIGN

We prospectively surveyed 210 pediatricians before and 18 months after participation in an evidence-based, concussion education program. Pediatricians were part of a network of 38 clinically integrated practices in metro-Atlanta. Participation was mandatory for at least 1 pediatrician in each practice. We assessed pediatricians' self-reported concussion knowledge, use of guidelines, and comfort level, as well as self-reported referral patterns for computed tomography (CT) and/or emergency department (ED) evaluation of children who sustained concussion.

RESULTS

Based on responses from 120 pediatricians participating in the 2 surveys and intervention (response rate, 57.1%), the program had significant positive effects from pre- to postintervention on knowledge of concussions (-0.26 to 0.56 on -3 to +1 scale; P < .001), guideline use (0.73-.06 on 0-6 scale; P < .01), and comfort level in managing concussions (3.76-4.16 on 1-5 scale; P < .01). Posteducation, pediatricians were significantly less likely to self-report referral for CT (1.64-1.07; P < .001) and CT/ED (4.73-3.97; P < .01), but not ED referral alone (3.07-3.09; P = ns).

CONCLUSIONS

Adoption of a multifaceted, evidence-based, education program translated into a positive modification of self-reported practice behavior for youth concussion case management. Given the surging demand for community-based youth concussion care, this program can serve as a model for improving the quality of pediatric concussion management.

Comparison of Support for Breastfeeding Beyond 12 Months of Age from Conventional and Alternative Pediatric Primary Care Providers

OBJECTIVE

Conventional medicine pediatric care providers (e.g., pediatricians) have been shown to be influential in women's decisions to initiate and sustain breastfeeding. Alternative pediatric care providers (e.g., naturopaths and chiropractors) may also provide breastfeeding support, but this has not been the subject of prior research. Our objective was to compare breastfeeding mothers' perceptions of support from these two provider types in a large sample of women who breastfed for more than 12 months.

METHODS

We conducted a cross-sectional study of 49,091 U.S. women through online questionnaire distributed through peer breastfeeding groups. We used log-binomial regression to compare those who used an alternative pediatric healthcare provider to care for their child to those who used a conventional provider on perceptions of support and key factors influencing the decision to breastfeed for more than 12 months.

RESULTS

Those who used an alternative provider were more likely to discuss breastfeeding (Adj RR = 1.25, 95% CI 1.17-1.33), feel comfortable discussing breastfeeding (Adj RR = 1.17; 95% CI 1.15-1.19), and feel supported by the provider (Adj RR = 1.25; 95% CI 1.23-1.28). However, providers' recommendations were not important factors in these women's decision to breastfeed beyond 12 months of age.

CONCLUSIONS

Mothers who used an alternative care provider as their child's primary source of healthcare rated the provider's breastfeeding support more favorable than those who used a conventional provider (usually a pediatrician). Improving breastfeeding support may be one way to retain families in conventional pediatric primary care, and thereby, ensure children receive comprehensive, evidence-based care.

Reducing Inpatient Hospital and Emergency Room Utilization Among Nursing Home Residents

OBJECTIVE

To examine the association among nursing home residents between strength of relationship with a primary care provider (PCP) and inpatient hospital and emergency room (ER) utilization.

METHOD

Medicare administrative data for beneficiaries residing in a nursing home between July 2007 and June 2009 were used in multivariate analyses controlling for beneficiary, nursing home, and market characteristics to assess the association between two measures-percentage of months with a PCP visit and whether the patient maintained the same usual source of care after nursing home admission-and hospital admissions and ER visits for all causes and for ambulatory care sensitive conditions (ACSCs).

RESULTS

Both measures of strength of patient-provider relationships were associated with fewer inpatient admissions and ER visits, except regularity of PCP visits and ACSC ER visits.

DISCUSSION

Policy makers should consider increasing the strength of nursing home resident and PCP relationships as one strategy for reducing inpatient and ER utilization.

