Abstracts In Press

The abstracts below are from articles currently ‘in press’ at the JABFM. Content and publication dates are subject to change during the copy editing process; please check back here for weekly updates.

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ORIGINAL RESEARCH

Comprehensive Medication Management Improves Primary Care Providers’ Work Life

Kylee A. Funk, PharmD, BCPS; Deborah L. Pestka, PharmD, PhD; Mary T. Roth McClurg, PharmD, MHS; Jennifer K. Carroll, MD, MPH; Todd D. Sorensen, PharmD​

Corresponding Author: Kylee A. Funk, PharmD, BCPS; University of Minnesota College of Pharmacy. Email: kafunk@umn.edu

Publication: July/August 2019 (Full article available online for free on July 12, 2019)

DOI: 10.3122/jabfm.2019.04.180376 

Purpose: In primary care, clinical pharmacists often deliver a service called comprehensive medication management (CMM). While research has identified that CMM positively influences most aspects of the quadruple aim, it is unclear how CMM—both the service and the role of the pharmacist—may influence the Primary Care Provider’s (PCP) clinical work, professional satisfaction, and burnout (described here as PCP’s work -life). We aimed to identify how PCPs perceive CMM impacts their work- life. Methods: Sixteen PCPs were interviewed. Interview questions centered on how CMM affects their work- life. After interviews were transcribed, a codebook was developed by two researchers and from the codes, themes were identified. Results: PCPs spoke of the pharmacist being an added skillset and resource and a collaborative partner in caring for patients. They also described seven outcomes of having CMM available that contribute to their work life. These outcomes were: decreased workload, satisfaction patients are receiving better care, reassurance, decreased mental exhaustion, enhanced professional learning, increased provider access, and achievement of quality measures. Lastly, the PCPs described barriers and areas of opportunity related to CMM. Conclusion: Our findings suggest PCPs believe CMM, in general, positively affects their work life. CMM’s impact on PCPs aligns with many previously identified drivers of burnout and engagement among providers. These results shed light on how CMM may foster achievement of the quadruple aim.

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ORIGINAL RESEARCH

High Risk Medication Prescriptions in Primary Care for Women without Documented Contraception

Bethany D. Panchal, MD; Rebecca Cash, MPH, NRP; Camille Moreno, DO; Emily Vrontos, PharmD; Cheryl Bourne, CNP; Sandra Palmer, DO; Amy Simpson, DO; Ashish R. Panchal, MD, PhD

Corresponding Author: Bethany Panchal, MD; Department of Family Medicine, The Ohio State University College of Medicine. Email: Bethany.panchal@osumc.edu

Publication: July/August 2019 (Full article available online for free on July 12, 2019)

DOI: 10.3122/jabfm.2019.04.180281

Introduction: During pregnancy, women may be exposed to teratogenic medications resulting in a risk of complications and poor maternal-fetal outcomes. The objective of this study was to evaluate the prescription of teratogenic medications in women of childbearing age and the associated prescription of contraception in the primary care setting. Methods: The use of high-risk, potentially teratogenic, medications was retrospectively evaluated in women of childbearing age (13-45 years old) at two family medicine practices. Charts were reviewed for medication use and whether patients received a form of birth control (medication, sterilization, or postmenopausal) with the teratogenic medications. A multivariable logistic regression model was used to estimate the age-adjusted association between receiving a teratogenic medication and contraception. A subgroup analysis excluding ondansetron was also performed. Results: A total of 3,956 non-pregnant women were included with 988 (25%) prescribed at least one high-risk medication. The most commonly prescribed high-risk medications were ondansetron (n=724) (73%) and lisinopril (n=195) (20%).  More than half (55%) of the women prescribed a high-risk medication were without a form of birth control. When ondansetron was excluded, 10% of the population was prescribed at least one high-risk medication with 62% also without a form of birth control. Women less than 25 years of age had decreased odds of receiving contraception when prescribed a teratogenic medication (aOR: 0.47, 95%CI: 0.34-0.66). Conclusion: In a family medicine setting, 25% of women of childbearing age were prescribed a high-risk medication with over half not having evidence of contraception management. Interestingly, younger age women had lower odds of receiving contraceptive management when prescribed high-risk medications. Prescribers should be aware of and counsel on the risks of teratogenic medications, and regularly evaluate reproductive plans for patients.

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ORIGINAL RESEARCH

A Successful Walk-in Psychiatric Model for Integrated Care

David S. Kroll, MD; Carol Latham, LICSW; Janice Mahal, LICSW; Meagan Siciliano, LICSW; Laura S. Shea, LICSW; Lisa Irwin; Bonnie Southworth, MD; David F. Gitlin, MD

Corresponding Author: David S. Kroll, MD; Department of Psychiatry, Brigham Health. Email: dskroll@bwh.harvard.edu

Publication: July/August 2019 (Full article available online for free on July 12, 2019)

