Community-based Primary Care Providers Research Articles

(025) DEVELOPING AND TESTING AN ONLINE PRIMARY CARE TOOLKIT FOR COMMUNITY MANAGEMENT OF VULVODYNIA

Abstract Introduction Vulvodynia is a chronic vulvar pain condition that affects 8-10% of women and people with vulvas. Despite its prevalence, healthcare providers (HCPs) often lack awareness, knowledge, and confidence in managing vulvodynia. This knowledge gap can lead to diagnostic delays, misdiagnoses, and reflex referrals to specialists. Moreover, research shows that patients feel invalidated in healthcare settings and perceive that their HCPs’ lack of vulvodynia awareness negatively impacts their care. Thus, there is a need for educational resources about vulvodynia that can be applied in healthcare settings. Specifically, community-based primary care providers could greatly benefit from vulvodynia resources because they are often a point of entry into the healthcare system. Objective To develop and test a new, online toolkit tailored to supporting community-based primary care providers with the assessment, diagnosis, and management of vulvodynia. In this pilot study, we sought to evaluate the adoption, acceptability, and preliminary efficacy of the vulvodynia toolkit in a pilot sample of community-based family physicians. Methods A working group of HCPs (family physicians, gynecologists, physiotherapist, psychologists) and patient partners with vulvodynia expertise developed the toolkit. The toolkit was designed in an online, modular format that could be integrated into short healthcare visits. A sample of 19 family physicians completed online surveys before and after piloting the toolkit in their community practice for 6 months. Adoption was measured in the post-toolkit survey by assessing the frequency and timing of toolkit use during the pilot period. Acceptability was measured in the post-toolkit survey by assessing physicians’ satisfaction with the toolkit content and quality. Preliminary efficacy was assessed by comparing physicians’ self-reported level of confidence with diagnosing, treating, and supporting patients with vulvodynia before and after the pilot period. Results Adoption. During the pilot period, physicians used the toolkit in advance of patient appointments (52.6%), during patient appointments (5.3%), or used a combination of both timepoints (42.1%). Over the 6-month pilot period, physicians used the toolkit an average of 2.61 times (SD = 1.50) in advance of seeing patients and 1.63 times (SD = 2.19) during patient appointments. Acceptability. Most physicians reported that they were satisfied or very satisfied with the toolkit overall (79.0%) and that it contained the right amount of information (68.4%). On average, the physicians rated their likelihood of recommending the toolkit to a colleague as 8/10 (SD = 1.75). Preliminary efficacy. Using repeated-measures MANOVAs, we found significant pre-toolkit to post-toolkit increases in physician’s confidence for diagnosing vulvodynia, p = .003, ηp 2 = .59, treating vulvodynia, p < .001, ηp2 = .72, and supporting patients with vulvodynia, p < .001, ηp2 = .73. Conclusions In this pilot study, we developed and tested an online vulvodynia toolkit tailored to educating community-based primary care providers. The toolkit demonstrated high acceptability and preliminary efficacy amongst a pilot group of family physicians, with large effect sizes. The results of this study exemplify the value of tailored education for improving physicians’ confidence with managing vulvodynia in community practice and lay the foundation for upscaling this tool to a wider population of HCPs. Disclosure No.

Primary care utilization and cardiovascular screening in adult-aged survivors of childhood cancer: A report from the childhood cancer survivor study (CCSS).