Pediatric discharge content: a multisite assessment of physician preferences and experiences

BACKGROUND AND OBJECTIVES

Professional medical societies endorse prompt, consistent discharge communication to primary care providers (PCPs) on discharge. However, evidence is limited about what clinical elements to communicate. Our main goal was to identify and compare the clinical elements considered by PCPs and pediatric hospitalists to be essential to communicate to PCPs within 2 days of pediatric hospital discharge. A secondary goal was to describe experiences of the PCPs and pediatric hospitalists regarding sending and receiving discharge information.

METHODS

A survey of physician preferences and experiences regarding discharge communication was sent to 320 PCPs who refer patients to 16 hospitals, with an analogous survey sent to 147 hospitalists. Descriptive statistics were calculated, and χ² analyses were performed.

RESULTS

A total of 201 PCPs (63%) and 71 hospitalists (48%) responded to the survey. Seven clinical elements were reported as essential by >75% of both PCPs and hospitalists: dates of admission and discharge; discharge diagnoses; brief hospital course; discharge medications; immunizations given during hospitalization; pending laboratory or test results; and follow-up appointments. PCPs reported reliably receiving discharge communication significantly less often than hospitalists reported sending it (71.8% vs 85.1%; P < .01), and PCPs considered this communication to be complete significantly less often than hospitalists did (64.9% vs 79.1%; P < .01).

CONCLUSIONS

We identified 7 core clinical elements that PCPs and hospitalists consider essential in discharge communication. Consistently and promptly communicating at least these core elements after discharge may enhance PCP satisfaction and patient-level outcomes. Reported rates of transmission and receipt of this information were suboptimal and should be targeted for improvement.

Primary care visits for asthma monitoring over time and association with acute asthma visits for urban Medicaid-insured children

OBJECTIVES

To examine the association between numbers of primary care provider (PCP) visits for asthma monitoring (AM) over time and acute asthma visits in the emergency department (ED) and at the PCP for Medicaid-insured children.

METHODS

We prospectively enrolled 2-10 years old children during ED asthma visits. We audited hospital and PCP records for each subject for three consecutive years. We excluded subjects also receiving care from asthma subspecialists. PCP AM visits were those with documentation that suggested discussion of asthma management but no acute asthma symptoms or findings. PCP "Acute Asthma" visits were those with documentation of acute asthma symptoms or findings, regardless of treatment. ED asthma visits were those with documented asthma treatment. Generalized liner models were used to analyze the association between numbers of AM visits and acute asthma visits to the ED and PCP.

RESULTS

One hundred three subjects were analyzed. Over the 3 years, the mean number of AM visits/child was 2.5 ± 2.3 (standard deviation), range 0-10. Only 50% of subjects had at least 1 PCP visit with an asthma controller medication documented. The mean number of ED asthma visits/child was 3.2 ± 2.8; range 1-18. The mean number of PCP Acute Asthma visits/child was 0.7 ± 1.6; range 0-11. Increasing AM visits was associated with more ED visits (estimate 0.088; 95% CI 0.001, 0.174), and more PCP Acute Asthma visits (estimate 0.297; 95% CI 0.166, 0.429). Increasing PCP visits for any diagnosis was not associated with ED visits (estimate 0.021; 95% CI -0.018, 0.06).

CONCLUSIONS

Asthma monitoring visits and documented controller medication for these urban Medicaid-insured children occurred infrequently over 3 years, and having more asthma monitoring visits was not associated with fewer ED or PCP acute asthma visits.

Circulating inflammatory cytokines and adipokines are associated with increased risk of Barrett's esophagus: a case-control study

BACKGROUND & AIMS

Obesity is associated with Barrett's esophagus (BE) and with changes in circulating levels of adipokines (leptin and adiponectin) and cytokines. Although studies have reported that adipokines and inflammatory cytokines are necessary for the development of BE, their role is controversial.

