Care Practice-based Research Network Research Articles

Changes in analgesic prescriptions in Dutch general practice

Background Increases in opioid prescriptions have been described; however, recent trends and prescribing patterns of analgesics in Dutch general practice are largely unknown. Objective To investigate recent changes in the number of analgesic prescriptions, and the indications for prescribing strong opioids. Furthermore, we aim to identify risk factors for chronic opioid use in Dutch general practice. Design and setting A retrospective cohort study from 1 July 2013 to 31 June 2022, using a primary care practice based research network. Subjects Patients with ≥1 prescription for analgesics during the study period were included. Main outcome measure Changes in the number of prescriptions for paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs) and opioids in Dutch general practice during the 9-year study period. Moreover, we analyzed indications for prescribing strong opioids by the general practitioner (GP). Results A total of 18,433 analgesic users were identified. Over time, prescriptions for paracetamol, NSAIDs and weak opioids decreased, while the number of strong opioid prescriptions increased. General practitioners prescribed more strong opioids for non-malignant pain, whereas prescriptions for malignant pain remained stable over time. Risk factors for chronic opioid use (≥90 days) included older age, lower educational level, smoking status and having a history of a musculoskeletal or psychological disorder, a malignancy or sexual, physical or psychological abuse. Conclusions Considering the increase in strong opioid prescriptions for benign conditions, GPs need to be vigilant for patients who are at risk for chronic use. Regular monitoring and awareness for psychosocial factors in treatment of chronic pain may be key in preventing harms associated with persistent opioid use.

Discriminative Accuracy of the CAPTURE Tool for Identifying Chronic Obstructive Pulmonary Disease in US Primary Care Settings

Chronic obstructive pulmonary disease (COPD) is underdiagnosed in primary care. To evaluate the operating characteristics of the CAPTURE (COPD Assessment in Primary Care To Identify Undiagnosed Respiratory Disease and Exacerbation Risk) screening tool for identifying US primary care patients with undiagnosed, clinically significant COPD. In this cross-sectional study, 4679 primary care patients aged 45 years to 80 years without a prior COPD diagnosis were enrolled by 7 primary care practice-based research networks across the US between October 12, 2018, and April 1, 2022. The CAPTURE questionnaire responses, peak expiratory flow rate, COPD Assessment Test scores, history of acute respiratory illnesses, demographics, and spirometry results were collected. Undiagnosed COPD. The primary outcome was the CAPTURE tool's sensitivity and specificity for identifying patients with undiagnosed, clinically significant COPD. The secondary outcomes included the analyses of varying thresholds for defining a positive screening result for clinically significant COPD. A positive screening result was defined as (1) a CAPTURE questionnaire score of 5 or 6 or (2) a questionnaire score of 2, 3, or 4 together with a peak expiratory flow rate of less than 250 L/min for females or less than 350 L/min for males. Clinically significant COPD was defined as spirometry-defined COPD (postbronchodilator ratio of forced expiratory volume in the first second of expiration [FEV1] to forced vital capacity [FEV1:FVC] <0.70 or prebronchodilator FEV1:FVC <0.65 if postbronchodilator spirometry was not completed) combined with either an FEV1 less than 60% of the predicted value or a self-reported history of an acute respiratory illness within the past 12 months. Of the 4325 patients who had adequate data for analysis (63.0% were women; the mean age was 61.6 years [SD, 9.1 years]), 44.6% had ever smoked cigarettes, 18.3% reported a prior asthma diagnosis or use of inhaled respiratory medications, 13.2% currently smoked cigarettes, and 10.0% reported at least 1 cardiovascular comorbidity. Among the 110 patients (2.5% of 4325) with undiagnosed, clinically significant COPD, 53 had a positive screening result with a sensitivity of 48.2% (95% CI, 38.6%-57.9%) and a specificity of 88.6% (95% CI, 87.6%-89.6%). The area under the receiver operating curve for varying positive screening thresholds was 0.81 (95% CI, 0.77-0.85). Within this US primary care population, the CAPTURE screening tool had a low sensitivity but a high specificity for identifying clinically significant COPD defined by presence of airflow obstruction that is of moderate severity or accompanied by a history of acute respiratory illness. Further research is needed to optimize performance of the screening tool and to understand whether its use affects clinical outcomes.