e22020 Background: Among the half million survivors of childhood cancer in the US, cardiovascular disease (CVD) is the leading non-cancer cause of premature death. Adult survivors of childhood cancer are largely managed by community-based primary care providers (PCPs), and healthcare utilization patterns related to CVD screening and survivorship care are not well-described. Methods: Within the CCSS cohort, we conducted a randomized intervention trial (NCT03104543) focused on improving CVD risk factor control among survivors at increased risk for CVD due to prior chest radiotherapy and/or anthracycline chemotherapy. Using medical records from participants’ PCPs over the 2 years preceding trial enrollment, we ascertained the numbers of PCP and specialist visits, CVD conditions (i.e., hypertension, dyslipidemia, diabetes) and screening (i.e., blood pressure, lipid, diabetes testing, and cardiac testing [ECG, echocardiogram, or other imaging completed or planned]). We also abstracted acknowledgement of participants’ cancer history, cardiotoxic treatment exposures, or a survivorship care plan (SCP). Multivariable logistic regression assessed characteristics associated with having cardiac testing, retaining covariates associated with p < 0.10 in univariate testing. Results: Of 347 enrolled participants, 293 (84%) had evaluable data (median age 40y, range 22–65; 49% female; 87% non-Hispanic White; mean 31y since childhood cancer). In the prior 2y, 81% of participants had a documented PCP office visit (median 3 visits [IQR 2–5]), 22% had a subspecialty visit (4% saw cardiology), and 16% had no visits. The prevalence of blood pressure, lipid, and diabetes screening was 82%, 57%, and 63%, respectively; 29% had cardiac testing done or planned, including 22% with echocardiography. Only 68% of participants had records referencing a history of cancer. PCP documentation of prior cardiotoxic exposures was low compared with known exposures: radiotherapy (35% vs 69%; p < 0.001), anthracycline chemotherapy (9% vs 76%; p = 0.017); only 12% had any documentation noting an increased risk for CVD. Few participants’ records referenced a need for cancer-related late effects surveillance (38%), and even fewer referenced an SCP (5%). In multivariable analysis, independent predictors of cardiac testing included documentation of increased CVD risk (Odds Ratio [OR] 11.61, 95% CI 3.31–40.67), presence of a late effects surveillance plan (OR 3.71, 95% CI 1.62–8.48), and existing CVD conditions (modeled as 0, 1, or 2+ conditions; OR 2.21, 95% CI 1.41–3.47, for each additional level). Conclusions: Adult survivors of childhood cancer at increased risk of CVD had low rates of cardiac testing and documentation of risk in PCP medical records. Increasing participant and PCP awareness of CVD risks and late effects surveillance recommendations may improve screening.

Exploring the question of financial incentives for training amongst non-adopters of MOUD in rural primary care

BackgroundMedication for opioid use disorder (MOUD) includes administering medications such as buprenorphine or methadone, often with mental health services. MOUD has been shown to significantly improve outcomes and success of recovery from opioid use disorder. In WV, only 18% of providers including physicians, physician assistants, and nurse practitioners are waivered, and 44% of non-waivered providers were not interested in free training even if compensated. This exploratory research seeks to understand intervention-related stigma in community-based primary care providers in rural West Virginia, determine whether financial incentives for training may be linked to levels of stigma, and what level of financial incentives would be required for non-adopters of MOUD services provision to obtain training.MethodSurvey questions were included in the West Virginia Practice-Based Research Network (WVPBRN) annual Collective Outreach & Research Engagement (CORE) Survey and delivered electronically to each practice site in WV. General demographic, staff attitudes and views on compensation for immersion training for delivering MOUD therapy in primary care offices were returned. Statistical analysis included logistic and multinomial logistic regression and an independent samples t-test.ResultsData were collected from 102 participants. Perceived stigma did significantly predict having a waiver with every 1-unit increase in stigma being associated with a 65% decreased odds of possessing a waiver for buprenorphine/MOUD (OR = 0.35; 95% CI 0.16–0.78, p = 0.01). Further, t-test analyses suggested there was a statistically significant mean difference in perceived stigma (t(100) = 2.78, p = 0.006) with those possessing a waiver (M = 1.56; SD = 0.51) having a significantly lower perceived stigma than those without a waiver (M = 1.92; SD = 0.57). There was no statistically significant association of stigma on whether someone with a waiver actually prescribed MOUD or not (OR = 0.28; 95% CI 0.04–2.27, p = 0.234).ConclusionThis survey of rural primary care providers demonstrates that stigmatizing beliefs related to MOUD impact the desired financial incentive to complete a one-day immersion, and that currently unwaivered providers endorse more stigmatizing beliefs about MOUD when compared to currently waivered providers. Furthermore, providers who endorse stigmatizing beliefs with respect to MOUD require higher levels of compensation to consider such training.

S350 Are Primary Care Providers Accurately Ordering Cologuard in the Community Setting?

