Ambulatory Primary Care Research Articles

The impact of creating vertically integrated organizations on hospital inpatient use

Introduction: One of the most recent important policy reforms in the Portuguese healthcare sector was the creation of seven new vertically integrated organizations, known as Local Health Units (LHU). These organizations are responsible for primary and secondary levels of care, providing comprehensive healthcare services on a population based approach. Currently LHUs cover approximately 12% of the total population and have a global yearly budget of 650 million euros. Theory/ Methods: Despite the lack of evidence about the empirical benefits of integrated care, it is recognized that more integrated organizations achieve improvements on healthcare outcomes. The perceived advantages of creating vertically integrated organizations are: a)the capacity to integrate the decision making process throughout the continuum of care; b)the possibility to encourage health promotion; c) the elimination of redundancies between levels of care, and d) the reduction of more costly interventions. The study focuses on inpatient use due to their high relevance and cost. Therefore, the main objective is to evaluate the impact of creating vertical integrated health care units on inpatient use in Portugal. We selected three inpatient hospital indicators: volume of cases, case-mix index (CMI) and length of stay (LOS). The data source was the national hospital discharge database from 2002 to 2013 (n=15.653.463). 15th International Conference on Integrated Care, Edinburgh, UK, March 25-27, 2015 1 International Journal of Integrated Care – Volume 15, 27 May – URN:NBN:NL:UI:10-1-117107– http://www.ijic.org/ The data was aggregated by Diagnosis Related Group or principal diagnosis, year and hospital/LHU (panel data). The admissions of LHUs’ patients occurring outside the LHU were attributed to the respective hospital. To control the differences between LHUs and non-LHUs time trend, the following difference in difference (DID) models were estimated: 〖LOS〗_gth=β_0+β_1 〖age〗_dht+β_2 〖sex〗_dht+β_3 〖Post〗_dht+β_4 〖ULS〗_dht+β_5 〖ULS〗_dht*〖Post〗_dht+e_dht 〖Volume〗_gth=β_0+β_1 〖age〗_ght+β_2 〖sex〗_ght+β_3 〖Post〗_ght+β_4 〖ULS〗 _ght+β_5 〖ULS〗_ght*〖Post〗_ght+e_ght 〖Casemix〗_th=β_0+β_1 〖age〗_ht+β_2 〖sex〗_ht+β_3 〖Post〗_ht+β_4 〖ULS〗_ht+β_5 〖ULS〗_ht*〖Post〗_ht+e_ht where 〖LOS〗_(g/dth): average length of stay of patients treated in DRG g/principal diagnosis d, hospital/LHU h in year t; 〖Volume〗_gth: total production in DRG g, hospital/LHU h in year t; 〖Casemix〗_th: average casemix in hospital/LHU h in year t; 〖age〗_gth: average patients’ age; 〖sex〗_gth: average patients’ sex; 〖Post〗_ght: Equals 1 in the year of creation of the LHU and henceforth; 〖ULS〗_ght: Equals 1 if LHU; The DID was used to isolate the differences between the LHUs, before and after integration, and all the other non-LHU hospitals. Results: Even though the results are not all statistical significant, it can be sustained that when comparing LHUs and non-LHUs, the hospital inpatient use in the last decade shows a slighter reduction trend in volume of cases and LOS on the LHU universe. This varies between the LHUs. Discussion: The results seem to indicate an improvement on hospital inpatient use in the LHU universe. Several arguments can contribute to explain these results, increased access, better primary care or shifting treatment to ambulatory care. The results may also reflect undesired situations as inadequate inpatient practices, or lack of access. The explanation is therefore complex and multifactorial. Lessons Learned: Despite there is more perception than evidence concerning integrated care results, in this case, there is evidence of a favorable change in the behavior of LHUs in inpatient use (measured by volume of cases, CMI and LOS) when compared with non-LHUs. Limitations and suggestions for future research: The LHUs have different times of existence. The results could therefore be biased due to the different maturity of the integration process. In fact, previous studies indicate differences on the degree of integration of the LHUs (as perceived by their staff), specifically in the important clinical and information integration dimensions. This study focused on inpatient use mainly due to ease of access to the information. To understand the big picture, future studies should analyze the time trend evolution of ambulatory care and primary care, or other important dimensions like quality of care or access to healthcare facilities. Conclusion: The recent development of the LHU model in Portugal is an example of vertically integrated organizations. The main objective of the study was to evaluate the impact of creating vertical integrated health care units on hospital inpatient use. A panel data for the last decade was uses and a DID method operationalized the study. The LHUs reduced the hospital inpatient use after integration, when compared with non-LHU hospitals. Further investigation should be performed to understand the causes of these findings. 15th International Conference on Integrated Care, Edinburgh, UK, March 25-27, 2015 2 International Journal of Integrated Care – Volume 15, 27 May – URN:NBN:NL:UI:10-1-117107– http://www.ijic.org/

