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.

PRACTICE-BASED RESEARCH 2020 - SPECIAL ISSUE (Publication Date: TBD)

OTHER MANUSCRIPTS ACCEPTED FOR PUBLICATION (Publication Date: TBD)

CLINICAL REVIEW

Providing Diagnosis and Symptoms Management for Patients With Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS)   

Kenneth J. Friedman, PhD; H. Andrew Selinger, MD

Corresponding Author:  H. Andrew Selinger, MD; Quinnipiac University. Email: haselinger@qu.edu

Publication: TBD

Up to 2.5 million Americans suffer from Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) making it likely that a family physician will see one or more of these patients. ME/CFS is a chronic disease, currently more disabling than HIV/AIDS and more difficult to treat. There are no medications to address its underlying cause or primary symptom: post-exertional malaise (PEM). Currently, diagnosis is based upon the presenting symptoms in accordance with Institute of Medicine criteria. Complete recovery is unlikely, although improvements of symptoms and quality of life are possible for the majority of patients. There is no disease-confirming, clinical, laboratory test, but such tests are useful in determining the presence of comorbidities. Patient care consists of providing symptom relief, managing comorbidities (if present), and educating the patients to stay within their energy envelope, “pacing” their activities, so as not to trigger PEM and other symptoms. School-age children are treated similarly but have the additional need of physician assistance in obtaining home instruction or partial day attendance at school, and support in maintaining social contacts with peers and family. The family physician who works with ME/CFS patients will be performing critical roles of coordinating care, determining appropriateness of referral and supporting patients as they develop broader insights into their own lifestyles and behaviors which will help them achieve their best possible quality of life.

ORIGINAL RESEARCH

Practitioner Engagement in Activities of the National Dental Practice-Based Research Network: 7-Year Results    

Rahma Mungia, BDS, MSc; Ellen Funkhouser, MS, DrPH; Sonia K. Makhija, DDS, MPH; Stephanie C. Reyes, BA; Rachel Cohen, MPH; David L. Cochran, DDS, MS, PhD; Cyril Meyerowitz, DDS, MS; D. Brad Rindal, DDS; Valeria V. Gordan, DDS, MS, MSCI; Jeffrey L. Fellows, PhD; Meredith Trejo, MPH; Thomas W. Oates, DMD, PhD; Jason D. McCargar, DMD; Pamela A. McMahon, DDS; Gregg H. Gilbert, DDS, MBA; National Dental PBRN Collaborative Group.

Corresponding Author: Rahma Mungia, BDS, MSc, DDPHRCS; University of Texas Health Science Center. Email: mungia@uthscsa.edu

Publication: TBD

Purpose: To (1) quantify practitioner activities of the National Dental Practice-Based Research Network for which Continuing Education (CE) credits were received (study training, videos, webinars, meetings, and symposia); (2) quantify practitioner co-authoring Network publications and presentations; and (3) test whether practitioner characteristics were associated with participation in these activities. Methods: A retrospective analysis of 4,361 practitioners who enrolled in the Network between April 12, 2012 and October 12, 2018.  Results: Overall, 59% (n=2,586) of practitioners earned CE credit from the Network; among these, 68% (n=1,757) from a video, 62% (n=1,592) attended an annual Network meeting, 31% (n=549) due to training for a Network clinical study, 9% (n=226) attended a national symposium, and 7% (n=170) participated in a Network webinar. Members of two large group practices earned on average more CEs than practitioners from other practice settings. Four percent (n=159) of practitioners co-authored a Network presentation or publication. Practitioners who received their dental degree before 2000, were general practitioners, or were members of two large group practices, were more likely to have co-authored a publication or presentation. Conclusion: This Network used a broad range of activities to engage community practitioners. These activities were successful in sustaining a high level of practitioner engagement in clinical research and its relevance to everyday clinical practice.

ORIGINAL RESEARCH

Practice Transformation Support and Patient Engagement to Improve Cardiovascular Care: A Report from EvidenceNOW Southwest    

W. Perry Dickinson, MD; Donald E. Nease, Jr., MD; Robert L. Rhyne, MD; Kyle E. Knierim, MD; Douglas H. Fernald, MA; Dionisia R. de la Cerda, MPA; L. Miriam Dickinson, PhD

Corresponding Author: W. Perry Dickinson, MD; University of Colorado. Email: perry.dickinson@cuanschutz.edu

Publication: TBD

Purpose: To improve cardiovascular care through supporting primary care practices’ adoption of evidence-based guidelines. Study Design: A cluster randomized trial compared two approaches:  1) standard practice support (practice facilitation, practice assessment with feedback, health information technology assistance, and collaborative learning sessions), and 2) standard support plus patient engagement support. Methods: Primary outcomes were cardiovascular clinical quality measures collected at baseline, 9, and 15 months. Implementation of the first 6 “Building Blocks of High Performing Primary Care” was assessed by practice facilitators at baseline, 3, 6, and 9 months. Clinical quality measures from practices not involved in the study served as an external comparison. Results: 211 practices completed baseline surveys. There were no differences by study arm (OR (95% CI)): aspirin use (1.03 (0.99,1.06)), blood pressure (0.98 (0.95,1.01)), cholesterol (0.96 (0.92,1.00)), smoking (1.01 (0.96,1.07)); however, there were significant improvements over time in  aspirin use (OR=1.04 (1.01,1.07)), cholesterol (OR=1.05 (1.03,1.08)), and smoking (OR=1.03 (1.01,1.06)), but not blood pressure (OR=1.01(0.998,1.03)). Improvement in enrolled practices was greater than external controls across all four measures (all p<0.05). Implementation improved in both arms for Team-Based Care, Patient-Team Partnership, and Population Management, and improvement was greater in enhanced intervention practices (all p<0.05).  Leadership and Data Driven Improvement (p<0.05) improved significantly, with no difference by arm. Greater improvement in Building Block implementation was associated with greater improvement in blood pressure measures (p<0.05). Conclusions: Practice transformation support can assist practices with improving quality of care. Patient engagement in practice transformation can further enhance practices’ implementation of aspects of new models of care.