Introduction: Colon cancer screening saves lives, and colonoscopy remains the gold standard test. Cologuard (CG), a non-invasive multi-target stool DNA + Fecal Immunohistochemical Test, is 92% sensitive for colon cancer detection, but only 42.4% sensitive for advanced adenoma detection, thus limiting its preventive role. CG is indicated as a screening test for asymptomatic patients without colon cancer risk factors, and is increasingly ordered by primary care providers (PCPs). It is unknown if PCPs are ordering CG according to approved indications. To determine if referring PCPs in our community are ordering the CG test in accordance with approved indications. Methods: Our practice has a wide network of referring providers with multiple offices. This prospective study enrolled all patients referred to our practice with a positive CG test from December 2020 to June 2021. Clinical information was obtained from medical records. Patients responded to a questionnaire asking: (1) Did you see blood in your stool or observe blood from your rectum, and (2) Did you have a stool test showing blood before your CG test? The colonoscopy results were recorded and the data was analyzed. Results: 81 patients (28M:53F) with a positive CG test were enrolled, with a median age 62 years (96.3% patients >50 years old). 9% of the study population self-identified as African-Americans. 54/81 (66.7%) of patients had >1 adenomatous polyp or colon cancer (n=3) on colonoscopy, and specifically 16% (13/81) had advanced adenomatous polyps/mass. 33.3% (27/81) of patients had either a hyperplastic polyp or a normal colonoscopy. The false positive rate for CG in this study was 33.3%. 16% (13/81) of patients who were prescribed a CG test had blood present in stool, and of these 13 patients, 12 reported overt bleeding prior to being prescribed CG. Conclusion: This study reveals that our community-based PCPs are incorrectly ordering CG as a screening test, and specifically, are unaware that overt bleeding is a contraindication for CG testing. 15% of patients initially reported overt bleeding prior to CG testing, and this contributed to the elevated false positive rate observed in our study (33.3%) compared to the accepted false positive rate of 12% for comparable patients. The cost of CG is $500-600 and widespread erroneous testing leads to increased healthcare cost. This study highlights an opportunity for PCP education, and suggests similar regional analysis should be conducted.

Improving the Delivery of Musculoskeletal Education in Primary Care Using the Innovative Echo (Extension for Community Healthcare Outcomes) Technology

Background: Extension for Community Healthcare Outcomes (ECHO) is a programme that employs videoconferencing technology to train community-based primary care providers to improve and standardize care across a wide geographical region. This method has not yet been trialled in the UK for improving the capacity of primary care services in managing common musculoskeletal (MSK) complaints. Aim: The aim was to assess the impact of introducing a year-long MSK ECHO education programme in Northern Ireland for general practitioners (GPs). Design and setting: Monthly sessions were held consisting of teaching and case based discussions. Each session lasted on average 90 minutes. A ‘hub’ consisting of local GP lead educators, supported by colleagues from secondary care, where linked to GPs around Belfast using video conferencing technology. Methods: Topics covered were chosen by participants at the start and covered common MSK complaints in primary care. An initial questionnaire was performed at the start and compared to an evaluation questionnaire at the end. Results: Ten GPs completed the evaluation one year after the project was initiated. The weighted average of the selfconfidence scores in examining a range of individual body parts in general practice increased from a baseline of 3.45 to 4.08. There was an increase in self-assessed ability in diagnosing and treating a number of common MSK complaints and the whole year-long programme was delivered for £ 14,980. Conclusion: This trial shows how a 12-month ECHO intervention can improve self-efficacy in a number of MSK capacities within GP. These preliminary results suggest that ECHO is an affordable, effective solution for providing postgraduate education to working GPs.

Suboptimal Retention in Care Among Recently Released Prisoners: Implications for Social Workers in HIV Primary Care.

Certain populations of people living with HIV (PLWH) are at greater risk for falling out of care, including PLWH with a history of incarceration. This is associated with increased risk of morbidity and mortality. In the current retrospective cohort study, we examined patient-level information for 340 PLWH who had transferred HIV care services from prison or from other community-based or private HIV primary care providers to a large urban HIV clinic in the southeastern United States. Results indicated that, compared to those transferring care from another community-based or private medical provider, PLWH transferring care from prison were significantly less likely to be retained in care than PLWH transferring care from other providers, even after controlling for other factors. HIV primary care social workers, who are trained to provide case management services, can help provide PLWH with a coordinated continuum of care that addresses the complex issues faced post-release.