Association of Late Preterm Birth and Size for Gestational Age With Cardiometabolic Risk in Childhood

The long-term cardiometabolic consequences of late preterm birth (34-36 weeks' gestation) are not well understood. To assess whether late preterm birth and size for gestational age are associated with cardiometabolic risk (CMR) in childhood. This retrospective cohort study included 1742 children born in Ontario, Canada, between April 1, 2006, and September 30, 2014, and followed up until September 30, 2019. Data from children enrolled in The Applied Research Group for Kids (TARGet Kids!) primary care practice-based research network were linked to administrative health care data at ICES (formerly known as the Institute for Clinical Evaluative Sciences). Participants were excluded if they had conditions affecting growth (eg, failure to thrive or cystic fibrosis), any acute or chronic conditions (other than asthma and high-functioning autism), severe developmental delay, or families who were unable to communicate in English. Late preterm birth, gestational age as a continuous measure, and size for gestational age. The primary outcome was composite CMR score (overall age- and sex-standardized z score of CMR components, including waist circumference, log triglyceride level, glucose level, systolic blood pressure, and high-density lipoprotein cholesterol level). Secondary outcomes were the individual CMR components. Multivariable linear regression analysis was used to separately evaluate the associations of late preterm birth, continuous gestational age, and size for gestational age with CMR at ages 3 to 12 years. Among 2440 eligible children, 1742 (mean [SD] age, 5.6 [2.2] years; 951 boys [54.6%]) were included in the final cohort. Overall, 87 children (5.0%) were born moderately preterm (<34 weeks' gestation), 145 (8.3%) were born late preterm (34-36 weeks' gestation), 455 (26.1%) were born early term (37-38 weeks' gestation), and 1055 (60.6%) were born full term (≥39 weeks' gestation). Compared with children born full term, those born moderately preterm (adjusted β = 0.50; 95% CI, 0.24-0.75) and late preterm (adjusted β = 0.27; 95% CI, 0.06-0.47) had higher CMR scores. Each additional gestational week was associated with a 0.06 U (adjusted β; 95% CI, -0.08 to -0.03 U) decrease in CMR. In this study, children born late preterm and moderately preterm had higher CMR. These results suggest that screening and early-life interventions for these children may prevent cardiometabolic outcomes.

Practice Transformation: Using Team-Based Care Training to Improve Diabetes Outcomes

Background: One of the key factors of the patient-centered medical home (PCMH) transformation require shifting mental models at the individual level and culture change at the practice level on how clinicians and support staff work together. This culture shift requires a reeducation on the roles and communication strategies within the medical practice. The objective of this project was to implement a team-based care training program based on the AHRQ TeamSTEPPS framework in 6 primary care practices affiliated with a Primary Care Practice Based Research Network to increase communication and performance of the care teams. Methods: Clinicians and staff from these sites received external facilitation by a certified TeamSTEPPS master trainer, who is a physician specializing in diabetes care, over a 1-year period. An analysis of their established diabetes patients’ hemoglobin A1c and low-density lipoprotein cholesterol before the training program and posttraining was performed using the paired t test and verified using the Wilcoxon sign rank test. Results: There was a statistically significant decrease in the mean hemoglobin A1c levels from 7.48% to 7.32% (P < .001) and low-density lipoprotein cholesterol from 92.34 to 88.34 mg/dL (P = .002) for all the practices combined but only 3 practices saw significant improvement individually. Conclusions: Even though the practices participating in this training are PCMHs and are part of a larger primary care network, they have achieved different levels of success, partly due to leadership and buy-in by staff. Practice leaders and team members need to fully embrace team care concepts and continuously monitor teamwork experiences to support effective team-based care.

46: Longitudinal Follow-Up of Temperament and Nutrition Risk in Preschool Children