Management of Polypharmacy in Dialysis Patients.

Most patients receiving dialysis have other common chronic conditions in addition to end-stage renal disease, including hypertension, diabetes, cardiovascular disease, and mineral and bone disorder, all of which require long-term medication management. Dialysis patients take an average of 10-12 prescribed and over-the-counter medications from an average of 4.7 prescribers, and an average of 19 pills per day. Thus, reducing polypharmacy is not adequate as a medication therapy goal for these patients. Instead, the dialysis community should focus on ensuring that all patients receive medications that are appropriate, effective, safe and convenient. Barriers to this include a fragmented health care system with inadequate communication between multiple prescribers and pharmacies, and frequent care transitions between ambulatory care sites (dialysis centre, ambulatory primary care practice, ambulatory specialty practice) and the hospital, skilled nursing facility or long-term care facility. Three distinct processes are necessary to prevent and solve the resultant medication-related problems (and reduce polypharmacy). These are medication reconciliation (creating an accurate medication list that reflects all medications the patients is taking and how they are being taken), medication review (evaluating the list for appropriateness, effectiveness, safety and convenience in conjunction with the patient's health status), and ongoing patient-centred medication therapy management (e.g., developing treatment plans centred on each patient's medication-related goals). A team approach including pharmacists as part of the dialysis team with the dialysis facility as the primary medication home is needed.

Estimating the residency expansion required to avoid projected primary care physician shortages by 2035.

The purpose of this study was to calculate the projected primary care physician shortage, determine the amount and composition of residency growth needed, and estimate the impact of retirement age and panel size changes. We used the 2010 National Ambulatory Medical Care Survey to calculate utilization of ambulatory primary care services and the US Census Bureau to project demographic changes. To determine the baseline number of primary care physicians and the number retiring at 66 years, we used the 2014 American Medical Association Masterfile. Using specialty board and American Osteopathic Association figures, we estimated the annual production of primary care residents. To calculate shortages, we subtracted the accumulated primary care physician production from the accumulated number of primary care physicians needed for each year from 2015 to 2035. More than 44,000 primary care physicians will be needed by 2035. Current primary care production rates will be unable to meet demand, resulting in a shortage in excess of 33,000 primary care physicians. Given current production, an additional 1,700 primary care residency slots will be necessary by 2035. A 10% reduction in the ratio of population per primary care physician would require more than 3,000 additional slots by 2035, whereas changing the expected retirement age from 66 years to 64 years would require more than 2,400 additional slots. To eliminate projected shortages in 2035, primary care residency production must increase by 21% compared with current production. Delivery models that shift toward smaller ratios of population to primary care physicians may substantially increase the shortage.

Laboratory Medicine Handoff Gaps Experienced by Primary Care Practices: A Report from the Shared Networks of Collaborative Ambulatory Practices and Partners (SNOCAP)