DOI: 10.3122/jabfm.2019.04.180357

Purpose: Accommodating walk-in psychiatry visits in primary care can improve access to psychiatric care for patients from historically underserved groups. We sought to determine whether a walk-in psychiatry model embedded within an integrated care practice could be sustained over time, and to characterize the patients who accessed care through it. Methods: We reviewed electronic health records linked to 811 psychiatry encounters in an integrated care practice between October 1, 2015 and September 30, 2017. Primary outcomes were the initial and return psychiatry encounters per month. Secondary outcomes were the demographics and diagnoses of patients who accessed their initial visits through walk-in sessions and scheduled appointments. Results: 490 initial psychiatry evaluations and 321 return encounters took place over the 2-year study period. The volume of initial psychiatry evaluations per month did not significantly change, but the volume of psychiatry follow-up encounters significantly increased after the walk-in session expanded. Medicaid recipients (OR, 1.9;95% CI, 1.2-3.0); individuals without a college degree (OR, 1.7;95% CI, 1.1-2.5); individuals who were single, divorced, or separated (OR, 1.7; 95% CI, 1.1-2.5); and individuals who identified as Black or Hispanic (OR, 2.5;95% CI 1.7-3.6) were more likely to access an initial psychiatry evaluation through a walk-in session as opposed to a scheduled appointment. Conclusions: Providing psychiatric care on a walk-in basis in integrated care is sustainable. Patients from historically underserved groups may access psychiatric care disproportionately through a walk-in option when it is available.

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ORIGINAL RESEARCH

Primary Care Practices' Implementation of Patient-Team Partnership: Findings from EvidenceNOW Southwest

Tristen L. Hall, MPH; Kyle E. Knierim, MD; Donald E. Nease, Jr., MD, MPH; Elizabeth W. Staton, MSTC; Carolina Nkouaga, MPH; L. Miriam Dickinson, PhD; Robert L. Rhyne, MD; W. Perry Dickinson, MD

Corresponding Author: Tristen L. Hall, MPH; Department of Family Medicine, University of Colorado Anschutz Medical Campus. Email: tristen.hall@ucdenver.edu

Publication: July/August 2019 (Full article available online for free on July 12, 2019)

DOI: 10.3122/jabfm.2019.04.180361

Introduction: Care teams partnering with patients is integral to quality primary care. Effective patient-team partnership recognizes patients’ contributions in decision-making, respecting patients’ goals and social context. We report practice characteristics associated with greater patient-team partnership scores. Methods: EvidenceNOW Southwest (ENSW) was a multi-state initiative to improve cardiovascular care in primary care practices through guideline concordant aspirin use, blood pressure control, cholesterol management, and smoking cessation. ENSW provided nine months of practice facilitation and information technology support through regular meetings and training to 211 Colorado and New Mexico primary care practices from 2015 to 2017. We analyzed surveys from 97% of participating practices regarding patient-team partnership activities of self-management support, social needs assessment, resource linkages, and patient input. We used linear and mixed effects regression modeling to examine relationships between patient-team partnership and practice characteristics. Results: Practice characteristics significantly associated with greater patient-team partnership were: using patient registries, medically underserved area designation, multispecialty mix, and using clinical cardiovascular disease management guidelines. Our findings suggest that patient-team partnership implementation in small primary care practices is moderate, with mean practice- and member-level scores of 52 of 100 (range=0-100) and 71 of 100 (range=10-100), respectively. Conclusion: Practices can improve efforts to partner with patients to assess social needs, gather meaningful input on practice improvement and patient experience, and offer resource connections. Our findings supplement recent evidence that patient registries and evidence-based guidelines may effectively prevent and manage cardiovascular disease. These strategies may also promote primary care patient-team partnership.

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ORIGINAL RESEARCH

Prediabetes Knowledge, Attitudes, and Clinical Practices at an Academic Family Medicine Practice

James W. Keck, MD, MPH; Alisha R. Thomas, MD, MPH; Laura Hieronymus, DNP, MSEd; Karen L. Roper, PhD

Corresponding Author: James W. Keck, MD, MPH; University of Kentucky College of Medicine, Department of Family & Community Medicine. Email: James.Keck@uky.edu

Publication: July/August 2019 (Full article available online for free on July 12, 2019)

DOI: 10.3122/jabfm.2019.04.180375

Purpose: Lifestyle change programs are an effective but underutilized approach to prevent or delay type 2 diabetes in people with prediabetes. Understanding clinician prediabetes knowledge, attitudes, and practices can inform implementation efforts to increase lifestyle change program referrals. Methods: We surveyed clinicians at an academic family medicine clinic about their prediabetes knowledge, attitudes and practices. From the same clinic, we reviewed electronic health records to assess prediabetes screening, diagnosis, and treatment coverage in the cohort of adults seen from 2015 to 2017. Results: Thirty-one clinicians (69.6%) completed the survey. Clinicians believed prediabetes was an important health issue (n=29, 93.7%) and that prediabetes screening (n=20, 64.5%) and diagnosis (n=31, 100%) were important for prediabetes management. About half of the respondents (n=14, 45.2%) reported familiarity with the National Diabetes Prevention Program (DPP). Electronic chart review included 15,520 adult patients. Most of the 5,360 nondiabetic patients meeting US Preventive Services Task Force diabetes screening guidelines (n=4,068, 75.9%) received a hemoglobin A1c test. Of the 1,437 patients with an A1c result diagnostic of prediabetes, 729 (50.7%) had the diagnosis in their chart. Prediabetes patients receiving point-of-care A1c testing instead of laboratory testing had 4.7 increased odds (95% CI, 3.5-6.4) of metformin prescription. No patients were referred to a DPP. Conclusions: Clinicians’ positive attitudes towards prediabetes screening, moderate knowledge of prediabetes management, and low awareness of DPPs were reflected by high diabetes screening coverage, limited prediabetes documentationdiagnosis, and no DPP referrals. We will tailor our implementation strategy to overcome these prediabetes care barriers.