ORIGINAL RESEARCH

Self-Reported Opioid Use and Driving Outcomes Among Older Adults: Findings from the AAA LongROAD Study    

Marian E. Betz, MD, MPH; Hailey Hyde, MPH; Carolyn DiGuiseppi, MD, PhD, MPH; Timothy F. Platts-Mills, MD, MSc; Jason Hoppe, DO; David Strogatz, PhD; Howard F. Andrews, PhD; Thelma J. Mielenz, PT, PhD, MS; Linda L. Hill, MD, MPH; Vanya Jones, PhD, MPH; Lisa J. Molnar, PhD; David W. Eby, PhD; Guohua Li, DrPH, MD

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

Publication: TBD

Background: Opioid medications are important therapeutic options to mitigate the harmful effects of pain but can also impair driving ability. We sought to explore opioid use, pain levels, and driving experiences among older drivers. Methods: Cognitively intact drivers age 65-79 were recruited for the multisite AAA Longitudinal Research on Aging Drivers (LongROAD) study (n = 2990). This cross-sectional analysis used data from the baseline questionnaire and “brown-bag” medication review. Results: Among LongROAD participants (47% male, 88% White, 41% aged 65-69 years), 169 (5.7%) reported currently taking an opioid, with a median daily dose of 20 morphine milligram equivalents. Participants did not differ significantly in opioid use by age, gender, race, or ethnicity (p>0.05). After adjustment for age, gender, race and ethnicity, participants who were taking opioids (versus not) were significantly more likely to report self-regulated driving reduction and reduced driving ability. However, these effects became non-significant when hospitalization, impaired physical function and other factors associated with opioid use were controlled. Conclusions: In this study from a large, geographically diverse sample of older adults, there was an association between opioid use and several self-reported measures of driving behavior and ability.  However, future work should clarify the effects on driving of opioid use from the effects of the painful medical conditions for which the opioids are being taken. Clinicians should continue to discuss the risks and benefits of opioid medications with patients, including risks related to driving safety.

ORIGINAL RESEARCH

Period Prevalence Rates and Impact of Comorbid Widespread Pain in Adults with Chronic Low Back Pain: A Pain Research Registry-Based Study

John C. Licciardone, DO, MS, MBA; Vishruti Pandya, MBBS, MHA

Corresponding Author: John C. Licciardone, DO, MS, MBA; University of North Texas Health Science Center. Email: john.licciardone@unthsc.edu

Publication: TBD

Introduction: Widespread pain (WP) is emerging as a key comorbid condition in patients with chronic low back pain (CLBP). This study measured the prevalence of comorbid WP in adults with CLBP, WP predictors, and impact on patients. Methods: Patients with CLBP were recruited from the Pain Registry for Epidemiological, Clinical, and Interventional Studies and Innovation from 2016 through 2019. They were followed over 12 months to measure annual WP period prevalence rates using an item from the minimum dataset recommended by the National Institutes of Health Task Force on Research Standards for Chronic Low Back Pain. Patients were classified as not having WP, having non-persistent WP, or having persistent WP. Pain intensity, back-related disability, and quality of life were measured using a numerical rating scale, the Roland-Morris Disability Questionnaire, and the PROMIS-29 instrument, respectively. Results: A total of 358 patients were studied, including 56 (16%) without WP, 272 (76%) with nonpersistent WP, and 30 (8%) with persistent WP. There were no significant differences among the WP groups with regard to age, sex, or CLBP duration. However, being non-White and having moderate or high levels of pain catastrophizing remained significant predictors of nonpersistent or persistent WP after adjusting for potential confounders. Patients reported greater pain intensity and back-related disability and poorer quality of life over 12 months with increasing levels of WP persistence (P<0.001 for each measure). Conclusion: Greater efforts are needed in primary care to help close these gaps in pain intensity, back-related disability, and quality-of-life outcomes associated with WP.

ORIGINAL RESEARCH

Implementing a Sustainable Model for the Delivery of Preventive Services in Rural Counties (The Healthier Together Study)

Zsolt Nagykaldi, PhD; Dewey Scheid, MD; Yan D Zhao, PhD; Bhawani Mishra, PhD; Tracy Greever-Rice, PhD

Corresponding Author: Zsolt Nagykaldi, PhD; University of Oklahoma Health Sciences Center. Email: znagykal@ouhsc.edu 

Publication: TBD

Objective: The Healthier Together study aimed to implement and evaluate a sustainable, rural community-based patient outreach model for preventive care provided through primary care practices located in three rural counties in Oklahoma. Community-based Wellness Coordinators (WCs) working with primary care practitioners (PCPs), county health departments, local hospitals, and health information exchange (HIE) networks helped residents receive high-priority evidencebased preventive services. Methods: The WCs used a wellness registry connected to electronic medical records and HIEs and called patients at the county level, based on PCP-preferred protocols. The registry flagged patientlevel preventive care gaps, tracked outreach efforts, and documented the delivery of services throughout the community. Return on investment (ROI) in participating organizations was estimated by the study team. Results: Forty four of the 59 eligible clinician practices participated in the study. Two regional HIEs supplied periodic health data updates for 71,989 patients seen in the three implementation counties. A total of 45,862 outreach calls were made by 6 WCs, 100,896 high-priority recommendations were offered to patients based on care gaps and 14,043 additional services were delivered. Of all the patients reached, only 1,917 (4.2%) were up-to-date on all prioritized services. Participating primary care practices significantly improved the delivery of preventive services (mean increase: 20.2% across 12 services; p<0.001; range: 7% to 43%) and realized a mean ROI of 68%. Health systems that employed the WCs earned a mean revenue of $175,000, realizing a 75% ROI for the outreach program. Conclusions: Although health care is under-resourced and segmented in many rural counties, when stakeholder partnerships are established, they may be able to achieve and economically sustain community-wide health improvement by creating a win-win situation for all partners.

