The value of comprehensive primary care follow-up

Objectives: To identify the information networks of caregivers and individuals with spinal cord injury (SCI) and how the health information is accessed and used. Methods: For this qualitative study, participants from the United States were recruited through hospital listservs, websites, social media, and word of mouth to participate in a phone interview. Fourteen individuals living with a traumatic SCI and 18 caregivers of individuals living with a traumatic SCI were interviewed using a semi-structured interview guide. The interviews were transcribed verbatim, coded using NVivo, and analyzed using qualitative thematic methods. Results: Participants reported that medical resources such as SCI specialists were considered the most reliable sources, but due to accessibility barriers the Internet was used the most. The Internet and social resources, such as online and in-person support groups, provided beneficial content information and emotional support, but they posed credibility concerns and left participants feeling unsure of reliability. Information gaps such as lack of education on basic care practices during the transition from acute to chronic care were identified by the participants. Conclusion: Because SCI is an overwhelming experience, it is difficult for patients to retain information in the initial acute care phase, leading to gaps in knowledge about long-term care. Patients are concerned about the reliability of online sources of information; therefore, there is a need for new methods of SCI information dissemination. Potentially, using primary care providers as conduits for information distribution might improve access to reliable long-term SCI information for caregivers and patients.

Commentary - Payment Policy Disruption and Policy Drift.

Accountable Care Organizations and the Allergist: Challenges and Opportunities

Spinal cord injury (SCI) creates unique needs that if not recognized and addressed timely can have detrimental effects on the health and quality of life (QOL) of people living with a SCI. Primary preventive health care is shown to decrease morbidity and mortality, yet the SCI population reportedly faces challenges getting access to this care. This area in SCI health care is still largely understudied with no consensus on the ideal way or which health care provider is best to provide primary care for this population. Preventive care is generally provided by general primary care providers, but not all primary care providers are trained in recognizing and addressing spinal cord injury-specific needs. SCI providers generally are not trained in addressing all aspects of preventive care. Knowing the recommended preventive care screenings, recognizing and managing specific conditions seen after a SCI, and seamless coordination of care between general practitioners and SCI specialists are some of the interventions to help prevent health complications, decrease morbidity and mortality, improve health outcomes, and promote QOL in this patient population. Prioritized focus on preventive care is necessary for a positive impact on the overall health and QOL in this population. Addressing the knowledge gap reported by primary care providers and SCI providers may help increase the probability of SCI patients getting their preventive and specialty care needs addressed. We present a "cheat sheet" of recommendations for the preventive care evaluation of a person living with a SCI.

Gastroenterology in a New Era of Accountability: Part 3. Accountable Care Organizations

Context/Objective Strategies to combine primary and specialized care are crucial to meet the needs of individuals with spinal cord injury (SCI) located in rural areas. We explored the collaboration between general practitioners (GPs) and SCI specialists who will participate in an intervention study to improve their collaboration. Design A questionnaire survey from August to October 2020. Setting Primary Care, Specialized SCI care. Participants Eight GPs and 13 SCI specialists. Interventions Baseline results from the SCI-Co study. Outcome Measures N/A. Results Overall, satisfaction ratings for the collaboration between GPs and SCI specialists were high, and all physicians agreed that they work together well. Especially, SCI specialists were satisfied in collaborating with GPs. Despite Switzerland’s fragmented primary and secondary care system, only a few physicians reported about issues with delays and waiting lists. While GPs wanted to improve the quality of their referral, most SCI specialists reported being content with it. GPs were also discontent about discharge organization by specialists. Conclusion Satisfaction with collaboration was high, both in GPs and specialists. Areas for improvement include discharge and referral processes.

APA says the method used by the Obama administration for designating primary care providers could negatively affect access to care in ACOs for “dually eligible” individuals and others with serious mental illness.