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ORIGINAL RESEARCH

Patient-Defined Visit Priorities in Primary Care: Psychosocial vs. Medically-Related Concerns

Eilann C. Santo; Michelle T. Vo; Connie S. Uratsu; Richard W. Grant

Corresponding Author: Richard W. Grant; Department of Internal Medicine, Kaiser Permanente Northern California. Email: Richard.W.Grant@KP.org

Publication: July/August 2019 (Full article available online for free on July 12, 2019)

DOI: 10.3122/jabfm.2019.04.180380

Background: Primary care providers (PCPs) are often challenged to address multiple patient concerns during time-limited visits. The need for PCPs to limit the number of issues addressed may have a negative impact on discussion of patient-defined visit priorities. Methods: Using data from a recent clinical trial (Aligning Patients and Providers, ClinicalTrials.gov: NCT02707146), we examined the association between patient-defined visit priorities and subsequent provider actions taken during, and after, the visit. We tested the hypothesis that psychosocial concerns (e.g. stress, anxiety, caregiving demands) are less likely to be addressed than traditional medical concerns. Results: We analyzed 147 patient-defined visit priorities submitted just prior to the visit by 109 patients (mean age 59.0±12.7 years, including 73.4% women, 47.7% non-White race/ethnicity). Nearly one-quarter of patient-defined visit priorities were related to psychosocial concerns (35/147, 23.8%). In models adjusting for age, gender, race/ethnicity, and familiarity with PCP, patients’ psychosocial priorities were significantly less likely than medical priorities to be addressed during the visit (63% vs 88%; aOR 0.16, 95%CI: 0.06 - 0.41, p < 0.001), to receive clinical action (51% vs 82%; aOR 0.15, 95%CI: 0.06 - 0.38. p < 0.001), or to receive post visit information from the primary care doctor (17% vs 32%; aOR 0.39, 95%CI: 0.14 – 1.08, p = 0.07). Conclusions: Patient-defined psychosocial priorities are less likely to be addressed during (or immediately after) primary care visits compared to patient-defined medical priorities.

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ORIGINAL RESEARCH

Adults with Housing Insecurity Have Worse Access to Primary and Preventive Care

Patricia Martin, DO; Winston Liaw, MD, MPH; Andrew Bazemore, MD, MPH; Anuradha Jetty, MPH; Stephen Petterson, PhD; Margot Kushel, MD

Corresponding Author: Patricia Martin, DO; Unity Health Care; Department of Community & Family Medicine, Howard University Hospital College of Medicine. Email: patricia.hughes9@gmail.com

Publication: July/August 2019 (Full article available online for free on July 12, 2019)

DOI: 10.3122/jabfm.2019.04.180374 

Objective: Housing insecurity has been linked to high-risk behaviors and chronic disease though less is known about the pathways leading to poor health. We sought to determine whether housing insecurity is associated with access to preventive and primary care. Methods: We conducted weighted univariate, bivariate and multivariate analyses using 2011-2015 BRFSS data (N=228,131 adults). The independent variable was housing insecurity derived from the question on worry about paying rent or mortgage. The outcome measures were health services utilization (no usual source of care, no routine checkup in the past one year, and delayed medical care due to cost), self-rated health (number of days reported physical, mental health not good, and poor overall health), and number of chronic diseases (zero, one, two or more). The covariates included age, sex, race/ethnicity, income, level of education, marital status and number of children in the family. We also adjusted for state fixed effects and survey year. We performed chi-squared tests and binary logistic regressions on categorical variables and ran t-tests and estimated linear regression models on continuous variables. Multinomial logistic regressions were estimated for the number of chronic diseases. Results: Of the 228,131 adults in the study sample, 28,704 adults reported housing insecurity. We found that those with housing insecurity were more likely to forgo routine check-ups and lack usual sources of care. Low income individuals, minorities, the unmarried, and middle-aged adults were more likely to report housing insecurity. Conclusion: Housing insecurity is associated with worse access to preventive and primary care. Interventions to enhance access for these patients should be developed and studied. 