ORIGINAL RESEARCH

The Impact of Social and Clinical Complexity on Diabetes Control Measures in Community Health Centers

Erika Cottrell, PhD, MPP; Jean P. O’Malley, MPH; Katie Dambrun, MPH; Michelle A Hendricks, PhD; Brian Park, MD; Hongzhi Xu, PhD, MPH, MS; Mary Charlson, MD; Andrew Bazemore, MD MPH; Elizabeth Ann Shenkman, PhD; Abby Sears, MHA, MBA; Jennifer E. DeVoe, MD, DPhil

Corresponding Author: Erika Cottrell, PhD, MPP; OCHIN, Inc. Email: cottrelle@ochin.org

Publication: TBD

Purpose: In an age of value-based payment, primary care providers (PCPs) are increasingly scrutinized on performance metrics that assess quality of care, including the outcomes of their patient population in key areas such as diabetes control. Although such measures often adjust for clinical complexity, most do not account for social risk factors, despite research demonstrating the strong association between social factors and health. Methods: Using patient electronic health record data from two large community health center networks serving safety net patients, we assessed the effect of both clinical and social risk factors on poor glucose control among diabetics. Logistic regression results were used to estimate the impact of adjusting for both clinical and social complexity on provider performance metrics. Clinical complexity was measured at the patient-level using the Charlson Comorbidity Index. Social complexity was measured at the neighbhorhood-level using the Social Deprivation Index. Results: Clinical complexity alone was not consistently associated with poor diabetes control (i.e., HbA1c>9) in diabetic patients with HbA1c testing during the study period. However, increasing social complexity was significantly associated with higher rates of poor diabetic control in both cohorts. After adding adjustment for social complexity down to the national median score, our models suggest that approximately 25% of providers would have 1-2% improvement in their diabetes control metric, with 45% showing a 2-5% improvement. Conclusions: Providers caring for patients with greater social risk factors may benefit from having their performance metrics adjusted for the social complexity of their patient populatiions. 

ORIGINAL RESEARCH

Implementing Office-Based Opioid Treatment Models in Primary Care Settings

 E. Marshall Brooks, PhD; Sebastion Tong, MPH, MD

Corresponding Author: E. Marshall Brooks, PhD; Virginia Commonwealth University. Email: edward.brooks@vcuhealth.org

Publication: TBD

Background: Primary care practices are ideal sites to integrate medication assisted treatment (MAT) for opioid use disorder (OUD), but little is known about how practices have achieved this. Our study aimed to describe the implementation experiences and treatment models of practices implementing MAT. Methods: We conducted a qualitative analysis of MAT integration at 26 practices across Virginia after the state implemented the Addiction and Recovery Treatment Services (ARTS) benefit in 2017. Data collection activities included interviews with clinic team members, including buprenorphine waivered prescribers, behavioral health clinicians, care coordinators, and peer counselors. We used a template analysis approach to thematically analyze data. Results: Our study identified various ways in which MAT can be implemented in primary care clinics and other ambulatory settings. While state regulations and treatment guidelines suggest co-locating behavioral health counseling and medication management, providing care coordination and conducting regular urine drug screens, we found a wide spectrum of ways in which practices can adapt and innovate treatment models to fit local needs. Discussion: As the fight against the opioid epidemic continues, we need to identify feasible and effective MAT treatment models and integration approaches for primary care. 

ORIGINAL RESEARCH

Primary Care Physician Characteristics Associated with Prescribing Potentially Inappropriate Medication in Elderly Patients

 Avanthi Jayaweera; YoonKyung Chung, PhD; Yalda Jabbarpour, MD

Corresponding Author: Yalda Jabbarpour, MD; Robert Graham Center for Policy Studies. Email: yjabbarpour@aafp.org

Publication: TBD

Background: Despite the high risk of adverse drug events associated with potentially inappropriate medications (PIMs), primary care physicians (PCPs) continue to prescribe them for the elderly. The objective of this study was to explore PIM prescribing behavior in relation to characteristics among PCPs practicing in the United States. Methods: We conducted a retrospective cohort study of PCPs in the 2013-2015 Medicare Part D Public Use File. We obtained physician characteristics from the 2015 AMA Masterfile. For each PCP, we calculated the ratio of primary care-relevant PIM claims to all drug claims (PIM rate) based on Beers Criteria. We used a multivariate regression model to assess the associations between physician characteristics and PIM rate. Results: The study sample contained 111,461 PCPs who specialized in family medicine, internal medicine, general practice and geriatric medicine. Although the mean PIM rate was low at 4.9%, it varied widely across PCPs with the bottom quartile at 1.2% and the top quartile at 10.1%. PCPs in the top quartile were on average older, more likely to be male, have a D.O degree, practice in the South, and have a smaller Medicare patient panel. A multivariate analysis confirmed that even after adjusting for patient panel characteristics, physician characteristics including gender, age, professional degree, specialty, practice location, practice size, and patient panel size were associated with PIM rate. Conclusion: Identifying PCPs with higher PIM rates can guide future interventions to increase safe prescribing for elderly populations.

