Established Primary Care Provider Research Articles

Implementing primary care follow-up for high-risk vascular surgery patients

Background: The Centers for Medicare and Medicaid Services consider the 30-day hospital readmission rate an outcome of care measure; a high rate is associated with high-cost and bed utilization. Purpose: The Division of Vascular Surgery at a large academic medical center implemented a 15-week quality improvement project in the fall of 2022 to reduce readmissions among patients deemed high-risk for readmission and discharged to home. Methods: The discharging provider utilized the “HOSPITAL Score for Readmission” tool to identify patients at high-risk for unplanned 30-day readmission to receive the intervention, which included follow-up with a primary care provider (PCP) within two weeks of hospital discharge to address non-surgical medical conditions that may have been exacerbated during the hospital stay. A hospital based transitional care clinic bridged medical care for identified patients without an established PCP or whose PCP could not accommodate an appointment until PCP assumption of care. Discharging providers included 11 nurse practitioners and 2 surgery residents; each received a one-on-one educational teaching session and a weekly reminder e-mail through week 9. Results: A total of 158 vascular surgery patients (low and high-risk) were discharged home over 15 weeks with 30 patients (19%) having an unplanned readmission within 30-days from discharge. Adherence issues with the intervention among staff allowed for the high-risk group to be divided into those who did not receive the intervention versus those who did. The high-risk patients who did not receive the intervention had a higher readmission rate (30.4%) than the high-risk patients who did receive the intervention (21.4%). Conclusions: Numerous acute and chronic medical problems were treated at the PCP/transitional care clinic visits, which may have contributed to the reduction in rate of readmissions occurring within 30-days for those patients. Increased usage of the transitional care clinic identified a gap that patients continue to require assistance with establishing care with a PCP and further process change in the future is needed to ensure successful transition for all patients.

Transitional care clinics for patients discharged from hospital without a primary care provider: A systematic review.

The transition from hospital to home is a high-risk period. Timely follow-up care is essential to reducing avoidable harms such as adverse drug events, yet may be unattainable for patients who lack attachment to a primary care provider. Transitional care clinics (TCCs) have been proposed as a measure to improve health outcomes for patients discharged from hospital without an established provider. In this systematic review, we compared outcomes for unattached patients seen in TCCs after hospital discharge relative to care as usual. We searched the following bibliographic databases for articles published on or before August 12, 2022: MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Cochrane Database of Systematic Reviews, PsycINFO, and Web of Science. Five studies were identified that examined the effects of a dedicated postdischarge clinic on emergency department (ED) visits, readmissions, and/or mortality within 90 days of discharge for patients with no attachment to a primary care provider. Studies were heterogeneous in design and quality; all were from urban centers within the United States. Four of the five studies reported a reduction in either the number of ED visits or readmissions in patients seen in a TCC following hospitalization. TCCs may be effective in reducing hospital contacts in the period following hospital discharge in patients with no established primary care provider. Further studies are required to evaluate the health benefits attributable to the implementation of TCCs across a broad range of practice contexts, as well as the cost implications of this model.

Disparities in Mammography Screening: Analyzing Barriers to Access Using Individual Patient Perspectives and the Health Belief Model.

The objective of our study is to explore Nepali women's beliefs about access to mammography screening, and motivations to get screened or not. This work was intended to be hypothesis generating for subsequent quantitative analysis and to inform policy and decision-making to improve access. We conducted structured qualitative interviews among nine Nepali women in the Northeast of the United States receiving care at a local community health center and among nine white women receiving mammography care at a large academic medical center in the Northeast. We analyzed the transcripts using a mixed deductive (content analysis) and inductive (grounded theory) approach. Deductive codes were generated from the Health Belief Model which states that a person's belief in the real threat of a disease with their belief in the effectiveness of the recommended health service or behavior or action will predict the likelihood the person will adopt the behavior. We compared and contrasted qualitative results from both groups. We found that eligible Nepali women who had not received mammography screening had no knowledge of its availability and its importance. Primary care physicians emerged as a critical link in addressing this disparity: trust was found to be high among Nepali women with their established primary care provider. The findings of this study suggest that the role of primary care practitioners in conversations around the importance and eligibility for mammography screening is of critical importance, especially for underserved groups with limited health knowledge of screening opportunities and potential health benefits. Follow-up research should focus on primary care practices.

Application of a Machine Learning Algorithm to Develop and Validate a Prediction Model for Ambulatory Non-Arrivals.