ECHO Autism STAT: Accelerating Early Access to Autism Diagnosis

Although early diagnosis of autism is critical for promoting access to early intervention, many children experience significant diagnostic delays. Shortages of healthcare providers, limited capacity at autism centers, and geographic and socioeconomic challenges contribute to these delays. The current pilot study examined the feasibility of a new model for training community-based primary care providers (PCPs) in underserved areas in screening and diagnosis of young children at highest risk for autism. By combining hands-on training in standardized techniques with ongoing virtual mentorship and practice, the program emphasized both timely diagnosis and appropriate referral for more comprehensive assessment when necessary. Results indicated improvements in PCP practice and self-efficacy, and feasibility of the model for enhancing local access to care.

Community Clinicians and the Veterans Choice Program for PTSD Care: Understanding Provider Interest During Early Implementation.

In 2014, the Department of Veterans Affairs (VA) implemented the Veterans Choice Program (VCP) to provide reimbursement for community-based care to eligible veterans. Inadequate networks of participating providers may impact the utility of VCP for veterans with posttraumatic stress disorder (PTSD), a complex condition occurring at lower frequency among civilians. To compare characteristics and attitudes of community-based primary care and mental health providers reporting interest or no interest in VCP participation during early implementation; and to examine perceptions and experiences of VCP among "early adopters." Cross-sectional surveys with 2 samples: a stratified random sample of mental health and primary care prescribers and psychotherapists drawn from state licensing boards (Community Sample); and a stratified random sample of prescribers and psychotherapists identified as VCP-authorized providers (VCP-Authorized). Five hundred fifty-three respondents in the Community Sample and 115 in the VCP-Authorized (total, n=668; 21.1% response). Surveys assessed provider and practice characteristics, attitudes to VA and VCP, and experiences and satisfaction with the VCP; an open-ended survey item assessed providers' reasons for interest or lack of interest in VCP participation. Few providers reported VCP participation during this period. Interest in VCP participation was associated across provider groups with factors including being a veteran and receiving VA reimbursement; currently providing treatment for PTSD was associated with interest in VCP participation among psychotherapists, but not prescribers. Developing networks of VCP providers to serve Veterans with PTSD is likely to require targeting more receptive provider groups, reducing barriers to participation, and more effectively communicating the value of VCP participation to providers.

The Effects of Electronic Prescribing by Community-Based Providers on Ambulatory Medication Safety

US federal policies are incentivizing use of electronic prescribing (e-prescribing) to improve safety. However, little is known about e-prescribing's actual impact on medication safety over time. A study was conducted to assess the effect of implementing a commercial electronic health record (EHR) with e-prescribing on rates and types of prescribing errors. Understanding safety effects from e-prescribing will be important as providers increasingly e-prescribe. Prescriptions written by 20 community-based primary care providers in the Hudson Valley region of New York from November 2008 to November 2009 were retrospectively studied. All providers adopted a commercial EHR with robust clinical decision support and extensive technical support to aid in prescribing. Errors were identified by standardized prescription and chart review. Some 1,629 prescriptions were analyzed at three months postimplementation, and 1,738 prescriptions were analyzed at one year postimplementation. Use of e-prescribing resulted in relatively low error rates (6.0 errors per 100 prescriptions). These rates were sustained over time but without further improvement (6.0 versus 4.5 errors per 100 prescriptions, p = .15). Antibiotics were the class of medications most frequently involved (12.7% of overall errors), and direction errors were most common (24% of errors). This study is the first, as far as known, to quantitatively evaluate prescribing errors early after EHR implementation and after sustained use among community-based primary care providers. Relatively low rates of errors with e-prescribing were found early and after prolonged use. Extensive support for providers before, during, and after implementation may mitigate potential safety threats from implementation of an EHR system and result in sustained safety benefits over the long-term.