ORIGINAL RESEARCH

A Scoping Review on Clinical Decision Support Systems for Opioid Prescribing for Chronic Non-Cancer Pain in Primary Care Settings

Sheryl Spithoff, MD, MSc; Stephanie Mathieson, PhD; Frank Sullivan, FRSE, FRCP, FRCGP; Qi Guan, MSc; Abhimanyu Sud, MD, CCFP; Susan Hum, MSc; Mary Ann O’Brien, PhD

Corresponding Author: Sheryl Spithoff, MD, MSc; University of Toronto. Email: sheryl.spithoff@wchospital.ca

Publication: TBD

Background and Objectives: Clinical decision support systems (CDSSs) may help clinicians prescribe opioids for chronic non-cancer pain (CNCP) more appropriately. This scoping review determined the extent and range of the current evidence on CDSSs for opioid prescribing for CNCP in primary care, and whether investigators followed best evidence and current guidance in designing, implementing and evaluating these complex interventions. Methods: We searched nine electronic databases and other data sources for studies from January 1st 2008 to October 11th 2019. Two reviewers independently screened the citations. One reviewer extracted data and a second verified for accuracy. Inclusion criteria: study of a CDSS for opioid prescribing for CNCP in a primary care clinical setting. We reported quantitative results in tables and qualitative results in narrative form. Results: Our search yielded 5068 records of which 14 studies met our inclusion criteria. All studies were conducted in the United States. Six studies examined local (eg, health centre) CDSSs and eight examined prescription drug monitoring program (PDMP) CDSSs. Three CDSSs incorporated evidence-based components. Study aims were heterogeneous and study designs included both quantitative and qualitative methodologies. No studies assessed patient health outcomes. Few studies appeared to be following guidance for evaluating complex interventions. Conclusions: Few studies have rigourously assessed the use of CDSSs for opioid prescribing for CNCP in primary care settings. Going forward, investigators should include evidence-based components into the design of CDSSs and follow guidance for the development and evaluation of complex interventions.

POLICY BRIEF

The Evolving Family Medicine Team

Yalda Jabbarpour, MD; Anuradha Jetty, MPH; Mingliang Dai, PhD; Michael Magill, MD; Andrew Bazemore, MD, MPH

Corresponding Author: Yalda Jabbarpour, MD; The Robert Graham Center for Policy Studies. Email: yjabbarpour@aafp.org

Publication: TBD

A decade of practice transformation, consolidation, and payment experimentation have highlighted the need for team-based primary care, but little is known about how team composition is changing over time.   Surveys of Family Physicians (FPs) from 2014-18 reveal they continue to work alongside inter-professional team members and suggest slow but steady growth in the proportion of FPs working with nurses, behaviorists, clinical pharmacists, and social workers.

BRIEF REPORT

From the Patient Perspective: The Value of Treating Opioid Use Disorder in Family Medicine

Claire Kane, BA; Catherine Leiner, BS; Chase Harless, MSW; Kathleen A. Foley, PhD; E. Blake Fagan, MD; Courtenay Gilmore Wilson, PharmD, BCACP, CPP

Corresponding Author: Courtenay Gilmore Wilson, PharmD, BCACP, CPP; UNC Health Sciences at MAHEC. Email: Courtenay.wilson@mahec.net

Publication: TBD

Introduction: Despite evidence demonstrating that medications for opioid use disorder (OUD) reduce morbidity and mortality, the majority of patients do not receive treatment. The National Academies of Science call for more research exploring the patient’s perspective of treatment modalities in order to increase access to individualized, patient-centered care. We aim to build on existing literature by describing patient experiences treated for OUD in a rural family medicine setting. Methods: We employed a convenience sampling methodology to complete brief, structured interviews with thematic data analysis for 30 of 57 eligible patients receiving office-based opioid treatment (OBOT) in the primary care setting. Results: Participants’ experiences with OBOT were generally positive and shaped by societal structures and institutions, their life before treatment, their treatment history, and the kind of care they received in OBOT. Patients identified accessibility and privacy as advantages to receiving OBOT in primary care. Discussion: This research identifies ways providers can provide individualized and effective OUD treatment within the family medicine setting.

BRIEF REPORT

The Ability of Smaller Primary Care Practices to Report Clinical Quality Measures: More Evidence of the Size Paradox?

Michael L. Parchman, MD, MPH; Melissa L. Anderson, MS; Robert B. Penfold, PhD; Elena Kuo, PhD, MPH; David A. Dorr, MD, MS

Corresponding Author: Michael L. Parchman, MD, MPH; Kaiser Permanente of Washington. Email: parchman.m@ghc.org 

Publication: TBD

Purpose: To assess if primary care practices with and without support from a larger organization differ in their ability to produce timely reports on cardiovascular disease (CVD) quality measures. Background: Although many primary care practices are now part of larger organizations, it is not clear if such a shift will improve the ability of those who work in these primary care settings to easily access and use their own data for improvement. Methods: Smaller primary care practices were enrolled in a trial of external practice support to build quality improvement (QI) capacity. A request for clinical quality measure (eCQM) data was sent to each practice and study outcomes were defined based on the date on which practices first submitted valid data for at least one of the three measures. A practice survey completed by a clinic manager captured practice characteristics, including the presence of quality improvement support from a larger organization. Results: Of the 209 enrolled practices, 205 had complete data for analysis. Practices without central QI support had higher rates of eCQM submission at 30 days (38% v. 20%) and 60 days, (63% v. 48%) than practices with central QI support. Practices with central QI support took longer to submit data (median 57 days) compared to practices without centralized support (median 40 days) although this difference was not significant. Conclusion: The ability of smaller practices without centralized QI support to report their eCQMs more quickly may have implications for their subsequent ability to improve these measures.