The majority of errors in laboratory medicine testing are thought to occur in the pre- and postanalytic testing phases, and a large proportion of these errors are secondary to failed handoffs. Because most laboratory tests originate in ambulatory primary care, understanding the gaps in handoff processes within and between laboratories and practices is imperative for patient safety. Therefore, the purpose of this study was to understand, based on information from primary care practice personnel, the perceived gaps in laboratory processes as a precursor to initiating process improvement activities. A survey was used to assess perceptions of clinicians, staff, and management personnel of gaps in handoffs between primary care practices and laboratories working in 21 Colorado primary care practices. Data were analyzed to determine statistically significant associations between categorical variables. In addition, qualitative analysis of responses to open-ended survey questions was conducted. Primary care practices consistently reported challenges and a desire/need to improve their efforts to systematically track laboratory test status, confirm receipt of laboratory results, and report results to patients. Automated tracking systems existed in roughly 61% of practices, and all but one of those had electronic health record-based tracking systems in place. One fourth of these electronic health record-enabled practices expressed sufficient mistrust in these systems to warrant the concurrent operation of an article-based tracking system as backup. Practices also reported 12 different procedures used to notify patients of test results, varying by test result type. The results highlight the lack of standardization and definition of roles in handoffs in primary care laboratory practices for test ordering, monitoring, and receiving and reporting test results. Results also identify high-priority gaps in processes and the perceptions by practice personnel that practice improvement in these areas is needed. Commonalities in these areas warrant the development and support of tools for use in primary care settings.

Improving Quality and Safety through Human Factors Collaborations with Healthcare

Multiple reports from the Institute of Medicine and the National Academy of Engineering, (IOM 2001; Reid et al., 2005; Kaplan et al., 2013) have called for the use of human factors engineering (HFE) and systems engineering principles and methods/tools to improve health care delivery. Yet, the integration of engineers into health care settings and the education of clinicians and other health care professionals on human factors and systems engineering principles and methods/tools remain in its infancy. A recent editorial by Xiao and Fairbanks (2011), discusses a small, but growing presence of professionals who are “bilingual” in both human factors and medicine. Indeed, Carayon (2011) identified human factors as an innovation that will require diffusion into healthcare through the use of HFE methods and tools, increasing the health care professional knowledge of HFE, and the hiring HFEs in healthcare organizations. To achieve the goal of integration, there will be many “models” of healthcare – human factors collaborations, from experts working together from their different ‘silos’ to true bilingualism. SEIPS, the Systems Engineering Initiative for Patient Safety (Carayon et al., 2006), aims to integrate human factors and systems engineering with healthcare disciplines. Our panel of SEIPS-affiliated engineers and healthcare professionals represents many different types of collaborations across this spectrum and their work spans multiple healthcare settings and disciplines, including: ambulatory primary care, inpatient pediatrics, community pharmacy, and oncology.

Effects of computer-aided clinical decision support systems in improving antibiotic prescribing by primary care providers: a systematic review.

To assess the effectiveness of computer-aided clinical decision support systems (CDSS) in improving antibiotic prescribing in primary care. A literature search utilizing Medline (via PubMed) and Embase (via Embase) was conducted up to November 2013. Randomized controlled trials (RCTs) and cluster randomized trials (CRTs) that evaluated the effects of CDSS aiming at improving antibiotic prescribing practice in an ambulatory primary care setting were included for review. Two investigators independently extracted data about study design and quality, participant characteristics, interventions, and outcomes. Seven studies (4 CRTs, 3 RCTs) met our inclusion criteria. All studies were performed in the USA. Proportions of eligible patient visits that triggered CDSS use varied substantially between intervention arms of studies (range 2.8-62.8%). Five out of seven trials showed marginal to moderate statistically significant effects of CDSS in improving antibiotic prescribing behavior. CDSS that automatically provided decision support were more likely to improve prescribing practice in contrast to systems that had to be actively initiated by healthcare providers. CDSS show promising effectiveness in improving antibiotic prescribing behavior in primary care. Magnitude of effects compared to no intervention, appeared to be similar to other moderately effective single interventions directed at primary care providers. Additional research is warranted to determine CDSS characteristics crucial to triggering high adoption by providers as a perquisite of clinically relevant improvement of antibiotic prescribing.