Evaluating the Role of Key Learning Theories in ECHO: A Telehealth Educational Program for Primary Care Providers

ECHO (Extension for Community Healthcare Outcomes) is a telehealth educational program that uses videoconference technology to train community-based primary care providers (PCP's) on the management of complex, chronic diseases. The main components of ECHO are didactics, case presentations, and case-based learning. ECHO was developed using the key principles of Social Cognitive Theory, Situated Learning Theory, and Community of Practice Theory. In a prior study, we implemented an ECHO curriculum to improve management of resistant hypertension. The goals of the current study were to determine the extent to which the learning theories served as the foundation of the ECHO curriculum and identify opportunities to more effectively incorporate key principles of these theories into the ECHO program. We conducted semi-structured interviews with the nine clinicians who participated in the pilot curriculum. A community-based PCP assisted with question development, analysis, and manuscript preparation. We analyzed the interview transcripts using Directed Content Analysis. Transcript analysis supported the contention that ECHO is based upon Social Cognitive Theory, Situated Learning Theory, and Community of Practice Theory. Comments from study participants highlighted benefits of each theory's principles. Conversely, they also suggested we could improve our implementation of ECHO by adhering more closely to specific learning theory strategies. Our results indicate that ECHO indeed reflects the key tenants of Social Cognitive Theory, Situated Learning Theory, and Community of Practice Theory. Several aspects of our ECHO curriculum can be improved by more complete application of these learning theories.

50. The Influence of Primary Care Provider Type on Adolescent Visits to the Emergency Department

Purpose: Adolescents frequently rely on emergency departments (EDs) for medical care, rather than using primary care providers (PCPs). Previous studies have examinedEDuse by young children and adults, but no recent studies have looked specifically at adolescents’ use of the ED. Our objectives were to characterize a population of adolescents presenting to a large, urban children’s hospital ED and to examine if the type of PCP or primary clinic (academic, community, or private) they reported attending influenced their triage level or reason for presenting to the ED rather than to their PCP. Methods: Adolescents ages 12 to 21 and their parents/guardians were approached in either the ED waiting room or patient care rooms and invited to participate. Age-eligible patients were excluded if they required immediate emergent care, were under 18 and not accompanied by a consenting adult, or could not complete the survey in either English or Spanish. We used a brief, online, 21-question survey to assess key characteristics of the PCP practice and the adolescents’ relationship to the PCP as well as their main reason for presentation to the ED instead of to the PCP. Demographic data and triage information were collected from participants’ electronic medical records. PCPs were classified by study staff as academic, community, or private based on the provider or clinic name supplied by each participant. Descriptive statistics were performed. Results: Of the 203 total participants from August 2010 to February 2011, 60% (n 121) were female and 80% (n 162) were Black/ African American, with a median age of 15 years (S.D. 2.37). Twothirds (66%, n 134) had a formof public insurance (Medicaid, CHIPs, etc), and 40% (n 82) were triaged as non-urgent. Nearly all (93%, n 189) reported that they had a PCP or primary clinic, and most were able to state a provider or clinic name. Forty-six percent (n 94) had a private PCP, 23% (n 46) had an academic PCP, and 21% (n 42) had a community-based PCP. Those with an academic PCP were slightly more likely (p 0.051) to be triaged as urgent compared to those with a community PCP. There were no other significant differences in triage level among groups of participants by PCP type. When asked to choose their main reason for presenting to the ED instead of to the PCP, those with private PCPs most commonly reported PCP instructions to go to the ED (31%, n 29) compared to those with academic and community PCPs who most frequently presented to the ED due to perceived illness requiring immediate care (37%, n 17 and 40%, n 17 respectively). Conclusions: Nearly all adolescents in this study were able to identify a PCP or primary clinic during their ED visit, most frequently from a private office setting. However, those with private PCPs most commonly reported being sent to the ED by their PCPs. Further research is needed examining why private PCP offices divert adolescents to the ED—perhaps discomfort in caring for this age group, issues with time constraints in the outpatient setting, or inadequate reimbursement. Sources of Support: None. 51.

Abstract A51: Understanding community-based primary care providers' attitudes toward caring for breast cancer survivors.