METHODS

We performed a case-control study; cases (n = 141) were patients who underwent esophagogastroduodenoscopy and were found to have BE, which was based on endoscopy and histology, and controls (n = 139) were primary care patients eligible for screening colonoscopies who agreed to undergo esophagogastroduodenoscopy. We examined the association between BE and circulating levels of adipokines and cytokines (interleukin [IL]-1β, IL-6, IL-8, IL-10, and IL-12p70; tumor necrosis factor-α; and interferon-γ). Cases and controls were compared by calculating odds ratios (ORs) and 95% confidence intervals (CIs) and using unadjusted and multiple logistic regression, adjusting for age, sex, race, waist-hip ratio, use of proton pump inhibitors and nonsteroidal anti-inflammatory drugs, and Helicobacter pylori infection.

RESULTS

The adjusted ORs for BE were 2.62 (95% CI, 1.0-6.8), 5.18 (95% CI, 1.7-15.7), and 8.02 (95% CI, 2.79-23.07) for the highest quintile vs the lowest quintile of levels of IL-12p70, IL-8, and leptin, respectively, but the OR was not significant for IL-6 (2.39; 95% CI, 0.84-6.79). The adjusted OR for BE was 0.14 for highest quintile of IL-10 compared with lowest quintile (95% CI, 0.05-0.35) and 0.03 for IL-1β ≥ median vs none detected (95% CI, 0.006-0.13). Higher levels of IL-8 and leptin and lower levels of IL-10 and IL-1β were associated with the presence of long-segment (≥3 cm) and short-segment BE. There were no differences between cases and controls in levels of interferon-γ, tumor necrosis factor-α, adiponectin, or insulin.

CONCLUSIONS

BE is associated with circulating inflammatory cytokines and leptin and low levels of anti-inflammatory cytokines. These findings could partly explain the effect of obesity on BE.

Insights from the POWER practice-based weight loss trial: a focus group study on the PCP's role in weight management

BACKGROUND

Despite U.S. Preventive Services Task Force recommendations, few primary care providers (PCPs) counsel obese patients about weight loss. The POWER practice-based weight loss trial used health coaches to provide weight loss counseling, but PCPs referred their patients and reviewed their patients' progress reports. This trial provided a unique opportunity to understand PCPs' actual and desired roles in a multi-component weight loss intervention.

OBJECTIVE

1) To explore the PCP role, inclusive of and beyond the trial's intended role, in a practice-based weight loss trial; and 2) to elicit recommendations by PCPs for wider dissemination of the successful multi-component program.

DESIGN

Qualitative focus group study of PCPs with ≥ 4 patients enrolled in trial.

PARTICIPANTS

Twenty-six out of 30 PCPs from six community practices participated between June and August 2010.

MAIN MEASURES

We used a semi-structured moderator guide. Focus groups were audio-recorded and transcribed verbatim. Two investigators independently coded transcripts for thematic content, identified meaningful segments within the responses and assigned codes using an editing style analysis. Atlas.ti software was used for organization/analysis.

MAIN RESULTS

We identified five major themes related to the PCP's role in patients' weight management: (1) refer patients into program, provide endorsement; (2) provide accountability for patients; (3) "cheerlead" for patients during visits; (4) have limited role in weight management; and (5) maintain the long-term trusting relationship through the ups and downs. PCPs provided several recommendations for wider dissemination of the program into primary care practices, highlighting the need for specific feedback from coaches as well as efficient, integrated processes.

CONCLUSIONS

Weight loss programs have the potential to partner with PCPs to build upon the patient-provider relationship to improve patient accountability and sustain behavior change. However, rather than directing the weight loss, PCPs preferred a peripheral role by utilizing health coaches.