Association between hospitalisation for chronic disease related ambulatory care sensitive conditions and primary health care resourcing

Association between hospitalisation for chronic disease related ambulatory care sensitive conditions and primary health care resourcing

Risk scoring and thromboprophylactic treatment of patients with atrial fibrillation with and without access to primary healthcare data: Experience from the Stockholm health care system

BackgroundEarlier validation studies of risk scoring by CHA2DS2VASc for assessments of appropriateness of warfarin treatment in patients with atrial fibrillation have been performed solely with diagnoses recorded in hospital based care, even though many patients to a large extent are managed in primary care. MethodsCross-sectional registry study of all 43 353 patients with a diagnosis of non-valvular atrial fibrillation recorded in inpatient care, specialist ambulatory care or primary care in the Stockholm County during 2006–2010. ResultsThe mean CHA2DS2VASc score was 3.82 (4.67 for women and 3.14 for men). 64% of the entire cohort of patients with atrial fibrillation had the diagnosis in primary care (12% only there). The mean CHA2DS2VASc score of patients with a diagnosis only in inpatient care or specialist ambulatory care increased from 3.63 to 3.83 when comorbidities registered in primary care were added. In 2010 warfarin prescriptions were claimed by 47.2%, and ASA by 41.6% of the entire cohort. 34% of patients with CHA2DS2VASc=1 and 20% with CHA2DS2VASc=0 had warfarin treatment. ASA was more frequently used instead of warfarin among women and elderly patients. ConclusionsRegistry CHA2DS2VASc scores were underestimated without co-morbidity data from primary care. Many individuals with scores 0 and 1 were treated with warfarin, despite poor documentation of clinical benefit. In contrast, warfarin appears to be underused and ASA overused among high risk atrial fibrillation patients. Lack of diagnoses from primary care underestimated CHA2DS2VASc scores and may thereby have overestimated treatment benefits in low-risk patients in earlier studies.

A systematic review of evidence on the association between hospitalisation for chronic disease related ambulatory care sensitive conditions and primary health care resourcing

BackgroundPrimary health care is recognised as an integral part of a country’s health care system. Measuring hospitalisations, that could potentially be avoided with high quality and accessible primary care, is one indicator of how well primary care services are performing. This review was interested in the association between chronic disease related hospitalisations and primary health care resourcing.MethodsStudies were included if peer reviewed, written in English, published between 2002 and 2012, modelled hospitalisation as a function of PHC resourcing and identified hospitalisations for type 2 diabetes as a study outcome measure. Access and use of PHC services were used as a proxy for PHC resourcing. Studies in populations with a predominant user pay system were excluded to eliminate patient financial barriers to PHC access and utilisation. Articles were systematically excluded based on the inclusion criteria, to arrive at the final set of studies for review.ResultsThe search strategy identified 1778 potential articles using EconLit, Medline and Google Scholar databases. Ten articles met the inclusion criteria and were subject to review. PHC resources were quantified by workforce (either medical or nursing) numbers, number of primary care episodes, service availability (e.g. operating hours), primary care practice size (e.g. single or group practitioner practice—a larger practice has more care disciplines onsite), or financial incentive to improve quality of diabetes care. The association between medical workforce numbers and ACSC hospitalisations was mixed. Four of six studies found that less patients per doctor was significantly associated with a decrease in ambulatory care sensitive hospitalisations, one study found the opposite and one study did not find a significant association between the two. When results were categorised by PHC access (e.g. GPs/capita, range of services) and use (e.g. n out-patient visits), better access to quality PHC resulted in fewer ACSC hospitalisations. This finding remained when only studies that adjusted for health status were categorised. Financial incentives to improve the quality of diabetes care were associated with less ACSC hospitalisations, reported in one study.ConclusionSeven of 12 measures of the relationship between PHC resourcing and ACSC hospitalisations had a significant inverse association. As a collective body of evidence the studies provide inconclusive support that more PHC resourcing is associated with reduced hospitalisation for ACSC. Characteristics of improved or increased PHC access showed inverse significant associations with fewer ACSC hospitalisations after adjustment for health status. The varied measures of hospitalisation, PHC resourcing, and health status may contribute to inconsistent findings among studies and make it difficult to interpret findings.