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ORIGINAL RESEARCH

Retail Clinic Use Effect of Continuity of Care among Medicare Beneficiaries

Ndidi Ogechi Abara, MD; Nicole Huang, BSc; Mukaila A. Raji, MD; Yong-Fang Kuo, PhD

Corresponding Author: Yong-Fang Kuo, PhD; Department of Preventive Medicine and Community Health, University of Texas Medical Branch. Email: yokuo@utmb.edu

Publication: July/August 2019 (Full article available online for free on July 12, 2019)

DOI: 10.3122/jabfm.2019.04.180349

Purpose: We examined the relationship between retail clinic use and primary care physician (PCP) continuity among Medicare enrollees in the Houston metropolitan area. Methods: We identified retail clinic providers in the study area using a 2015 healthcare provider database. Medicare claims data from enrollees who received care from retail clinics in 2015 were compared with propensity score-matched sample of enrollees who received no care from retail clinics. Results: There were 2.32 retail clinic visits per 1000 beneficiaries in a month. Approximately 1.3% of Medicare beneficiaries used retail clinics. Retail clinic users were more likely to be aged 65-74, female, White, and Medicaid ineligible. In multivariable analyses with adjustment for covariates, significant predictors of retail clinic use included having ≥ 3 chronic conditions (Odds Ratio, OR: 1.53 vs no condition), living within one mile of a retail clinic (OR: 2.44 vs. living ≥ 5 miles), and having no PCP (OR: 1.11 vs having PCP). Compared to propensity-matched controls, among enrollees with an identified PCP, likelihood of seeing their PCP (OR: 0.82, 95% CI: 0.73-0.93) and continuity of care was lower (0.75 ± 0.33 vs. 0.80 ± 0.31) if they had retail clinic visits. Conclusions: Retail clinic use was lower in the elderly population compared to the previously published rate in the younger populations. The lower rate of continuity of care observed among retail clinic users is concerning, especially for those with chronic medical conditions.

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ORIGINAL RESEARCH

Impact of Alternative Payment Methodology on Primary Care Visits and Scheduling

John Heintzman, PhD; Erika Cottrell, PhD; Heather Angier, PhD; Jean O’Malley, MPH; Steffani Bailey, PhD; Lorie Jacob, ScM; Jennifer DeVoe, DPhil; Maria Ukhanova, PhD; Erin Thayer, BA; Miguel Marino, PhD

Corresponding Author: John Heintzman, PhD; Department of Family Medicine, Oregon Health & Science University. Email: heintzma@ohsu.edu

Publication: July/August 2019 (Full article available online for free on July 12, 2019)

DOI: 10.3122/jabfm.2019.04.180368

Background: In 2013, Oregon initiated an Alternative Payment Methodology (APM) Experiment for select health centers, initiating capitated payments for patients with Medicaid. Objective: To use electronic health record data to evaluate the impact of APM on visit and scheduling metrics in the first wave of experiment clinics. Research Design: Retrospective clinic cohort. Difference-in-differences analysis using generalized linear mixed modeling across two time thresholds: the initiation of APM and the start of the Affordable Care Act Medicaid expansion. Subjects: Eight primary clinics enrolled in APM on March 1, 2013 and 10 comparison clinics not enrolled in APM during the study period (July 1, 2012 to February 28, 2015). Measures: Independent variable: intervention status of the clinics (APM or comparison). Dependent variables: total patient encounters, total alternative encounters, new patient visits, provider appointment availability, number of appointment overbooks and no-shows/late cancellations. Results: Comparison clinics had smaller patient panels and more advanced practice providers than APM clinics, but both had similar proportions of Hispanic, Medicaid, and uninsured patients. APM clinics had a 20% greater increase in same-day openings than non-APM clinics across the APM implementation (1.20, 95% CI 1.02-1.42). Otherwise, there were minimal differences in APM clinics and control clinics in wait times, visit rates, patient no-shows, and overbooks. Conclusions: APM clinics experienced a greater increase in same-day visits over the course of this experiment, but did not significantly differ from comparators in other visit metrics. Further research into other impacts of this experiment are necessary and ongoing.

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ORIGINAL RESEARCH

Identifying Problematic Substance Use in a National Sample of Adolescents Using Frequency Questions

Laura J. Chavez, PhD, MPH; Katharine A. Bradley, MD, MPH; Gwen T. Lapham, PhD, MPH, MSW; Thomas M. Wickizer, PhD, MPH; Deena J. Chisolm, PhD

Corresponding Author: Laura J. Chavez, PhD, MPH; Ohio State University, College of Public Health, Division of Health Services Management and Policy; Nationwide Children’s Hospital, Research Institute. Email: Laura.Chavez@nationwidechildrens.org

Publication: July/August 2019 (Full article available online for free on July 12, 2019)

DOI: 10.3122/jabfm.2019.04.180284

Background: Brief, substance use screening questions for tobacco, alcohol, cannabis, and other drugs need further validation in adolescents. In particular, optimal age-specific screening cutpoints are not known, and no study has been large enough to evaluate screening questions for non-cannabis illicit drug use. Methods: Adolescent respondents to an annual national household survey were included (2008- 2014; n=169,986). Days of tobacco use in the past month, and days of alcohol, cannabis, other illicit drug use in the past year, were assessed as brief screens for tobacco dependence and DSMIV alcohol, cannabis and other illicit drug use disorders (AUD, CUD, and DUD, respectively). Areas under receiver operating characteristics curves (AUCs), sensitivity and specificity were estimated separately by age group (12-15, 16-17, and 18-20 year olds) and cut-points that maximized combined values of sensitivity and specificity were considered optimal. Results: The prevalence of tobacco dependence, AUD, CUD, and DUD was 5.8%, 7.1%, 4.5%, and 2.0%, respectively. AUCs ranged 0.84-0.99. The optimal cut-points for screening for tobacco dependence and DUDs was the same for all age groups: ≥1 day. The optimal cut-points for alcohol and cannabis varied by age: ≥3 days for 12-15 year olds and ≥12 days for older adolescents. Conclusions: Brief measures of past-year use, or past-month use for tobacco, accurately identified adolescents with problematic substance use. However, health systems should use agespecific screening cut-points for alcohol and cannabis to optimize screening performance. 