Nutrition plays an essential role in the growth and development, school-readiness and well-being of children. Temperament is defined as constitutionally based individual differences in reactivity and self-regulation. While temperament tends to be relatively stable over time, there is evidence that links between early temperament and child health outcomes are malleable. Temperament is increasingly recognized as an early childhood behavioral risk factor, and may impact screen time use, outdoor play and childhood obesity. The relationship between temperament and child nutrition is however less clear. The primary objective is to investigate if early temperament factors in preschool aged children are associated with later nutritional risk. The secondary objective is to examine the relationship between early temperament and later dietary intake and eating behaviour. Longitudinal data was collected through a primary care practice based research network (TARGet Kids!). At each visit nutritional risk was assessed with the total score of the Nutrition Screening Tool for Every Preschooler (NutriSTEP®) and its dietary intake and eating behavior subscales. In addition temperament was measured at each visit with the very short form of the Child Behavior Questionnaire including three domains: Negative Affectivity (e.g. discomfort, frustration), Effortful Control (e.g. inhibitory- and attentional control) and Surgency (e.g. impulsivity, activity). Multivariate linear regression modeling was used to examine the effect of the three temperament domains with changes in total score of nutritional risk, and dietary intake and eating behavior subscores over time adjusted for the covariates age, gender, neighborhood income, maternal education, parent BMI, and baseline NutriSTEP score. 693 children were included (mean age at baseline 3.1 years, 49.7% male, mean follow-up 14 months) with a mean total NutriSTEP® score of 13.9 (SD 5.9) at follow-up. For each one point increase in effortful control at baseline (mean score 5.4 [SD 0.7]) there was a significant decrease in total nutritional risk score (adjusted β −0.68 [95% CI −1.06 to −0.29]) and a healthier dietary intake (adjusted β −0.51 [95% CI −0.78 to −0.25]) over time, independent of covariates. For each one point increase in negative affectivity (mean score 3.7 [SD 0.8]), there was a small increase in poor dietary behaviours (adjusted β 0.01 [95% CI 0.00 to 0.02]) but no effect on total nutritional risk score or dietary intake subscore was found. No relationship with surgency was identified. Early childhood temperament impacts future nutritional risk in preschool children. Interventions to promote early effortful control in young children may lead to reduced nutritional risk.

Method of electronic health record documentation and quality of primary care

Physicians who more intensively interact with electronic health records (EHRs) through their documentation style may pay greater attention to coded fields and clinical decision support and thus may deliver higher quality care. We measured the quality of care of physicians who used three predominating EHR documentation styles: dictation, structured documentation, and free text. We conducted a retrospective analysis of visits by patients with coronary artery disease and diabetes to the Partners Primary Care Practice Based Research Network. The main outcome measures were 15 EHR-based coronary artery disease and diabetes measures assessed 30 days after primary care visits. During the 9-month study period, 7000 coronary artery disease and diabetes patients made 18 569 visits to 234 primary care physicians of whom 20 (9%) predominantly dictated their notes, 68 (29%) predominantly used structured documentation, and 146 (62%) predominantly typed free text notes. In multivariable modeling adjusted for clustering by patient and physician, quality of care appeared significantly worse for dictators than for physicians using the other two documentation styles on three of 15 measures (antiplatelet medication, tobacco use documentation, and diabetic eye exam); better for structured documenters for three measures (blood pressure documentation, body mass index documentation, and diabetic foot exam); and better for free text documenters on one measure (influenza vaccination). There was no measure for which dictators had higher quality of care than physicians using the other two documentation styles. EHR-assessed quality is necessarily documentation-dependent, but physicians who dictated their notes appeared to have worse quality of care than physicians who used structured EHR documentation. ClinicalTrials.gov Identifier: NCT00235040.

Mothers With Positive or Negative Depression Screens Evaluate a Maternal Resource Guide

Introduction Social isolation is common in mothers with high depressive symptoms. This study tested the hypothesis that a maternal resource guide that provided mothers with links to community human service agencies would be deemed more helpful by mothers with positive depression screens (PDS) compared with mothers with negative depression screens (NDS). Method This investigation was a cross-sectional survey study of a convenience sample from a primary care practice–based research network, the Southwestern Ohio Ambulatory Research Network (SOAR-Net). English-speaking mothers who took their child(ren) to SOAR-Net practices were eligible to participate in the study. Data were collected between May 2006 and March 2009. A total of 1048 mothers completed the survey, and 234 mothers refused to participate. Results Mothers were more likely to report that “This guide is helpful to me” if they were single (odds ratio [OR] = 4.05; 95% confidence interval [CI]: 2.77-5.94), their child had public health insurance (OR = 3.59; 95% CI: 2.39-5.40), or they had PDS (OR = 3.57; 95% CI: 2.13-5.98). After adjusting for a number of demographic variables, PDS continued to be significantly associated with “This guide is helpful to me” (adjusted OR = 2.68; 95% CI: 1.58-4.56). Discussion Mothers with PDS were more likely to report that the maternal resource guide would be personally helpful compared with mothers with NDS.