ORIGINAL RESEARCH

HPV Vaccination Initiation and Completion Among Adult Males in the United States: Prevalence and Associated Factors

Yuqi Guo, PhD; Jessamyn Bowling, PhD

Corresponding Author: Yuqi Guo, PhD; University of North Carolina at Charlotte. Email: yguo16@uncc.edu 

Publication: TBD

Background: Men accounted for 43% of HPV-related cancer cases, but the HPV vaccination rate of adult males remain low. The purposes of this study were to a) estimate the initiation and completion rate of HPV vaccine and b) analyze factors associated with HPV vaccine initiation and completion among adult males. Method: This study analyzed predisposing factors, enabling factors, reinforcing factors, and situational factors associated with the initiation of HPV vaccine among 3228 male adult participants of the 2018 Behavioral Risk Factor Surveillance System. Two binary logistic regressions were estimated based on the Systems Model of Clinical Preventive Care. Results: The initiation rate and completion rate of HPV vaccine among males aged 18 to 33 years old was 14.1% (n=454) and 35.4% (n=161) respectively. Among male adults in the U.S., the likelihood of initiating HPV vaccine significantly associated with age (odds ratio [OR] = 0.87, p < 0.00), having routine check-ups (OR = 1.29, p < 0.05), and having high HPV risk behaviors (OR = 1.53, p < 0.01). However, the likelihood of completing HPV vaccines significantly associated with age (OR = 0.85, p < 0.00) and having high HPV risk behaviors (OR = 1.79, p < 0.01). Conclusions: Having primary healthcare providers and regular check-ups are important to male adults to have HPV vaccines. Promoting access to health care resources may improve current vaccination rates among males.

CLINICAL REVIEW

Diagnosis and Management of Atopic Dermatitis for Primary Care Providers

Patrick Fleming, MD, MSc, FRCPC; Yue Bo Yang, BSc; Charles Lynde, MD, FRCPC; Braden O’Neill, MD, DPhil, CCFP; Kyle O. Lee, BM, BS, CCFP

Corresponding Author: Kyle O. Lee, BM, BS, CCFP; Sumac Creek Health Centre. Email: Kyle.Lee@mail.utoronto.ca 

Publication: TBD

Objective: To provide primary care providers an up-to-date approach to the diagnosis and management of atopic dermatitis (AD). Quality of evidence: PubMed, MEDLINE, and Cochrane databases were searched for relevant meta-analyses, randomized controlled trials, systematic reviews, and observational studies about the diagnosis and management of AD. Main message: AD is a common chronic skin disease characterized by immune dysregulation and skin barrier dysfunction. It has a substantial impact on quality of life across all ages. Despite this, AD is often still undertreated due to inaccurate diagnoses, even by many experienced dermatologists. Many primary care providers may not be aware of its commonly associated medical and psychiatric co-morbidities or be familiar with new treatment options. Conclusion: In this clinical review, we describe the pathophysiology, epidemiology, diagnosis and treatment of AD, specifically highlighting commonly used therapies and novel medications.

ORIGINAL RESEARCH

Misdiagnosis of Diverticulitis in Patients with prior Diagnosis of Irritable Bowel Syndrome

George F. Longstreth, MD; Carrie Wong, MD; Qiaoling Chen, MS

Corresponding Author: George F. Longstreth, MD;  Kaiser Permanente Southern California. Email: gflongstreth@gmail.com

Publication: TBD

Introduction: Irritable bowel syndrome (IBS) and diverticulitis share clinical features. Misdiagnosed diverticulitis can cause unnecessary antibiotic therapy. Among IBS and non-IBS patients, we compared outpatient, clinically diagnosed (no computed tomography) diverticulitis rates. Among primary-care diverticulitis-diagnosed, IBS patients, we assessed imaged diverticulosis and probable misdiagnosed diverticulitis. Methods: Among 3836-patient IBS and 67,827-patient non-IBS cohorts identified from 2000 to 2002, we retrospectively compared the frequency of outpatient, clinically diagnosed, antibiotic-treated diverticulitis from 2003 to endpoints of December 31, 2017, disenrollment or death. In IBS patients, we reviewed records of initial, primary care-managed episodes for misdiagnosis. Results: In 3,836 clinically diagnosed IBS and 63,991 non-IBS cohorts, follow-up (median [interquartile range]) was 12.4 (3.9-15.0) years versus 10.2 (3.0-15.0) years, respectively (P < .001). The incidence rate/1000 patient-years (95% confidence interval [CI]) of diagnosed diverticulitis was 14.0 (12.1-16.3) and 4.2 (4.0-4.5), respectively, (crude incidence rate ratio [IRR], 3.3 [2.8-3.9]; P <.001). Of examined features, the diagnosis of IBS was most strongly associated with clinically diagnosed diverticulitis (adjusted IRR [95% CI]; 2.64 [2.21-3.15], P <.001). Of initial diverticulitis diagnoses in 189 IBS patients, objective evidence-based diagnosis revision or exclusion occurred in 12 (6.3%), including 6 hospitalized; 29 (15.3%) had colon imaging before and/or afterward without diverticulosis reported; 143 (75.1%) had image-documented diverticulosis; and 6 (3.2%) had no imaging. Conclusions: Outpatient, clinically diagnosed, antibiotic-treated diverticulitis was increased 3-fold in IBS patients. Primary care clinical misdiagnosis of initial episodes occurred in 1 of 5 patients, but additional misdiagnosis due to misattribution of IBS pain to diverticulitis is suggested.