Abstract Background: Of the 13.7 million cancer survivors in the United States, 22% are breast cancer survivors. By 2050, this number is expected to double. The 2005 Institute of Medicine's Report “From Cancer Patient to Cancer Survivor: Lost in Transition,” identified 4 essential components of survivorship care. Central to this includes the coordination between specialists and primary care providers. Primary Care Providers (PCPs) often play a critical role in the follow-up care for patients with chronic diseases. Cancer survivorship can now be viewed as a chronic disease however PCPs have little access to training and education in survivorship care. By offering culturally appropriate and trusted care in a setting that is familiar and accessible to their patients, PCPs in the community setting are in a unique position to impact cancer follow-up care for their patients. Thus greater involvement by community PCPs is likely to impact cancer survivorship disparities. We sought to survey PCP attitudes regarding cancer survivorship care delivery. Methods: The Illinois Breast and Cervical Cancer Program (IBCCP) is part of the Center for Disease Control's National Breast and Cervical Cancer Early Detection Program. This program provides access to breast and cervical cancer screening services to underserved women. Illinois has 36 lead agencies. A 10-question survey based on the National Cancer Institute's Survey of Physician Attitudes Regarding the Care of Cancer Survivors (SPARCCS) was given to IBCCP providers. Providers were surveyed about their attitudes and self-efficacy as well as preferences for breast cancer care delivery. The SPARCCS surveyed over 1000 PCPs on their knowledge and attitudes on breast cancer survivorship care. 83% of SPARCCS PCPs work in either private practice or as part of a large healthcare system. Results: 110 PCPs completed the IBCCP survey. 54% (n=59) were physicians, 28% (n= 31) nurse practitioners, and 17% (n= 19) identified as other. 94.5% (n= 104) of the respondents reported having patients with a breast cancer history. Compared to PCPs in the original SPARCCS survey, 37% IBCCP providers' preferred oncologists take primary responsibility (SPARCCS 25%, p=0.0057) and 13% IBCCP providers' preferred survivorship care be delivered in specialized survivorship clinics led by a clinician other than a physician (SPARCCS 4%, p=0.0002). The other survivorship care model preference differences were not statistically significant. Overall, community-PCPs surveyed preferred follow-up care be delivered through specialized clinics and/or by cancer specialists. Conclusions: Limited information exists regarding the role of community PCPs in breast cancer survivorship follow-up care for the underserved. Most providers in our survey stated they preferred follow-up care be delivered by the cancer specialist or through specialized survivorship clinics. The role to which improving provider knowledge, attitudes, and self-efficacy can impact preferences for care delivery needs to be explored. Citation Format: Zakiya Moton, Danielle Weston, Rebecca McFarland, Tamara Hamlish, Daniel Johnson, Maureen Mencarni, Shannon Lightner, Jean Becker, Funmi Olopade, Susan Hong. Understanding community-based primary care providers' attitudes toward caring for breast cancer survivors. [abstract]. In: Proceedings of the Fifth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2012 Oct 27-30; San Diego, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2012;21(10 Suppl):Abstract nr A51.

The proposed national mental health law in China: a landmark document for the protection of psychiatric patients' civil rights.

The proposed national mental health law in China: a landmark document for the protection of psychiatric patients' civil rights.

Missed Opportunities for Universal HIV Screening in Primary Care Clinics.

BackgroundThe Centers for Disease Control and Prevention (CDC) has reported that the number of new cases of HIV infection has been underreported annually by at least 40,000 cases. In 2006, the CDC recommended that voluntary HIV counseling and testing (VCT) was given to all patients aged 13 to 64 years in ambulatory care settings. The purpose of this qualitative study was to explore primary care providers’ (PCP) perspectives on and experiences of facilitators and barriers to offering VCT as part of annual screening.MethodsThis was a descriptive, exploratory study where fifteen primary care providers were individually interviewed. Only community-based primary care providers were interviewed, and no obstetrician/gynecologists were enrolled, as VCT is standard of care in that specialty.ResultsBarriers included doubts about the CDC recommendation, time constraints, fear, and assumptions about age and marital status. Facilitators included normalizing HIV testing and the availability of resources and training. PCPs’ role as an advocate and their professional style had the paradoxical potential of being both a barrier and a facilitator to VCT. Providers’ ability to connect patients to community resources was linked to their persistence and experience.ConclusionsFindings suggest more effort is needed by PCPs to facilitate HIV counseling and testing more frequently to their ambulatory care patients.