Provider Specialty and Atrial Fibrillation Treatment Strategies in United States Community Practice: Findings From the ORBIT‐AF Registry

BackgroundThe prevalence of atrial fibrillation (AF) continues to increase; however, there are limited data describing the division of care among practitioners in the community and whether care differs depending on provider specialty.Methods and ResultsUsing the Outcomes Registry for Better Informed Treatment of AF (ORBIT‐AF) Registry, we described patient characteristics and AF management strategies in ambulatory clinic practice settings, including electrophysiology (EP), general cardiology, and primary care. A total of 10 097 patients were included; of these, 1544 (15.3%) were cared for by an EP provider, 6584 (65.2%) by a cardiology provider, and 1969 (19.5%) by an internal medicine/primary care provider. Compared with those patients who were cared for by cardiologists or internal medicine/primary care providers, patients cared for by EP providers were younger (median age, 73 years [interquartile range, IQR, 64, 80 years, Q1, Q3] versus 75 years [IQR, 67, 82 years] for cardiology and versus 76 years [IQR, 68, 82 years] for primary care). Compared with cardiology and internal medicine/primary care providers, EP providers used rhythm control (versus rate control) management more often (44.2% versus 29.7% and 28.8%, respectively, P<0.0001; adjusted odds ratio [OR] EP versus cardiology, 1.66 [95% confidence interval, CI, 1.05 to 2.61]; adjusted OR for internal medicine/primary care versus cardiology, 0.91 [95% CI, 0.65 to 1.26]). Use of oral anticoagulant therapy was high across all providers, although it was higher for cardiology and EP providers (overall, 76.1%; P=0.02 for difference between groups).ConclusionsOur data demonstrate important differences between provider specialties, the demographics of the AF patient population treated, and treatment strategies—particularly for rhythm control and anticoagulation therapy.

Improving evidence-based primary care for chronic kidney disease: study protocol for a cluster randomized control trial for translating evidence into practice (TRANSLATE CKD).

BackgroundChronic kidney disease (CKD) and end stage renal disease (ESRD) are steadily increasing in prevalence in the United States. While there is reasonable evidence that specific activities can be implemented by primary care physicians (PCPs) to delay CKD progression and reduce mortality, CKD is under-recognized and undertreated in primary care offices, and PCPs are generally not familiar with treatment guidelines. The current study addresses the question of whether the facilitated TRANSLATE model compared to computer decision support (CDS) alone will lead to improved evidence-based care for CKD in primary care offices.Methods/DesignThis protocol consists of a cluster randomized controlled trial (CRCT) followed by a process and cost analysis. Only practices providing ambulatory primary care as their principal function, located in non-hospital settings, employing at least one primary care physician, with a minimum of 2,000 patients seen in the prior year, are eligible. The intervention will occur at the cluster level and consists of providing CKD-specific CDS versus CKD-specific CDS plus practice facilitation for all elements of the TRANSLATE model. Patient-level data will be collected from each participating practice to examine adherence to guideline-concordant care, progression of CKD and all-cause mortality. Patients are considered to meet stage three CKD criteria if at least two consecutive estimated glomerular filtration rate (eGFR) measurements at least three months apart fall below 60 ml/min. The process evaluation (cluster level) will determine through qualitative methods the fidelity of the facilitated TRANSLATE program and find the challenges and enablers of the implementation process. The cost-effectiveness analysis will compare the benefit of the intervention of CDS alone against the intervention of CDS plus TRANSLATE (practice facilitation) in relationship to overall cost per quality adjusted years of life.DiscussionThis study has three major innovations. First, this study adapts the TRANSLATE method, proven effective in diabetes care, to CKD. Second, we are creating a generalizable CDS specific to the Kidney Disease Outcome Quality Initiative (KDOQI) guidelines for CKD. Additionally, this study will evaluate the effects of CDS versus CDS with facilitation and answer key questions regarding the cost-effectiveness of a facilitated model for improving CKD outcomes. The study is testing virtual facilitation and Academic detailing making the findings generalizable to any area of the country.Trial registration Registered as NCT01767883 on clinicaltrials.gov NCT01767883

Risk scoring and thromboprophylactic treatment of patients with atrial fibrillation with and without access to primary healthcare data: experience from the Stockholm health care system