Bringing a 'best practices' theme to Family Practice

Greetings to the international community of Family Practice readers, authors and peer reviewers. I’m honoured to succeed Brendan Delaney as the new editorin-chief. In this inaugural editorial, I would like to introduce myself and discuss a few plans that have emerged from a recent strategic planning initiative. Best regards to Brendan and editorial assistant, Vivienne Tsimbili, both of whom will focus on new endeavours (Brendan will remain on as an associate editor). Our new editorial assistant is Louise Whelan, who has worked in publishing for >10 years, with experience as a production editor, team leader and journal publishing manager. She also worked as a freelance editorial assistant for a number of titles, where she acquired experience with the peer-review process and the ScholarOne manuscript management system. Louise holds a degree in marine biology, and she is an on-call marine mammal medic for the British Divers Marine Mammal Rescue organization. You can contact Louise at fampra.editorialoffice@oxfordjournals .org. I am confident that you will find her a pleasure to work with. Although there is a lot to learn about the Family Practice editorial processes from the perspective of the editor-in-chief, I have served as an associate editor since 2006. A year ago, I started as editor-elect focusing on strategic planning, which included a survey of the editorial board to obtain suggestions for process improvements and future directions. This resulted in a review of procedures to identify opportunities for reducing the time lag from manuscript submission to first decision. To that end, we have already instituted changes that take greater advantage of the efficiencies provided by the Scholar One system. A current project underway includes expanding the keyword list to improve our ability to match reviewers to manuscripts. Other process improvements will be opaque to authors and readers but should contribute to our objective to improve response time. Additional suggestions from the editorial board survey included: refresh the peer reviewer data base, increase the visibility of Family Practice internationally and develop a mechanism to acknowledge the service contributions of peer reviewers for the purpose of supporting applications for tenure or promotion. We are working on all of these! My own research interests currently center on identifying research best practices specific to primary care research and practice-based research network (PBRN) settings. Recently, I conducted a study titled

Primary Care: Too Important to Fail

The principal goals of health care reform are to improve quality, increase access, and contain costs. In this issue, Pham and colleagues calculated that a typical primary care clinician must coordi...

The Health Consequences of Peripheral Neurological Deficits in an Elderly Cohort: An Oklahoma Physicians Resource/Research Network Study

To determine whether the belief that loss of deep tendon reflexes and vibratory sensation in the ankles in older patients is of no great consequence is valid. Four-year longitudinal cohort study. Primary care practice-based research network. Six hundred four noninstitutionalized individuals aged 65 and older with no self-reported medical conditions known to cause peripheral neuropathy (PN), recruited from the practices of 23 primary care physicians in central Oklahoma. Annual standardized peripheral neurological examination performed by two research nurses plus a questionnaire that included self-reported measures of health, health-related quality of life (HRQoL Quality of Well-Being--Self Administered (QWB-SA) and Health Utilities Index-3 (HUI-3), physical functioning--(Medical Outcomes Study 36-item Short Form Survey (SF-36)), falls, and use of healthcare services. Deaths were determined from participant contacts, primary care physicians, and the Social Security death index. One hundred sixty of 604 participants had symmetrical peripheral neurological deficits (SPNDs). After controlling for age, sex, race, education, income, body mass index, HRQoL, physical functioning, self-rated health, cognitive test score, and a variety of medical conditions, SPNDs were associated with earlier hospitalization (P=.03); greater mortality (P<.001); and declines in HRQoL (QWB-SA, P<.001), self-rated health (P=.02) physical functioning (SF-36, P=.005), and bodily pain (SF-36, P=.001). SPNDs of undetermined cause, found in older patients on physical examination, appear to be associated with greater morbidity and mortality.

Time, Cost, Information Seeking Skills and Format of Resources Present Barriers to Information Seeking by Primary Care Practitioners in a Research Environment