BRIEF REPORT

Family-Oriented Social Service Touchpoints as Opportunities to Enhance Diabetes Screening Among Women with a History of Gestational Diabetes

Maya Venkataramani, MD, MPH; Tina Cheng, MD, MPH; Hsien-Chieh Yeh, PhD; Wendy Bennett, MD, MPH; Nisa M. Maruthur, MD, MHS

Corresponding Author: Maya Venkataramani, MD, MPH; Johns Hopkins University School of Medicine. Email: mvenkat2@jhmi.edu

Publication: TBD

Introduction: Women with a history of gestational diabetes (GDM) are at increased risk for type 2 diabetes and thus require regular follow-up screening for diabetes; however, many women do not receive this screening, and in particular low-income women face disparities in receipt of recommended follow-up care. While these women may have limited access to healthcare following pregnancy, they may more regularly access social service programs that serve themselves or their young children. Leveraging these social service touchpoints could broaden opportunities to improve follow-up care receipt among women with a history of GDM. To describe these potential opportunities, we used nationally -representative data to characterize diabetes screening needs among women with a history of GDM who access the child-oriented social service programs WIC and Head Start. Methods: We analyzed nationally-representative data from the National Health Interview Survey from calendar years 2016 and 2017. Our analytic sample included women aged 18-45 years, who were linked to at least one of their children in the dataset, and had a self-reported history of GDM but did not have prediabetes or diabetes. We examined the proportion of these women who accessed WIC or Head Start who did not report having testing for diabetes within the past 3 years. Results: Of 432 (representing 2,002,675 weighted) women meeting inclusion criteria, 21.7% had accessed WIC and 8.7% Head Start. Nearly 1 in 10 women with a history of GDM in either group did not report recent diabetes screening. In sensitivity analyses that excluded likely pregnancy-related testing, 35.0% of women accessing WIC and 21.2% of those accessing Head Start had not had recent screening. Discussion: There is an unmet need for follow-up diabetes screening among women with a history of GDM who access WIC or Head Start services for themselves or their young children. Leveraging women’s touchpoints with these programs could enhance opportunities to improve recommended diabetes screening among a high-risk population. 

POLICY BRIEF

Proportion of Family Physicians Caring for Children is Declining

Aimee R. Eden, PhD, MPH; Zachary J. Morgan, MS; Anuradha Jetty, MPH; Lars E. Peterson, MD, PhD

Corresponding Author: Aimee R. Eden, PhD, MPH; American Board of Family Medicine. Email: aeden@theabfm.org

Publication: TBD

Using data from 2014 to 2018, we found that the proportion of family physicians caring for children under age 5 and ages 5 to 18 has significantly declined. This has implications for the pediatric primary care workforce and may exacerbate inequities in access to care for pediatric patients in all geographies, particularly those in areas with a shortage of pediatricians. 

ORIGINAL RESEARCH

Asthma Care Quality, Language, and Ethnicity in a Multi-State Network of Low-Income Children

John Heintzman, MD, MPH; Jorge Kaufmann, ND, MS; Jennifer Lucas, PhD; Shakira Suglia, PhD; Arvin Garg, MD; Jon Puro, MS; Sophia Giebultowicz, MA; David Ezekiel-Herrera, MS; Andrew Bazemore, MD; Miguel Marino, PhD

Corresponding Author: John Heintzman, MD, MPH; Oregon Health & Science University. Email: heintzma@ohsu.edu

Publication: TBD

Introduction: Prior research has documented disparities in asthma outcomes between Latino children and non-Hispanic whites, but little research directly examines the care provided to Latino children over time in clinical settings. Methods: We utilized an electronic health record (EHR)-based dataset to study basic asthma care utilization (timely diagnosis documentation and medication prescription) between Latino (Spanish and English-preferring) and Non-Hispanic white children over a thirteen-year study period. Results: In our study population (n=37,614), Latino children were more likely to have Medicaid, be low-income, and be obese than non-Hispanic white children. Latinos (Spanish and Englishpreferring) had lower odds than non-Hispanic whites of having their asthma recorded on their problem list on the first day the diagnosis was noted (odds ratio [OR]=0.83, 95% CI: 0.77-0.89 Spanish-preferring; OR=0.93, 95% CI: 0.87-0.99 English-preferring). Spanish-preferring Latinos had higher odds of ever receiving a prescription for albuterol (OR = 1.96, 95% CI: 1.52-2.52), inhaled corticosteroids (OR=1.45, 95% CI: 1.01-2.09) or oral steroids (OR=1.48, 95% CI: 1.07- 2.04) than non-Hispanic whites. Among those with any prescription, Spanish-preferring Latinos had higher rates of albuterol prescriptions compared to non-Hispanic whites (RR=1.07, 95% CI: 1.01-1.13). Conclusions/Relevance: In a multi-state network of clinics, Latino children were less likely to have their asthma entered on their problem list the first day it was noted than non-Hispanic white children, but otherwise did not receive inferior care to non-Hispanic white children in other measures. Further research can examine other parts of the asthma care continuum to better understand asthma disparities.