INTRODUCTION: Cervical spinal cord injury (SCI) results in devastating paralysis. Spinal column injury (i.e., traumatic SCI) may result in worse outcomes as compared to non-traumatic SCI. However, there remains a lack robust data determining the role of traumatic etiology in prognosticating outcomes after cervical SCI. METHODS: From prospective cohort of SCI model systems, we included adult patients >15 years with traumatic SCI, neurological-level C1-C8, ASIA impairment-scale (AIS) A-D, presented within 30-days of SCI. Traumatic SCI was defined as SCI resulting from spinal column injury and non-traumatic SCI was defined as SCI without any spinal column injury. The primary outcome was composite independence in eating, bladder-management, and transfers domains of functional independence measure at 1-year. Each domain ranges from 1-7; lower score indicating greater functional dependence. Composite independence was defined as score of >=6 in at least 2 domains. RESULTS: Between 1992-2016, 853 patients with cervical SCI and complete neurological/functional measures were included. At baseline, 86% (737) had traumatic SCI and 14% (116) had non-traumatic SCI. Patients with traumatic SCI had significantly larger rates of motor-complete SCI (AIS A-B); 71% versus 31% in non-traumatic SCI (p<0.001). At one-year follow-up, non-traumatic SCI had significantly larger recovery rates in FIM functions compared to traumatic SCI; 53% of non-traumatic cervical SCI patients gained composite independence in FIM functions vs. 39% in traumatic cervical SCI (p=0.007). In multivariable regression, after accounting for age, sex, symmetry-of-SCI, and SCI severity by AIS grade, traumatic SCI was not a significant predictor of functional outcome (p=0.47). CONCLUSIONS: Although patients with traumatic SCI present with worse injury severity as compared to non-traumatic SCI. However, both traumatic and non-traumatic cervical SCI have a similar recovery potential. Optimization of clinical pathways is needed to provide appropriate rehabilitation care for patients with cervical SCI.

Study designAn online questionnaire.ObjectivesTo gauge spinal cord injury (SCI) specialists’ assessment of their communications with general practitioners (GPs). To determine whether economic or health-care system-related factors enhance or inhibit such communication.SettingA collaboration of co-authors from a health-care system.MethodsAn online survey interrogating a number of aspects of communication between SCI specialists and GPs was developed, distributed, and made available for 4 months. Responses were analyzed for the entire cohort then according to descriptions of participants’ home nations’ economies and the type of health-care delivery systems in which they work.ResultsA total of 88 responses were submitted. The majority (64%) were from nations with developed economies, a plurality (47.1%) were from countries that offer universal health coverage, and half used a combination of paper and electronic health records. A majority of respondents (61.8%) reported routinely communicating with their patients’ GPs, but most (53.4%) rated those communications as only “fair”. The most commonly listed barriers to communication with GPs were lack of time (46.3%) and a perceived lack of receptivity by GPs (26.9%). Nearly all respondents (91.6%) believed that the care they provide would be enhanced by improved communication with GPs. Participants who used electronic means of communication were more likely to communicate with GPs and to describe those interactions as “positive”.ConclusionsAlthough there are a number of barriers to communication between SCI specialists and GPs, most SCI specialists are eager for such inter-physician communication and believe it would enhance their care they deliver.

doi: 10.1310/sci2201-13 Individuals with spinal cord injury (SCI) often experience complex health problems that, if untreated, can be costly and debilitating. In turn, they are high users of primary care. One study found that, during primary care visits, approximately 80% of the problems mentioned by patients with SCI were related to secondary conditions, such as urinary tract infections, pain, and skin problems. In a study of SCI patients in the Netherlands, over half (52%) of the contact with a primary care doctor was related to secondary conditions, with 34% considered to be preventable. Despite the necessity for quality health care, individuals with SCI face structural and environmental barriers, such as problems with transportation and inaccessible provider offices and equipment; studies have consistently found that these barriers hinder patients with disabilities from receiving needed care, including preventive screenings. Process barriers, such as physician’s lack of SCI knowledge, are also an ongoing problem. One study reported that emergency department (ED) residents displayed appropriate knowledge of 6 serious complications for SCI patients in the ED only 47% of the time. Other studies reported that SCI patients have difficulty finding knowledgeable doctors and feel the need to educate them about their disability. While potentially dangerous, limited provider knowledge can also pose a substantial hurdle for SCI patients in accessing primary health care. Lack of funding and service fragmentation are also cited as major process barriers. In navigating the numerous barriers within the health care system, individuals with SCI often struggle to get their health care needs met. When surveyed, 33% of patients with SCI expressed an unmet primary care need, with greater unmet needs related to lower income and poorer health status. A study of ED use by individuals with traumatic SCI classified half of ED visits as potentially preventable or of low urgency. Every consumer must navigate a complex interplay of socioeconomic, environmental, and physical factors unique to their situation as they try to access quality primary care. While many studies have documented barriers to care and health disparities, as well as recommended systems-level changes, few have focused on the navigation strategies utilized by consumers to effectively get their needs met. A fuller understanding of consumer-level strategies could facilitate the development of effective interventions – which