Objective – To determine the information seeking behaviors of primary care practitioners in order to inform future efforts towards the design of information services that would support quality in primary care.&#x0D; &#x0D; Design – A cross-sectional survey.&#x0D; &#x0D; Setting – A primary care practice based research network (PBRN) of caregivers who serve a broad population while simultaneously studying and disseminating innovations aimed at improvements in quality, efficiency and/or safety of primary health care in the United States. &#x0D; &#x0D; Subjects – All primary care practitioners in the PBRN including family practitioners, general practitioners, nurse practitioners and physician assistants. &#x0D; &#x0D; Methods – A questionnaire comprising twenty-six questions was distributed to 116 practitioners. Practitioners attached to academic centres (who were also members of the PBRN) were excluded in order “to achieve a sample of practices more representative of the primary care practising population” (208). Descriptive data were collected and analyzed. SPSS v11.5 was used for statistical analyses.&#x0D; &#x0D; Main results – There was a response rate of 51% (59 of 116). Fifty-eight percent of the respondents stated that they sought information (excluding drug dosing or drug interactions information) to support patient care several times a week. Sixty-eight per cent sought this information while the patient waited. Almost half of the respondents had access to a small medical library (48%) or a hospital library (46%), while 21% used a university medical library. Approximately 14% had no immediate access to a medical library. Almost 60% of practitioners stated that they had an e-mail account. Thirty-four percent agreed that the use of e-mail to communicate with patients enhanced medical practice, while 24% disagreed. There was frequent prescribing of Internet-based consumer health information to patients by only 16% of the practitioners, while Internet support groups were frequently recommended by 5%. The main barriers to information seeking were lack of time (76%), cost (33%), information seeking skills (25%), and format of information sources (22%). The use of EBM resources was fairly low, while there was a high preference for ready reference and interpersonal sources. When compared with print information resources, the use of online resources was moderate. A significant correlation was found between use of online sources and use of print sources, namely, that practitioners who used online sources more frequently, also sought information from print sources more frequently, with the inverse being true for those who sought information less frequently from either electronic or print sources.&#x0D; &#x0D; Conclusion – Primary care practitioners in this rural PBRN used print and interpersonal sources more than online sources. Practitioners who are more likely to use print sources are also more likely to seek online information. Librarians working in PBRN environments will need to identify interventions that address barriers such as time, cost, and information-seeking skills.

Patient Visits to a National Practice-Based Research Network: Comparing Pediatric Research in Office Settings With the National Ambulatory Medical Care Survey

Our objective with this study was to assess the extent to which patients who are seen by practitioners in Pediatric Research in Office Settings, a national primary care practice-based research network, are representative of those who are seen in ambulatory office-based pediatric primary care in the United States. Pediatric Research in Office Settings patient data were collected from the offices of 57 randomly selected network practitioners as part of an Agency for Healthcare Research and Quality-funded effort to describe primary care visits and replicate the National Ambulatory Medical Care Survey in primary care practice-based research networks. These data were from 1706 randomly selected pediatric patient visits that occurred between March and June 2002. National comparison data were 948 randomly selected pediatric patient visits that occurred between March and June 2000 in the offices of the 33 primary care pediatric practitioners who had participated in the National Ambulatory Medical Care Survey. The groups were compared on patient demographics (age, gender, race, ethnicity, and socioeconomic status, as represented by Medicaid status), visit characteristics (percentages of patients referred, practitioner designation of visit as acute versus nonacute, and continuity of care), the top patient/parent-articulated reasons for visit, and the top practitioner diagnoses. Comparisons revealed substantial similarities between Pediatric Research in Office Settings and national data, including gender, ethnicity, socioeconomic status, and visit characteristics. Differences were noted for age and race, with Pediatric Research in Office Settings children approximately 1 year older and comprising a significantly lower proportion of black patients than their National Ambulatory Medical Care Survey counterparts. Although the top 6 reasons that were articulated by parents for outpatient visits in the 2 groups were remarkably similar in rank order and proportions, there were overall differences, mostly attributable to a larger number of the "other" category in the Pediatric Research in Office Settings cases. There were no significant differences among the top 5 practitioner visit diagnoses between the Pediatric Research in Office Settings and National Ambulatory Medical Care Survey data. The Pediatric Research in Office Settings patient population is reasonably representative of patients who are seen in US ambulatory office-based pediatric primary care practices; therefore, the Pediatric Research in Office Settings is an appropriate laboratory for studies of care in such settings.

The Midwest Nursing Centers Consortium Research Network: Translating Research Into Practice

Community nursing centers (CNCs) serve the health needs of culturally diverse populations that are often marginalized and likely to experience disparities in health. CNCs utilize innovative models of primary health care that blend traditional medical management with nursing case management and community-based health promotion strategies. This article describes the mission and activities of the Midwest Nursing Centers Consortium Research Network (MNCCRN), a practice-based research network (PBRN) funded by the Agency for Healthcare Research and Quality, and is one of only two federally funded nonphysician primary care PBRNs and the only PBRN in the United States comprising exclusively CNCs. The MNCCRN utilizes Advanced Practice Nurses to deliver primary health care with a particular emphasis on reducing health disparities. The MNCCRN has successfully established a multisite, multistate collaboration for community-based participatory research that will ultimately inform practice, education, and health policy.