ORIGINAL RESEARCH

Insurance Types, Usual Sources of Care and Perceived Discrimination in Health Care

Héctor E. Alcalá; Amanda Ng; Sujoy Gayen; Alexander N. Ortega

Corresponding Author: Héctor E. Alcalá; Stony Brook University. Email: hectorapm@ucla.edu

Publication: TBD

Introduction: Discrimination can compromise access to and utilization of health care and lead to poorer health. As such, it is important to understand factors associated with experiences of discrimination in health care. Methods: Using data from the 2015-2017 California Health Interview Survey (N=63,100), this study examined if insurance types and sites of usual sources of care were associated with reasons for perceived discrimination in health care and if the reasons were associated with delaying health care. Odds of study outcomes were calculated among insured adults using logistic regressions. Insurance coverage types and sites of usual sources of care were main independent variables. Six reasons for lifetime discrimination in health care were examined: 1) dissatisfaction with the health care system; 2) race or skin color; 3) age; 4) way the participant speaks English or other barrier to communication; 5) insurance status or type and 6) income or education. Results: Adults with Medicaid perceived more discrimination due to race or skin color, relative to those with employer-sponsored coverage. This association does not vary by race/ethnicity. Perceived discrimination due to 1) dissatisfaction with the health care system, 2) insurance status or type and 3) barriers to communication were each associated with increased delays in getting needed medical care. Conclusions: Findings highlight potential insurance types and sources of care that could contribute to perceptions of being discriminated.

ORIGINAL RESEARCH

An Exploration into Patterns of Clinical Care Subsequent to Non-indicated Vitamin D Testing in Primary Care

Michelle S. Rockwell, PhD, RD; YingXing Wu, MD, MS; Mariana Salamoun, MA; Matthew W. Hulver, PhD; John W. Epling, MD, MSEd

Corresponding Author: Michelle Rockwell PhD, RD; Virginia Tech. Email:  msrock@vt.edu

Publication: TBD

Background: Exponential increases in non-indicated, low value vitamin D testing have been reported over the past 15 years. Downstream effects of such testing have not been wellquantified. Methods: The purpose of this study was to describe patterns of vitamin D testing within primary care of a large regional health system, and to explore downstream health service utilization subsequent to non-indicated testing. Instances of vitamin D testing in 2015 were obtained via electronic health record automated search. A subset of patients for whom vitamin D testing was classified as non-indicated was identified, and vitamin D-related service utilization was tracked for 24 months. Results: Of the 77,836 adult primary care patient records identified in 2015, vitamin D tests were conducted on 8042 (10.3%), with 24.3% of tests yielding abnormal results. In the nonindicated test subset (n= 574), substantial clinical variability was illustrated by 85 care pathways and 26 vitamin D prescriptions. Forty-five percent of abnormal vitamin D lab tests were not followed up with repeat vitamin D tests. Vitamin D-related services (laboratory tests, imaging, and prescriptions) occurred at an average rate of 1.6 services per patient during the 24 months following non-indicated vitamin D testing. Some of these services were also classified as nonindicated. Conclusions: Evidence of a health service cascade following a non-indicated vitamin D testing exists. Opportunities for improved consistency and quality of care related to vitamin D were observed in our health system. These results may inform clinical pathways related the prevention, evaluation, and treatment of low vitamin D. 

BRIEF REPORT

Case Report on Anti-HMGCR Myopathy: A Rare and Serious Side Effect of Statins

LT Nathaniel Irvine, MD

Corresponding Author: LT Nathaniel Irvine, MD; Naval Health Clinic New England. Email: nathaniel.j.irvine.mil@mail.mil 

Publication: TBD

Cardiovascular disease is a leading cause of morbidity and mortality in the United States. Since their initial discovery statins have become the first line treatment in decreasing the risk of cardiovascular disease. While typically well tolerated side effects do occur and tend to affect the musculature. Most are benign and resolve after discontinuing the statin. A subset of immune mediated necrotizing myositis, anti-3-hydroxy-3-methylglutaryl coenzyme A reductase (HMGCR) myopathy is a rare disease that occurs in 0.9 to 1.4 cases per 100,000 people. It causes significant muscle weakness that does not resolve with discontinuation of the statin. Unlike other known complications it has a late onset occurring years after the statin was initially prescribed. It can also present in patients previously treated with statins who have not taken them for several years. This case report details the case of a 54-year old woman who developed anti-HMGCR myopathy after several years of uncomplicated statin use. Differences between other reported cases and this one are discussed including the patient’s strong response to steroid therapy which resulted in the normalization of her serum creatinine kinase (CK) and alleviation of her muscle weakness. This case highlights the need for clinicians to be aware of anti-HMGCR myopathy and to consider it as a potential cause of proximal muscle weakness and persistent serum CK elevations in patients exposed to statins even if they were previously well tolerated by the patient.

BRIEF REPORT

Electronic Health Record Reminder Effect on Hepatitis C Antibody Screening

Elie Mulhem; Indigo Brown; Ke Song

Corresponding Author: Elie Mulhem; Oakland University William Beaumont School of Medicine. Email: Elie.mulhem@beaumont.edu

Publication: TBD

In the United States, national guidelines recommend screening adults born between 1945 and 1965 for hepatitis C, but screening rates in this population continue to be low. We added a hepatitis C screening reminder to the Epic Electronic Health Record and educated physicians on the use of Health Maintenance section of Epic. We assessed the effect of this intervention on the completion of screening hepatitis C antibody tests. We examined data from two years before and after the addition of the reminder. Completed hepatitis C antibody testing increased from 733 to 6502, and the rate of positive testing decreased from 5.9% to 2.0%. Implementing the electronic health record reminder and educating providers on the routine use of the Health Maintenance section increased hepatitis C screening for at risk adults. 