Purpose: To evaluate the CHA2DS2VASc-scores and thromboprophylactic treatment in patients with atrial fibrillation using diagnoses not only from inpatient care and specialist ambulatory care, but also from primary care in the Stockholm region. Methods: Cross-sectional registry study of 43 353 patients with a record of non-valvular atrial fibrillation in inpatient care, specialist ambulatory care or primary care in the Stockholm County Council diagnosed during 2006-2010. Results: The mean CHA2DS2VASc score was 3.82 (4.67 for women and 3.14 for men). 64% of the entire cohort of patients with atrial fibrillation had the diagnosis in primary care (12% only there). The mean CHA2DS2VASc score of patients with a diagnosis only in inpatient or specialist ambulatory care increased from 3.63 to 3.83 when comorbidities registered in primary care were added. In 2010 warfarin prescriptions were claimed by 47.2%, and ASA by 41.6% of the entire cohort. 34% of patients with CHA2DS2VASc =1 and 20% with CHA2DS2VASc = 0 had warfarin treatment. Tabel 1. Co-morbidities among patients with and without diagnoses from primary care Mean percantages (95% Confidence Intervals). Conclusions: Registry CHA2DS2VASc scores underestimated the risk without co-morbidity data from primary care. Relatively many individuals with scores 0 and 1 were treated with warfarin, despite poor documentation for clinical benefit among such patients. On the other hand, warfarin appears to be underused among high risk atrial fibrillation patients. Lack of co-morbidity diagnoses from primary care may have underestimated CHA2DS2VASc scores and thereby overestimated treatment benefits in low-risk patients in earlier studies.

Primary care patient characteristics associated with completion of 6-month buprenorphine treatment

BackgroundOpioid addiction is prevalent in the United States. Detoxification followed by behavioral counseling (abstinence-only approach) leads to relapse to opioids in most patients. An alternative approach is substitution therapy with the partial opioid receptor agonist buprenorphine, which is used for opioid maintenance in the primary care setting. This study investigated the patient characteristics associated with completion of 6-month buprenorphine/naloxone treatment in an ambulatory primary care office. MethodsA retrospective chart review of 356 patients who received buprenorphine for treatment of opioid addiction was conducted. Patient characteristics were compared among completers and non-completers of 6-month buprenorphine treatment. ResultsOf the 356 patients, 127 (35.7%) completed 6-month buprenorphine treatment. Completion of treatment was associated with counseling attendance and having had a past injury. ConclusionsFuture research needs to investigate the factors associated with counseling that influenced this improved outcome. Patients with a past injury might suffer from chronic pain, suggesting that buprenorphine might produce analgesia in addition to improving addiction outcome in these patients, rendering them more likely to complete 6-month buprenorphine treatment. Further research is required to test this hypothesis. Combination of behavioral and medical treatment needs to be investigated for primary care patients with opioid addiction and chronic pain.

P2.155 Adherence Matters: A Patient-Centered Adherence Strategy to Achieve Maximum Health and Quality of Life Outcomes For Persons Living With HIV/AIDS in Plainfield, New Jersey

BackgroundNeighborhood Health Services Corporation (NHSC), an urban community-based not-for-profit ambulatory primary care health centre located in Plainfield, New Jersey, USA, provides HIV care and treatment services to over 350 uninsured,...

Variations in antibiotic prescribing of acute rhinosinusitis in United States ambulatory settings.

To identify variations in antibiotic treatment of acute rhinosinusitis (ARS) on a national level. Cross-sectional study of a national database. Otolaryngology and primary care ambulatory settings. A nationally representative sample of adult outpatient visits was extracted from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Care Survey data for 2006 to 2009. Antibiotic prescriptions associated with ARS were tabulated. Statistical analyses were conducted to identify variations in antibiotic prescribing by patient and physician characteristics. Antibiotics were prescribed in 82.3% ± 2.6% of 18.7 million visits for ARS (mean age, 46.2 years; 65.9% female). The ratio of primary care physician (PCP) to otolaryngologist (ENT) ARS visits was 18.6:1. Antibiotic prescription rates were inversely related to increasing age groups of 18 to 39, 40 to 64, and ≥ 65 years (87.8%, 81.2%, and 71.0%, respectively; P = .02). Physicians in general medicine outpatient departments, internal medicine, and family medicine were more likely to prescribe antibiotics compared with ENTs (adjusted odds ratio [OR], 7.9 [95% confidence interval (CI), 3.5-17.8]; 6.9 [2.5-19.2]; and 3.9 [2.0-7.7], respectively). The most commonly prescribed antibiotics were azithromycin, amoxicillin, and amoxicillin/clavulanate acid (27.5%, 15.5%, and 14.6%, respectively). The ENTs selected broad-spectrum antibiotics more often than PCPs (94.3% vs 75.7% of visits with antibiotics were broad-spectrum agents; P = .01). Antibiotics were prescribed frequently despite recent consensus guidelines that discourage antibiotic use in mild cases. Furthermore, antibiotic prescription was more likely for younger patients and in primary care settings. This highlights the need to promote awareness of practice guidelines.