Ambulatory prescribing errors among community-based providers in two states

Little is known about the frequency and types of prescribing errors in the ambulatory setting among community-based, primary care providers. Therefore, the rates and types of prescribing errors were assessed among community-based, primary care providers in two states. A non-randomized cross-sectional study was conducted of 48 providers in New York and 30 providers in Massachusetts, all of whom used paper prescriptions, from September 2005 to November 2006. Using standardized methodology, prescriptions and medical records were reviewed to identify errors. 9385 prescriptions were analyzed from 5955 patients. The overall prescribing error rate, excluding illegibility errors, was 36.7 per 100 prescriptions (95% CI 30.7 to 44.0) and did not vary significantly between providers from each state (p=0.39). One or more non-illegibility errors were found in 28% of prescriptions. Rates of illegibility errors were very high (175.0 per 100 prescriptions, 95% CI 169.1 to 181.3). Inappropriate abbreviation and direction errors also occurred frequently (13.4 and 4.2 errors per 100 prescriptions, respectively). Reviewers determined that the vast majority of errors could have been eliminated through the use of e-prescribing with clinical decision support. Prescribing errors appear to occur at very high rates among community-based primary care providers, especially when compared with studies of academic-affiliated providers that have found nearly threefold lower error rates. Illegibility errors are particularly problematical. Further characterizing prescribing errors of community-based providers may inform strategies to improve ambulatory medication safety, especially e-prescribing. http://www.clinicaltrials.gov, NCT00225576.

Development and validation of a tool to improve paediatric referral/consultation communication

ObjectiveTo develop a template to promote brief but high-quality communication between paediatric primary care clinicians and consulting specialists.MethodsThrough an iterative process with academic and community-based paediatric primary care providers and...

Community-wide Intervention to Improve the Attention-Deficit/Hyperactivity Disorder Assessment and Treatment Practices of Community Physicians

The goals were to implement and to test a quality-improvement intervention aimed at improving community-based primary care providers' adherence to the American Academy of Pediatrics, evidence-based diagnostic and treatment guidelines for attention-deficit/hyperactivity disorder. Nineteen practices (with 84 primary care providers) from a large urban community were trained by using quality-improvement methods with some academic detailing. Pretraining and posttraining adherence to evidence-based practices was assessed through review of patient charts. Preintervention rates of guideline usage were uniformly low. After the intervention, primary care providers showed substantial improvement in their use of the guidelines for the assessment and treatment of elementary school-aged patients with newly diagnosed attention-deficit/hyperactivity disorder. Use of parent and teacher assessment rating scales increased from levels of 52% to 55% to levels of nearly 100%. Systematic monitoring of responses to medication improved from a baseline level of 9% to 40%. Quality-improvement interventions such as the one used in this study seem quite effective in improving primary care providers' practices at offices that express interest in improving the quality of care for attention-deficit/hyperactivity disorder. The design of the intervention, problems associated with improving and sustaining treatment monitoring, and issues related to generalizability of the intervention model are discussed.