RESEARCH LETTER

Primary Care Clinician Decision-Making Around Surveillance Colonoscopies in Older Adults with Prior Adenomas

Nancy L. Schoenborn, MD, MHS; Cynthia M. Boyd, MD, MPH; Jacqueline Massare, BS; Reuben Park; Youngjee Choi, MD; Craig E. Pollack, MD, MHS

Corresponding Author: Nancy L. Schoenborn, MD;  The Johns Hopkins University School of Medicine. Email: nancyli@jhmi.edu

Publication: TBD

Introduction: While guidelines recommend against routine colorectal cancer screening in adults >75 years and/or those with limited life expectancies, there is no clear guidance on when surveillance colonoscopies following prior adenoma detection should stop. How primary care clinicians weigh the potential risks and benefits of surveillance colonoscopies in older adults with prior adenomas is unknown. Methods: We conducted semi-structured in-person interviews with 30 primary care clinicians from 21 clinics in Maryland. We asked how clinicians decided whether to continue or stop surveillance colonoscopies in older patients with prior adenomas. Interview transcripts were independently coded by two investigators using qualitative content analysis. Results: Participants described a range of decision-making approaches. Some deferred to specialists because they did not feel confident making decisions about stopping surveillance in light of the higher cancer risk involved. Some took a more active role and discussed the decision with patients and/or specialists. Other clinicians felt comfortable stopping surveillance colonoscopies and made these decisions based on patient age, comorbidities, or life expectancy. Discussion: We found a range of decision-making approaches among primary care clinicians on whether to continue surveillance colonoscopies in older adults with prior adenomas. Separate bodies of evidence currently exist on how prior adenoma characteristics influence colorectal cancer risk and on how older age and declining health influence the benefit/harm balance of screening. Information is lacking on the benefits and harms of surveillance in older adults with prior adenomas. Developing the evidence to address this knowledge gap is critically needed to inform clinical decision-making. 

ORIGINAL RESEARCH

Patient Safety in Primary Care: Conceptual Meanings to Clinicians, Administrators, Staff, and Patients

Alden Yuanhong Lai; Christina T. Yuan; Jill A. Marsteller; Susan M. Hannum; Elyse Lasser; JaAlah-Ai Heughan; Tyler Oberlander; Zackary D. Berger; Ayse P. Gurses; Hadi H. Kharrazi; Samantha I. Pitts; Sarah H. Scholle; Sydney E. Morss Dy

Corresponding Author: Alden Yuanhong Lai; New York University School of Global Public Health. Email: aldenlai@nyu.edu 

Publication: TBD

Introduction: Patient safety in primary care is an emerging priority, and experts have highlighted medications, diagnoses, transitions, referrals, and testing as key safety domains. This study aimed to: (1) describe how front line clinicians, administrators, and staff conceptualize patient safety in primary care; and (2) compare and contrast these conceptual meanings from patients’ perspective. Methods: We conducted interviews with 101 front line clinicians, administrators and staff, and focus groups with 65 adult patients at 10 Patient-Centered Medical Homes. We used thematic analysis to approach coding. Results: Findings indicate that front line personnel conceptualized patient safety more in terms of work functions, which reflect the grouping of tasks or responsibilities to guide how care is being delivered. Front line personnel and patients conceptualized patient safety in largely consistent ways. Discussion: Function-based conceptualizations of patient safety in primary care may better reflect front line personnel and patients’ experiences than domain-based conceptualizations, which are favored by experts.

ORIGINAL RESEARCH

Low-Intensity Intervention Supports Diabetes Registry Implementation: Results from a Cluster-Randomized Trial in the Ambulatory Care Outcomes Research Network (ACORN)

Roy T Sabo, PhD; Rebecca S Etz, PhD; Martha M Gonzalez, BA; Nicole J Johnson, BA; Jonathan P O’Neal, BA; Sarah R. Reves, FNP; Jesse C Crosson, PhD

Corresponding Author: Roy T. Sabo, PhD; Virginia Commonwealth University. Email: roy.sabo@vcuhealth.org

Publication: TBD

Background: Previous research demonstrated that registries are effective for improving clinical guideline adherence for care of patients with type 2 diabetes. However, registry implementation has typically relied on intensive support (such as practice facilitators) for practice change and care improvement. Objective: To determine whether a remotely-delivered, low-intensity organizational change intervention supports implementation and use of diabetes registries in primary care. Design: Cluster-randomized controlled effectiveness trial of providing limited external support leveraging internal practice resources and problem-solving capacities for driving diabetes registry implementation in 32 practices in Virginia. Intervention: All practices identified local implementation champions who participated in an in-person education session on the value and use of diabetes registries, while intervention practices were also paired with peer mentors and had access to a physician informaticist, who worked remotely to assist practices with implementation. Main Measures: Practice champions reported progress on registry implementation milestone achievement, and reported practice-level organizational capacity using a modified version of the Assessment of Chronic Illness Care (ACIC). Key Results: Intervention practices were significantly more likely to have implemented a registry (44% vs. 6%, p=0.04) and to have achieved more implementation milestones (5.5 vs. 2.6, p<0.0001) than control practices. Baseline ACIC scores indicated room for organizational improvement with regard to chronic illness care (overall median 6.4; range 3.8-10.8) and clinical information systems use (median 6.0; range 0, 11) with no significant differences between intervention and control practices. Conclusions: Remotely-provided guidance paired with limited in-person assistance can support rapid implementation of diabetes registries in typical primary care practices.

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