Sex- and age-specific trends in antibiotic resistance patterns of Escherichia coli urinary isolates from outpatients

BackgroundUrinary tract infections (UTIs) are one of the most common infections treated in ambulatory care settings, however the epidemiology differs by age and sex. The incidence of UTI is far greater in females than males, and infection in pediatric patients is more often due to anatomical abnormalities. The purpose of this research was to describe age- and sex-specific trends in antibiotic susceptibility to common urinary anti-infectives among urinary isolates of Escherichia coli from ambulatory primary care patients in a regional health maintenance organization.MethodsClinical microbiology data were collected for all urine cultures from patients with visits to primary care clinics in a regional health maintenance organization between 2005 and 2010. The first positive culture for E. coli tested for antibiotic susceptibilities per patient per year was included in the analysis dataset. The frequency of susceptibility to ampicillin, amoxicillin-clavulanate, ciprofloxacin, nitrofurantoin, and trimethoprim/sulfamethoxazole (TMP/SMX) was calculated for male and female patients. The Cochrane-Mantel-Haenzel test was used to test for differences in age-stratified susceptibility to each antibiotic between males and females.ResultsA total of 43,493 E. coli isolates from 34,539 unique patients were identified for study inclusion. After stratifying by age, E. coli susceptibility to ampicillin, amoxicillin-clavulanate, ciprofloxacin, and nitrofurantoin differed significantly between males and females. However, the magnitude of the differences was less than 10% for all strata except amoxicillin-clavulanate susceptibility in E. coli isolated from males age 18–64 compared to females of the same age.ConclusionsWe did not observe clinically meaningful differences in antibiotic susceptibility to common urinary anti-infectives among E. coli isolated from males versus females. These data suggest that male sex alone should not be used as an indication for empiric use of second-line broad-spectrum antibiotic agents for the treatment of UTIs.

The growth and composition of primary and community-based care services. Metrics and evidence from the Italian National Health Service

BackgroundOver the past few decades, in OECD countries there has been a general growing trend in the prevalence of out-of-hospital healthcare services, but there is a general lack of data on the use of these services.MethodsWe defined a list of 303 indicators related to primary and community healthcare services in collaboration with 13 Italian Local Health Authorities (LHAs). Then, for each LHA, we collected and analyzed these indicators for two different years (2003 and 2007).ResultsOut-of-hospital care absorbs 56% of all costs in our sample of LHAs. Expenditure on outpatients’ visits to specialists and on diagnostic examinations accounts for 13% of the costs, while spending on primary care (including prevention and public health) accounts for 9%, and for intermediate structures (including those related to rehabilitation, elderly people, disabled people, and mental health) the figure is 11%. Different Italian LHAs have made different strategic choices with respect to primary and community-based care (PCC).ConclusionsTwo distinct strategic orientations in the adoption of PCC services by LHAs has emerged from our study. The first has been an investment mainly in ambulatory and home-based primary care services in order to increase the number of low-complexity settings. A second strategy has prioritized the allocation of resources to intermediate inpatient structures for specific types of patients, namely elderly and disabled people, post-acute patients in need of rehabilitation and long-term care, and patients in hospices.