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ORIGINAL RESEARCH

Multimodal Local Opioid Prescribing Intervention Outcomes in Chronic Noncancer Pain Management

Natalia P. Arizmendez, MD; Fabiana Kotovicz, MD; Jessica J. F. Kram, MPH; Dennis J. Baumgardner, MD

Corresponding Author: Fabiana Kotovicz, MD; Aurora Health Care, Department of Family Medicine, Aurora St. Luke’s Medical Center; Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health. Email: fabiana.kotovicz@aurora.org

Publication: July/August 2019 (Full article available online for free on July 12, 2019)

DOI: 10.3122/jabfm.2019.04.180296

Background: Opioid misuse in the United States has made it challenging for physicians to treat chronic noncancer pain (CNCP). We implemented an educational program aimed at promoting safe opioid prescribing practices in hopes of increasing the level of appropriateness associated with prescribing of opioids for CNCP. Methods: We conducted a quality improvement study with retrospective chart review of adult patients who were prescribed opioids for CNCP for at least 90 consecutive days at two academic primary care clinics. Patients were reviewed at baseline (07/2014 – 05/2015) and after initial interventions (01/2016-06/2016; i.e., following multimodal educational activities on appropriate opioid prescription implemented from 6/2015 to12/2015). An opioid appropriateness score was calculated based on documentation of nine items. Categorical variables were analyzed with Fisher exact tests, continuous variables by 2-sample T-tests and regression analysis. Binary logistic regression was used for multivariable modeling. Mann-Whitney test was used to compare appropriateness scores before and after intervention. Results: A total of 177 and 96 patients were evaluated at baseline and post-intervention, respectively. Patient demographic characteristics were not statistically different. Overall, postintervention level of appropriateness was significantly different from pre-intervention (P < 0.0001) with means increasing from 5.54 pre-intervention to 6.29 post-intervention. Both clinics had significant improvement from baseline (both P-values < 0.003). Conclusions: Clinician education on best practices while treating CNCP is associated with an increase in the level of opioid use appropriateness. 

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ORIGINAL RESEARCH

Effect of Electronic Cigarettes on Smoking Reduction and Cessation in Korean Male Smokers: A Randomized Controlled Study

Seung-Hwa Lee; Sang-Hyun Ahn; Yoo-Seock Cheong

Corresponding Author: Yoo-Seock Cheong, MD, PhD; Department of Family Medicine, Smoking Cessation Center, Dankook University College of Medicine. Email: fmdoctor@hanmail.net

Publication: July/August 2019 (Full article available online for free on July 12, 2019)

DOI: 10.3122/jabfm.2019.04.180384

Introduction: New approaches to electronic cigarettes (e-cigarettes) as a form of nicotine replacement therapy (NRT) may reduce the rates of tobacco-related disease and mortality. Therefore, we investigated the effect of e-cigarettes on smoking cessation compared with nicotine gum. Methods: A total of 150 subjects were randomly assigned to two groups, and each was allocated a 12-weeks supply of either e-cigarettes or nicotine gum. The continuous abstinence rate (CAR), 7-day point prevalence (PP) of abstinence, smoking reduction rate and amount, and tolerability were evaluated. Results: There were no statistically significant differences in the effectiveness-related parameters of smoking cessation, such as 9-12- and 9-24-week and 12- and 24-week PP of abstinence, between the two groups. However, although the reduction in cigarette smoking was similar, the proportion of subjects who showed smoking reduction at 24 weeks was higher in the e-cigarette group than the nicotine gum group. Also, adverse events were significantly less frequent in the e-cigarette group than in the nicotine gum group. Conclusions: In our study, the effect of e-cigarettes on smoking cessation was similar compared to that of nicotine gum, a well-documented NRT. In addition, e-cigarettes were welltolerated by the study population. Therefore, the use of e-cigarettes as an NRT may be considered for smoking-cessation purposes. A large-scale prospective randomized controlled trial is necessary to clarify our results.

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ORIGINAL RESEARCH

Predicting Knee Pain and Knee Osteoarthritis among Overweight Women

M.L.A. Landsmeer, MD; J. Runhaar, PhD; M. van Middelkoop, PhD; E.H.G. Oei, MD, PhD; D. Schiphof, PhD; P.J.E. Bindels, MD, PhD, Prof; S.M.A. Bierma-Zeinstra, PhD, Prof

Corresponding Author: Marieke L.A. Landsmeer, MD; Erasmus MC, Department of General Practice. Email: m.landsmeer@erasmusmc.nl

Publication: July/August 2019 (Full article available online for free on July 12, 2019)