The asthma dialogues: A model of interactive education for skills

A gap exists between asthma guidelines and actual care delivered. We developed an educational intervention using simulated physician-patient encounters as part of a project to improve asthma management by community-based primary care providers. We hypothesized that this type of skills-based interactive training would improve learners' care choices for simulated patients after training compared with their choices before training. After a pilot project was done on a small group of providers, a larger group of primary care providers (PCPs) was recruited to be trained with our interactive materials. The pilot session, with 39 providers, showed that the cases were felt to be appropriate, that the time allocated for discussion was adequate, that the models were useful, that the experience was educational, and that the experience captured their interest. Two subsequent training sessions were held with 240 PCPs. Participants completed a questionnaire to elicit perceived barriers and self-efficacy and then viewed a short simulated physician-patient dialogue. They then completed a set of scaled questions about treatment choices. This served as a pretest assessment. A similar simulation was then shown, and the group discussed their thoughts on diagnosis and treatment. Finally, they viewed another physician-patient interaction and responded to the same questions as posed for the pretest assessment; the responses before and after assessment were compared. Following completion of the intervention, providers were significantly (p < 0.05) more likely to make use of controller medications, asthma equipment, and patient training. Significant (p < 0.05) increases were also seen in action plan development and the availability of office visits. Providers were significantly (p < 0.05) less likely to refer asthma patients to an emergency department or for hospitalization. Significant (p < 0.05) improvements were also seen in perceptions of self-efficacy and barriers to treatment. There were significant (p < 0.05) increases in learners' confidence about their own and patients' abilities to improve asthma care, and fewer barriers to asthma management were reported after the training. This method of training resulted in learners showing a measurable improvement in their intent to follow guidelines as applied to simulated patients. An evaluation addressing actual patient outcomes will need to be done.

National Heart, Lung, and Blood Institute Guidelines and Asthma Management Practices Among Inner-City Pediatric Primary Care Providers

Most surveys of pediatric outpatient asthma management obtain information from parents and caregivers. Studies based on surveys of primary health-care providers are sparse. Suboptimal outpatient management may play a role in the high hospitalization rates among inner-city asthmatic children. Asthma management practices were compared between hospital-based and community-based primary care providers (PCPs). Adherence to National Heart, Lung, and Blood Institute (NHLBI) guidelines was evaluated, along with practices not clearly defined in the guidelines such as use of oral cough medicines and albuterol suspension. An 8-point questionnaire was administered to 48 community-based and 32 hospital-based PCPs practicing in inner-city neighborhoods. The questionnaire addressed three "positive" practices (classification of asthma severity, use of asthma action plan, and use of a spacer) and three "negative" practices (use of cough syrup, use of albuterol suspension, and preferential use of leukotriene modifiers instead of inhaled corticosteroids as the first line of preventive therapy). Response options were as follows: never, rarely, sometimes, and always, scored from 0 to 3. The two physician groups were compared on score means for the positive and negative practices using a t test with statistical significance set at p < 0.05. Overall, the rate of adherence to the positive practices was high, with no significant difference between the two groups. Negative practices, while present in both the groups, were reported significantly more often by the community-based group, particularly the use of cough suppressants and albuterol suspension. Greater emphasis is needed to increase the awareness among PCPs of the NHLBI guideline recommendations, as suboptimal outpatient asthma management may contribute to the disproportionately higher hospitalization rates among inner-city asthmatic children. Clarification on the use of potentially harmful medications and those of doubtful value need to be incorporated in the guidelines. The extent to which these negative practices contribute to the elevated pediatric hospitalization rates warrants further investigation.

Third sector primary care for vulnerable populations

This paper aims to describe and explain the development of third sector primary care organisations in New Zealand. The third sector is the non-government, non-profit sector. International literature suggests that this sector fulfils an important role in democratic societies with market-based economies, providing services otherwise neglected by the government and private for-profit sectors. Third sector organisations provided a range of social services throughout New Zealand's colonial history. However, it was not until the 1980s that third sector organisations providing comprehensive primary medical and related services started having a significant presence in New Zealand. In 1994 a range of union health centres, tribally based Mäori health providers, and community-based primary care providers established a formal network — Health Care Aotearoa. While not representing all third sector primary care providers in New Zealand, Health Care Aotearoa was the best-developed example of a grouping of third sector primary care organisations. Member organisations served populations that were largely non-European and lived in deprived areas, and tended to adopt population approaches to funding and provision of services. The development of Health Care Aotearoa has been consistent with international experience of third sector involvement — there were perceived “failures” in government policies for funding primary care and private sector responses to these policies, resulting in lack of universal funding and provision of primary care and continuing patient co-payments. The principal policy implication concerns the role of the third sector in providing primary care services for vulnerable populations as a partial alternative to universal funding and provision of primary care. Such an alternative may be convenient for proponents of reduced state involvement in funding and provision of health care, but may not be desirable from the point of view of equity and social cohesion insofar as the role of the welfare state is diminished.