Political advocacy in pharmacy: challenges and opportunities

Many pharmacists have expressed a desire to become more involved in patient care, in part by being compensated for patient counseling, as well as by providing services traditionally offered by physicians and nurse practitioners. Recent efforts to develop collaborative care models, as well as major restructurings of US health insurance coverage, provide a unique opportunity for pharmacists to become recognized as independent health care providers and be reimbursed as primary care providers. Achieving that goal would require addressing advocacy challenges familiar to other health care professionals who have achieved provider status under existing reimbursement rules. Historically, political advocacy has not been a major part of pharmacy practice, or even viewed as necessary. However, pharmacists would be more politically effective with a single organization to speak for them as a profession, and with further education in advocacy.

The Midwest Exercise Trial for the Prevention of Weight Regain: MET POWeR

Weight reduction in overweight and obese individuals results in physiological and behavioral changes that make the prevention of weight regain more difficult than either initial weight loss or the prevention of weight gain. Exercise is recommended for the prevention of weight regain by both governmental agencies and professional organizations. To date, the effectiveness of exercise recommendations for the prevention of weight regain has not been evaluated in a properly designed, adequately powered trial. Therefore, we will conduct a randomized trial to evaluate the effectiveness of 3 levels of exercise on the prevention of weight regain, in initially overweight and obese sedentary men and women. Participants will complete a 3 month weight loss intervention of decreased energy intake (EI) and increased exercise (100 min/week). Participants achieving clinically significant weight loss (≥ 5% of initial weight), will then be randomly assigned to 12 months of verified exercise at 3 levels (150, 225 or 300 min/week). This study will evaluate: 1) the effectiveness of 3 levels of exercise on the prevention of weight regain over 12 months subsequent to clinically significant weight loss (≥ 5%); 2) gender differences in weight regain in response to 3 levels of exercise; and 3) potential compensatory changes in daily physical activity (PA) and EI on weight regain in response to the 3 levels of exercise. The results of this investigation will provide information to develop evidence-based recommendations for the level of exercise associated with the prevention of weight regain.

Responding to pediatric providers' perceived barriers to adolescent weight management

Primary care clinics are an ideal setting for early identification and possibly treatment of adolescent obesity. However, despite practice recommendations promoting preventive screening and monitoring of obesity, implementation has been modest. In this study, we interviewed providers to determine barriers to managing pediatric obesity, perceived skill in obesity interventions, and interest in additional training. The sensitivity of weight-related discussions and time were the 2 most significant barriers reported. We designed a brief training program, implemented it within a larger randomized controlled trial, and surveyed providers regarding its utility. The training was satisfactory to attendees and led to reported changes in practice patterns. Providers who received more complete training reported greater ease working with overweight teens and greater confidence that they could motivate teen patients to make healthy lifestyle changes compared with those who received less training. A fairly modest training intervention could improve patient care in the primary care setting.

What the primary care provider needs to know for limb salvage

Primary care providers are often the first providers to evaluate a patient for peripheral arterial disease (PAD). Understanding the various presentations of PAD symptoms can prevent the disease from progressing to critical limb ischemia and eventual limb loss. This article provided the primary care provider with information needed to prevent limb loss and promote limb salvage, including risk factor management, clinical presentation, physical exam findings, and treatment options.

Screening male primary care patients for intimate partner violence perpetration

BACKGROUND

Primary prevention of intimate partner violence (IPV) at the level of the primary care provider is unexplored.

OBJECTIVE

We sought to identify whether men disclose current IPV perpetration when asked by a primary care provider.

DESIGN

Cross-sectional study.

PARTICIPANTS

Consecutive male patients of 6 providers in public health, university, and VA hospital clinics.

MEASUREMENTS

Men were screened for IPV perpetration during routine visits, then given a Conflict Tactics Scale questionnaire (CTS2) to complete and mail back anonymously.