Simplifier le dépistage de la dénutrition du sujet âgé en médecine générale : test de concordance entre un outil simple, le « Malnutrition Universal Screening Tool » (« MUST ») et le « Mini Nutritional Assessment-Short Form » (« MNA-SF »)

ObjectiveThe main goal of this study is to assess how results from two clinical tools, the Mini Nutritional Assessment-Short Form (MNA-SF) and the Malnutrition Universal Screening Tool (MUST), correlate in the framework of nutritional status evaluation of elderly under ambulatory care. Additionally, determinants of nutritional risk have been analyzed. MethodsThe evaluation of a multicentric diagnostic test has been carried out with 81 patients over 70-years-old, while consulting at their general practitioner's office, or at home. For each patient, MUST and MNA-SF scores were calculated and compared with the kappa coefficient. Subjects were classified into two groups according to the absence or presence of nutritional risk. Univariate comparative analyses were realized between MUST and MNA-SF data. ResultsRespectively, MNA-SF and MUST screened 33.3% and 18.5% of the patients at nutritional risk. Consistency between both tools was moderate: κ=0.438±0.2058. Compared with subjects at nutritional risk, patients with a good nutritional status were younger, took less drugs, their body mass index was higher (for a limit at 23), they were less lonely and tended to have a higher weight. ConclusionsMUST isn’t a satisfying screening tool of elderly malnutrition in ambulatory primary care. Thus, MNA-SF remains the gold standard.

Prevalence of Diagnosed Sleep Apnea Among Patients With Type 2 Diabetes in Primary Care

Although up to 90% of patients with type 2 diabetes mellitus (T2DM) have obstructive sleep apnea (OSA), the rate at which primary care providers diagnose OSA in patients with diabetes has not been assessed. A retrospective, population-based, multiclinic study was performed to determine the proportion of patients with T2DM managed in primary care clinics who were given a diagnosis of OSA and to identify factors associated with an OSA diagnosis. Electronic health records of adult patients with a diagnosis of T2DM were reviewed for a coexisting diagnosis of OSA, and the diagnostic prevalence of OSA was compared with the expected prevalence. A total of 16,066 patients with diabetes with one or more primary care office visits in 27 primary care ambulatory practices during an 18-month period from 2009 to 2010 were identified. Analysis revealed that 18% of the study population received an OSA diagnosis, which is less than the 54% to 94% prevalence reported previously. The 23% prevalence of OSA among obese study patients was lower than the expected 87% prevalence. In a logistic model, male sex, BMI, several chronic conditions, and lower low-density lipoprotein levels and hemoglobin A1c identified patients more likely to carry an OSA diagnosis (likelihood ratio, χ(2) = 1,713; P < .0001). Primary care providers underdiagnose OSA in patients with T2DM. Obese men with comorbid chronic health conditions are more likely to receive a diagnosis of OSA. Efforts to improve awareness of the association of OSA with T2DM and to implement OSA screening tools should target primary care physicians.

Effect of Comorbid Depression on Outcomes in Diabetes and Its Relationship to Quality of Care and Patient Adherence

To determine whether current depression was associated with poorer quality of care and poorer patient adherence to treatment regimens and whether current depression was associated with patient diabetes outcomes independent of its relationships to quality of care and patient adherence among patients with diabetes. This study was conducted in the offices of family physicians who belong to the Statewide Primary Care Ambulatory Research and Resources Consortium from March 2006 to March 2011. Seven primary care physicians enrolled 10 to 20 English- or Spanish-speaking patients with diabetes presenting for routine follow-up visits. Subjects included 106 patients who completed a questionnaire documenting their depressive symptoms, compliance with diabetes therapy, diabetes-related quality of life, and patient satisfaction. The physicians completed a 4-item questionnaire concerning whether the patient had depression and any depression treatments that they ordered. All questions were answered either "yes" or "no." A practice research coordinator evaluated the quality of diabetes care provided and ordered hemoglobin A(1c) (HbA(1c)) testing for the patient. Depression was associated with poorer compliance, quality of care, diabetes-related quality of life, and patient satisfaction; only HbA(1c) levels did not correlate with depression. When adjusting for compliance and quality of care, depression was still associated with poorer quality of life and satisfaction (P ≤ .001). While physician recognition and treatment of depression were less than optimal, depression severity was a significant predictor of receiving some form of mental health intervention (P ≤ .05) except for the provision of mental health counseling. Poor diabetes control was associated with the provision of counseling (P ≤ .10), while poor quality of life was associated with recognition of depression (P ≤ .10). Depression was independently associated with satisfaction and quality of life but not diabetes control. Although depression severity was an important predictor of depression recognition and treatment, poor quality of life was a predictor of recognition, and poor diabetes control was a predictor of receiving mental health counseling.