DOI: 10.3122/jabfm.2019.04.180302

Background: There is a need for prediction of knee osteoarthritis (KOA) in general practice to motivate subjects for preventive therapies and optimize preventive trials. Aim: To develop a prediction model, with questionnaire and physical examination variables, for incident frequent knee pain (FKP) and symptomatic KOA after 2.5 and/or 6.5 years among overweight and obese middle-aged women. Design and Setting: Models were developed in PROOF (age 50-60 years, BMI≥27kg/m2 ) (ISRCTN 42823086). FKP was defined as knee pain during most days in the past month. Symptomatic KOA was defined according to the combined (clinical and radiographic) American College of Rheumatology criteria. Method: Multivariable analysis by backward stepwise deletion was performed for questionnaire and physical examination variables. The prediction model was externally validated in Rotterdam Study(RS)-III. Area under the curves (AUCs) of receiver operating characteristic were calculated. Results: 32% of 237 women (mean age 55.7±3.2 years, mean BMI 31.9±3.8kg/m2 ) developed FKP and 30% developed symptomatic KOA. AUC of age and BMI was 0.63(0.55–0.71) for incident FKP. The final model included age, BMI, mild knee symptoms, knee problems climbing stairs, morning stiffness, postmenopausal status and heavy work. AUC was 0.71(0.63-0.78). Results were similar for incident KOA. Applying external validation, similar results were observed in the RS-III. Conclusion: In this study, easy-obtainable variables modestly improved the prediction of FKP and symptomatic KOA above age and BMI. To improve the identification of high-risk individuals, development of valid tests for other known risk factors, like meniscal damage, that are applicable in primary care, are urgently needed. 

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ORIGINAL RESEARCH

Implementing Social Risk Stratification in Primary Care: Challenges and Strategies

Jesse Wagner, MA; Jennifer D. Hall, MPH; Rachel L. Ross, BA; David Cameron, BA; Bhavaya Sachdeva, MPH; Devan Kansagara, MD; Deborah J. Cohen, PhD; David A. Dorr, MD

Corresponding Author: Jesse Wagner, MA; Oregon Health & Science University. Email: wagnerje@ohsu.edu

Publication: July/August 2019 (Full article available online for free on July 12, 2019)

DOI: 10.3122/jabfm.2019.04.180341

Introduction: Primary care risk stratification (RS) has been shown to help practices better understand their patient populations’ needs and may improve health outcomes and reduce expenditures by targeting and tailoring care to high-need patients. This study aims to understand key considerations practices faced and practice experiences as they began to implement RS models. Methods: We conducted semi-structured interviews about experiences in RS with 34 stakeholders from 15 primary care practices in Oregon and Colorado and qualitatively analyzed the data. Results: Three decisions were important in shaping practices’ experiences with RS: choosing established versus self-created algorithms or heuristics, clinical intuition, or a combination; selecting mechanisms for assigning risk scores; determining how to integrate RS approaches into care delivery. Practices using clinical intuition found stratification time-consuming and difficult to incorporate into existing workflows, but trusted risk scores more than those using algorithms. Trust in risk scores was influenced by data extraction capabilities; practices often lacked sufficient data to calculate their perceived optimal risk score. Displaying the scores to the care team was a major issue. Finally, obtaining buy-in from care team members was challenging, requiring repeated cycles of improvement and workflow integration. Discussion: Practices used iterative approaches to RS implementation. As a result, procedural and algorithmic changes were introduced and were influenced by practices’ health IT, staffing, and resource capacities. Practices were most successful when able to make iterative changes to their approaches, incorporated both automation and human process in RS, educated staff on the importance of RS, and had readily accessible risk scores.

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BRIEF REPORT

Lifestyle Intervention Programs for Adults at High-Risk for Type 2 Diabetes: A Platform to Reach High-Risk Children?

Maya Venkataramani MD MPH; Tina L Cheng MD, MHS; Hsin-Chieh Yeh PhD; Nisa M Maruthur MD, MHS

Corresponding Author: Maya Venkataramani MD MPH; Division of General Internal Medicine, Johns Hopkins University School of Medicine; Department of Pediatrics, Johns Hopkins University School of Medicine; Welch Center for Prevention, Epidemiology and Clinical Research. Email: mvenkat2@jhmi.edu

Publication: July/August 2019 (Full article available online for free on July 12, 2019)

DOI: 10.3122/jabfm.2019.04.180317

Introduction: Children of adults eligible for the National Diabetes Prevention Program (DPP) lifestyle intervention may themselves be high-risk for type 2 diabetes development, and high-risk children may be reached through programs which target high-risk adults. To understand the potential multi-generational impact of family-oriented diabetes prevention programming, we explored the correlation between parental eligibility for the National DPP program and child weight status using nationally representative data. Methods: We analyzed data from the National Health Interview Survey from 2016 and 2017, focusing upon children ages 12 through 17 years of age for whom BMI data was available and who could be linked to one sample parent. We explored the association between parent and child weight status and parental DPP eligibility and child weight status using Chi-squared analyses. Results: Our final sample consisted of 3905 (unweighted) children, linked to either a mother or father. 25.9% of children were overweight or obese; 68.1% of linked parents were overweight or obese, and child and parent weight status were correlated (Pearson’s Chi-squared p <0.001). 9.5% of parents were likely eligible to participate in the National DPP. Parental program eligibility was positively correlated with child overweight/obese status (Chi-squared p <0.001); over one-third of children with eligible parents were themselves overweight/obese. Discussion: In this nationally representative sample, parental BMI and child BMI categories were positively correlated, as was parental eligibility for diabetes prevention programming and child BMI. This highlights the potential of leveraging the national platform for adult diabetes prevention to reach high-risk children through family-oriented programming.