RESULTS

One hundred twenty-eight men were screened; 46 (36%) returned CTS2 questionnaires. Twenty-three and 2 men disclosed past and current perpetration to providers, respectively. Providers assessed lethality/safety issues in 58% of those reporting a perpetration history (including both with current perpetration), responded with direct counseling to 63% (including both with current perpetration), and referred 17% for services related to the screening (including 1 with current perpetration). Nine and 26 men reported current, CTS2-assessed physical and psychological aggression of a partner, respectively.

CONCLUSIONS

Men appear to underreport current IPV perpetration in face-to-face primary care encounters when compared to other methods of reporting. Men may more readily report past IPV perpetration in face-to-face encounters.

Factors associated with frequency of emergency department visits for chronic obstructive pulmonary disease exacerbation

BACKGROUND

Little is known about the factors associated with frequency of emergency department visits (FEDV) in chronic obstructive pulmonary disease (COPD) patients with recurrent exacerbations.

OBJECTIVE

To characterize the use of emergency department (ED) services in patients with COPD exacerbation and identify factors associated with FEDV.

DESIGN

A prospective, multicenter cohort study.

PATIENTS

Three hundred eighty-eight patients were included. Fifty-two percent were women and the median age was 69 years (interquartile range 62-76).

MEASUREMENTS

Using a standard questionnaire, consecutive ED patients with COPD exacerbation were interviewed. The number of ED visits in the previous year was retrospectively collected.

RESULTS

Over the past year, this cohort reported a total of 1,090 ED visits because of COPD exacerbation. Thirteen percent of COPD patients had 6 or more ED visits, accounting for 57% of the total ED visits in the past year. Multivariate analysis showed that patients with an increased FEDV were more likely to be Hispanic (incidence rate ratio [IRR] 1.97, 95% confidence interval [CI] 1.16-3.33), to have more severe COPD as determined by previous hospitalizations (IRR 2.06, 95% CI 1.51-2.82), prior intubations (IRR 1.49, 95% CI 1.02-2.18), prior use of systemic corticosteroids (IRR 1.57, 95% CI 1.16-2.13) and methylxanthine (IRR 1.48, 95% CI 1.04-2.12), and less likely to have a primary care provider (IRR 0.51, 95% CI 0.31-0.82).

CONCLUSIONS

Our results suggest that both disease and health care-related factors were associated with FEDV in COPD exacerbation. Multidisciplinary efforts through primary care provider follow-up should be assessed to test the effects on reducing the high morbidity and cost of recurrent COPD exacerbations.

United States Chiropractic Practice Acts and Institute of Medicine defined primary care practice

OBJECTIVE

This review was conducted to analyze the law for the practice of chiropractic throughout the United States, including the District of Columbia, Puerto Rico and the U.S. Virgin Islands, to determine the legal ability of the Doctor of Chiropractic in each jurisdiction to provide primary care service as described by the 1996 Institute of Medicine Definition of Primary Care.

METHOD

The practice acts for each State, the District of Columbia, Puerto Rico and the U.S. Virgin Islands were reviewed for language that would permit the chiropractic doctor to meet the 9 criteria of primary care practice described by the Institute of Medicine. Forty-four practice acts were cross referenced with the results of a scope of practice survey of State Boards of Chiropractic in 1999.

RESULTS

The review of the practice acts and the survey on chiropractic scope of practice revealed a varied degree of chiropractic scope of practice with 23 of 53 of the jurisdictions limiting the ability of the chiropractic doctor to fully provide IOM defined primary care.

CONCLUSION

The varied practice act definitions for chiropractic practice throughout the United States the District of Columbia, Puerto Rico and the U.S. Virgin Islands reveal an inability of the chiropractic profession to respond to a call for a standard nationally-based primary-care policy that could be readily achieved by all chiropractic practitioners throughout the Union. This void of primary-care qualification in many State and Commonwealth practice acts will need to be addressed by the leaders of the profession if government entities and national third party organizations are to utilize chiropractic health care services to the standard of chiropractic education and clinical experience. The need for a broad range chiropractic scope of practice model practice act is suggested.