Background: Although a number of experimental therapies for spinal cord injury (SCI) have recently emerged, few authors have examined the goals of individuals with SCI considering experimental therapies, and none have determined whether sociodemographic and injury-specific characteristics influence that engagement. Objectives: To determine (a) the goals of individuals with SCI who are considering experimental therapies; (b) whether sociodemographic factors, injury-specific characteristics, and concerns over adverse events influence those goals and/or participation in experimental therapies and clinical trials; and (c) whether people with SCI feel they have adequate information about experimental therapies and clinical trials. Methods: An online survey that yielded 364 responses. Results: Most respondents (83.7%) had sought information about experimental therapies, and just under half (47.8%) had received one. The most frequently cited functional goals were improvement in bowel and bladder function and elimination of dysreflexia (60.4%). Several goals were influenced by age and level and completeness of injury, and most respondents (93.4%) wanted more information about experimental therapies. Just over one-third (34.6%) of respondents had participated in a clinical trial, and nearly all (96.9%) wanted more information about them. Having received experimental therapies and participated in clinical trials was positively correlated with seeking SCI-specific care from an SCI specialist rather than from a primary care physician. Most (83.9%) respondents would avoid or be reluctant to engage with a medical center if they were made aware of harm done to trial participants. Conclusion: This work suggests that there are unmet information needs among people with SCI, specifically pertaining to experimental therapies and clinical trials. It also reveals that improved access to SCI specialists may enhance access to novel treatments and research efforts. Being made aware of harm to trial participants may influence the decision of individuals with SCI to seek care at or enroll in trials at these clinical sites.

# Presentation CPSS1: Spinal insufficiency fracture in the geriatric pediatric spine {#article-title-2} Regular corticosteroid has become standard for slowing disease progression in Duchenne muscular dystrophy (DMD). However, patients must contend with the insidious side effect of osteopenia and

Barriers to expanding primary care roles for chiropractors: the role of chiropractic as primary care gatekeeper

A new era of collaboration for primary care and psychiatry.

Cardiovascular disease is the leading cause of death in the United States and accounts for ≈17% of national health expenditures and 30% of Medicare spending.1 Among physician groups and professional societies, cardiologists have been among those leading efforts to create evidence-based guidelines and to measure quality of care. In the post-health reform era, national efforts have expanded beyond quality to include innovative delivery models, such as the patient-centered medical home (PCMH), the medical neighborhood, and accountable care organizations (ACOs). This next generation of care models and the payment strategies that support them incentivize efficiency, patient-centeredness, and care coordination with an emphasis on primary care. We propose strategies for cardiologists to create collaborative opportunities within these new models drawing from examples from around the country within the context of a framework developed by the American College of Physicians.2 Pursuing these approaches or others along similar lines will enable cardiologists to lead and to be active participants in shaping delivery system transformation. These innovative delivery models share similar features. The PCMH is a model of care that emphasizes additional support for primary care providers within a patient-centered team, whereas a medical neighborhood represents a broader collection of primary care doctors, specialists such as cardiologists, hospitals, and other stakeholders within a region that seek to reduce fragmented care by sharing accountability.2,3 The ACO, too, is a broader care delivery arrangement, but in this case, groups of providers are accountable for the quality, cost, and overall care of a particular population, typically defined by the payer. In the Medicare Shared Savings Program (MSSP), an ACO model for Medicare beneficiaries, the ACO can capture shared savings if it reduces its healthcare expenditures and meets certain quality performance standards, nearly half of which are related to cardiovascular disease.4 Within the …