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BRIEF REPORT

Sugar-Sweetened Beverage Intake in a Rural Family Medicine Clinic

Laura Pinon, MD; Birgit Khandalavala, MD; Jenenne Geske, PhD

Corresponding Author: Laura Pinon, MD; Memorial Family Medicine Residency Program, Physicians at Sugar Creek. Email: lpinon17@gmail.com

Publication: July/August 2019 (Full article available online for free on July 12, 2019)

DOI: 10.3122/jabfm.2019.04.180170

Background: Sugar sweetened beverages (SSB) are a major source of calories, and are associated with adverse health outcomes. Because the majority of studies are undertaken in urban areas, the rural intake of SSB presents a significant gap in current knowledge. The objective of our study was to assess SSB intake in a rural primary care clinic. Methods: The Beverage Intake Questionnaire (BEVQ-15) is a 15-item self-reported questionnaire and has been extensively validated to assess habitual SSB consumption. The survey was administered to adult primary care clinic patients presenting for routine care over a 6-week period at a clinic in a rural central Nebraska community (population <1,000). Results: Survey participants (n= 121) were primarily Caucasian with an average age of 61 years (SD=18.0) and an average body mass index (BMI) of 29.9 (SD=7.5). Participants consumed an average of 1.05 SSBs per day (SD=1.3), and 33.5% of respondents consumed one or more SSBs per day. The average daily caloric intake from SSBs was 153 Kilocalories (Kcals) compared to the national average intake of 145 Kcals. The most commonly consumed caloric beverages, based on Kilocalories consumed, were 100% juice and regular soda. SSB consumption was not related to with BMI. Discussion: In a rural primary care clinic, the daily consumption of SSB by patients was found to be a noteworthy source of calories, with no significant difference in consumption across BMI categories. Mitigation of SSB consumption by rural primary care clinicians is imperative for optimizing health.

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BRIEF REPORT

Physician and Family Discussions about Driving Safety: Findings from the LongROAD Study

Marian E. Betz, MD, MPH; Leon Villavicencio, MPH; Deepika Kandasamy, MPH; Tara Kelley-Baker, PhD; Woon Kim, PhD; Carolyn DiGuiseppi, MD, PhD; Thelma J. Mielenz, PT, PhD; David W. Eby, PhD; Lisa J. Molnar, PhD; Linda Hill, MD, MPH; David Strogatz, PhD; David B. Carr, MD; Guohua Li, MD, DrPH; on behalf of the LongROAD Research Team

Corresponding Author: Marian E. Betz, MD, MPH; University of Colorado School of Medicine. Email: marian.betz@ucdenver.edu

Publication: July/August 2019 (Full article available online for free on July 12, 2019)

DOI: 10.3122/jabfm.2019.04.180326

Background: Older adult drivers may experience decreases in driving safety with age or health status change. Discussing driving safety may help them plan for driving restriction and eventual cessation. Here, we sought to examine conversations between older adults and their family members and physicians. Methods: In this multi-site cross-sectional analysis of baseline data from the AAA Longitudinal Research on Aging Drivers (AAA LongROAD) cohort study, we measured the prevalence and characteristics of family and physician driving discussions. We examined associations between having driving discussions and participant characteristics using multivariate logistic regression. Results: Of 2990 current drivers aged 65-79 years (53% female, 85.5% White), only 14.2% reported discussing driving safety with family and 5.5% had discussions with physicians. Men (adjusted OR: 1.32, 95%CI 1.05-1.66) and those with Master’s degrees or higher (adjusted OR: 1.65, 95%CI, 1.27-2.13) more often had family discussions. Those with at least a Master’s degree were also more likely to speak with their physician (adjusted OR: 1.77, 95%CI 1.17- 2.68). Conclusion: Few older adults had driving safety conversations with their family or physicians. Practical and effective interventions are needed to engage family and physicians in assisting older adults with risk assessment and driving cessation planning to maintain mobility and well-being.

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BRIEF REPORT

Opioid Medications Prescribing and the Pain-Depression Dyad in Primary Care: Analysis of 2014-2015 NAMCS Data

Susan X. Lin, DrPH; Khusbu Patel, PharmD; Richard G. Younge, MD, MPH

Corresponding Author: Susan X. Lin, DrPH; Center for Family and Community Medicine, Columbia University, Irving Medical Center. Email: xl18@columbia.edu

Publication: July/August 2019 (Full article available online for free on July 12, 2019)

DOI: 10.3122/jabfm.2019.04.180311

Background: Increased drug overdose deaths have become a serious public health problem. Primary care providers prescribe about 50% all opioid medications. This study examined opioids prescribing during primary visits to patients with a pain-depression dyad and patient demographic characteristics associated with opioids prescribing. Method: This study analyzed data from the 2014-2015 National Ambulatory Medical Care Survey (NAMCS) and included primary care visits by adult patients (aged 18 or older) with non cancer pain. Results: An opioid medication was prescribed in 26.4% (95% CI: 22.6%-30.6%) of the primary care visits by patients with non-cancer pain. Opioid medications were more likely to be prescribed during visits by patients with a pain and depression dyad (AOR=1.8, 95%CI: 1.4-2.4). Narcotic analgesics were more likely to be prescribed during visits by patients aged 46-64; by male patients or non-Hispanic white patients. Discussion/Conclusions: Pain-depression dyad is associated with higher odds of opioids prescribing during primary care visits. Future studies are needed to understand the complexity of these factors and identify effective strategies to prevent opioids addiction and overdose among patients with pain and depression. 

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FAMILY MEDICINE AND THE HEALTH CARE SYSTEM

Evaluation of a Family Medicine Transitional Care Service Line

Bryan Farford, DO; Sally Ann Pantin, MD; John Presutti, DO; Collen S. Ball, MS 

Corresponding Author: Bryan Farford, DO; Mayo Clinic, Florida Department of Family Medicine. Email: Farford.Bryan@mayo.edu

Publication: July/August 2019 (Full article available online for free on July 12, 2019)

DOI: 10.3122/jabfm.2019.04.180272

Introduction: As of 2013, the all-cause readmission rate among Medicare fee-for-service beneficiaries was 17.5 percent. In addition to poor outcomes, 30-day hospital readmissions account for over $17 billion in Medicare expenditures. The presence and involvement of a primary care provider (PCP) can be essential during the transition period from hospital discharge to the outpatient setting. Objective: In an effort to reduce 30-day hospital readmissions a transitional care management service was implemented in a multi-site family medicine practice. Methods: The transitional care service line was structured after the 2013 Centers for Medicare & Medicaid Services recommended process for transitioning patients from an inpatient to an outpatient setting. The service included a care team RN, electronic documentation in an electronic medical record and the primary care physician. Results: The 30-day readmission rate was 12.0% in the 10 months prior to implementation of the new service line and 12.4% in the first 10 months after implementation of the new service line. There was no evidence of an impact of the new service line on a decline in 30-day readmission rates (P=0.18). Discussion: Hospital readmissions generate unnecessary costs and often present a major burden on patients and their families. Early engagement with patients after hospital discharge will help to address any acute needs, verify medication adherence and ensure that necessary equipment and services are available. Conclusion: Although there was no evidence of an impact of the new service line on a decline in 30-day readmission rates it was decided that this service was a benefit to the patients and the physicians involved.

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CLINICAL REVIEW

Drug-Induced Hyperpigmentation: Review and Case Series

Rosa Mª Giménez García; Sergio Carrasco Molina

Corresponding Author:  Rosa Mª Giménez García; Department of Medicine, Dermatology and Toxicology; Dermatology Department, Hospital Universitario Rio Hortega. Email: rosagim@hotmail.com

Publication: July/August 2019 (Full article available online for free on July 12, 2019)

DOI: 10.3122/jabfm.2019.04.180212

Background: Hyperpigmentation is a common dermatological problem that may have substantial impact on the patient, since it affects the appearance and quality of life, and may influence treatment adherence. There are few studies of drug-induced hyperpigmentation. Methods: We studied drug-induced hyperpigmentation in patients attending an outpatient dermatology clinic in the Western Area of Valladolid (Spain) from August 1, 2017 to April 20, 2018. Results: The incidence of drug-induced hyperpigmentation was 1.31% in patients attending a first dermatology consultation in the study period. Of the 16 patients, 8 were taking more than one drug. The most frequent drugs identified were non-steroidal anti-inflammatory agents (25%), antihypertensive agents (18.75%), antimalarials (12.5%), antibiotics, antineoplastic agents, psychoactive agents, simvastatin, allopurinol, amiodarone and mucolytic (6.25% each). Hyperpigmentation was found in the mucosa in 25% of patients and in photo-exposed areas in 37.5%. Discussion: Diagnosing drug-induced hyperpigmentation is a dermatological challenge. A differential diagnosis with hyperpigmentation caused by endocrine and metabolic disorders, the most closely-related disorders to drug-induced hyperpigmentation, and with hyperpigmentation of idiopathic origin, should be carried out. Drug-induced hyperpigmentation is a relatively frequent reason for consultation, especially in polypharmacy patients . The sample may have been biased as many patients receiving treatments frequently associated with drug-induced hyperpigmentation, such as antineoplastic drugs, are diagnosed and treated by other specialties, such as oncologists. Conclusion: Family physicians and specialists should consider drugs as a cause of hyperpigmentation to facilitate the correct diagnosis and treatment.

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POLICY BRIEF

Declining Endoscopic Care by Family Physicians in Both Rural and Urban Areas

Lars E. Peterson, MD, PhD; Urooj Nasim; Vashisht Madabhushi, MD

Corresponding Author: Lars E. Peterson, MD, PhD; American Board of Family Medicine. Email: lpeterson@theabfm.org

Publication: July/August 2019 (Full article available online for free on July 12, 2019)

DOI: 10.3122/jabfm.2019.04.190064

Using data from 2014 through 2016, we demonstrated a decline in the percentage of family physicians providing endoscopic services in both rural and urban areas. Our findings suggest that forces in the health care system may be influencing the reduction in scope, rather than specific geographic factors.

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