Non-arrivals to scheduled ambulatory visits are common and lead to a discontinuity of care, poor health outcomes, and increased subsequent healthcare utilization. Reducing non-arrivals is important given their association with poorer health outcomes and cost to health systems. To develop and validate a prediction model for ambulatory non-arrivals. Retrospective cohort study. Patients at an integrated health system who had an outpatient visit scheduled from January 1, 2020, to February 28, 2022. Non-arrivals to scheduled appointments. There were over 4.3 million ambulatory appointments from 1.2 million adult patients. Patients with appointment non-arrivals were more likely to be single, racial/ethnic minorities, and not having an established primary care provider compared to those who arrived at their appointments. A prediction model using the XGBoost machine learning algorithm had the highest AUC value (0.768 [0.767-0.770]). Using SHAP values, the most impactful features in the model include rescheduled appointments, lead time (number of days from scheduled to appointment date), appointment provider, number of days since last appointment with the same department, and a patient's prior appointment status within the same department. Scheduling visits close to an appointment date is predicted to be less likely to result in a non-arrival. Overall, the prediction model calibrated well for each department, especially over the operationally relevant probability range of 0 to 40%. Departments with fewer observations and lower non-arrival rates generally had a worse calibration. Using a machine learning algorithm, we developed a prediction model for non-arrivals to scheduled ambulatory appointments usable for all medical specialties. The proposed prediction model can be deployed within an electronic health system or integrated into other dashboards to reduce non-arrivals. Future work will focus on the implementation and application of the model to reduce non-arrivals.

Understanding Caregiver Burden with Accessing Sickle Cell Care and Their Perspective on Telemedicine

Background: Sickle cell disease (SCD) is associated with a wide range of complications. However, a multitude of barriers prevent SCD patients from receiving adequate healthcare, including difficulties with transportation and lack of provider knowledge about disease sequelae. Importantly, studies have demonstrated the benefits of telemedicine in addressing barriers to healthcare. Few studies have explored barriers which affect the pediatric SCD patient population in areas such as the Midwest, wherein the geographical landscape can prohibit healthcare access. Furthermore, few studies have established acceptability of telemedicine among caregivers and patients with SCD. The objective of this study was to increase understanding of barriers to care and perceptions of telemedicine by caregivers of pediatric SCD patients. Methods: An 88-item statewide survey was distributed to caregivers of children with SCD cared for at Riley Hospital for Children in Indianapolis, IN. Caregivers were contacted by the research team via secure text messaging or in-person. Questions for the survey were developed based on previously performed semi-structured interviews with caregivers and the validated Barriers to Care Questionnaire (BCQ). The survey included questions regarding their experience accessing care, including barriers and facilitators of care, as well as their perspective on the use of telemedicine in SCD. Responses were analyzed using t-tests or chi square tests where appropriate. Results: Of the 300 caregivers contacted, 101 completed the survey, resulting in a response rate of 34%. The majority had 1 child with SCD, with most having Hb SS genotype. Eighteen percent of families drove more than 1 hour to access comprehensive sickle cell care. Caregivers reported having a median of 2 other healthcare providers that their child regularly sees. However, nearly 10% did not have an established primary care provider. Caregivers identified a median number of 6 barriers to accessing SCD care, with other household responsibilities, childcare, lost time from work and school as the most common. About 20% of caregivers felt these barriers affected their and/or their child's well-being and/or mental health at times, yet less than half reported their healthcare team ever discussing ways to address these barriers. Approximately 40% felt having a child with sickle cell disease impacted their daily stress and/or mental health. Sixty-three percent of caregivers worried about others (e.g. school staff) caring for their child, and nearly 50% worried about the care and knowledge of medical providers other than their SCD team. Forty percent of caregivers had participated in some form of telemedicine, the majority being direct-to-consumer. Eighty-one percent were willing to participate in telemedicine visits sometimes or always. However, nearly half felt the lack of a physical exam was a negative for telemedicine, and about 25% stated it was harder to build trust via telemedicine. Willingness to participate in telemedicine was not associated with prior telemedicine use, perceived positives/negatives of telemedicine, caregiver worry about others caring for their child, or distance from SCD center. Conclusion: The experiences of caregivers accessing healthcare for their child with SCD suggests caregiver burden and barriers to care that may be unique to patients with SCD. Additionally, while the majority are willing to participate in telemedicine for future sickle cell care, the negatives of telemedicine that caregivers reported are significant. Future studies should evaluate models of telemedicine care adapted for this specific population.

Prostate Cancer Screening Disparities in Persons Experiencing Homelessness.

The purpose of this study was to assess prostate-specific antigen (PSA) testing rates in persons experiencing homelessness (PEH), identify factors associated with screening, and compare PSA screening rates in PEH with a matched cohort of persons not experiencing homelessness (non-PEH). We identified 9,249 potentially eligible PEH cared for at a large metropolitan hospital system from an institutional registry of all patients who presented to the health care system as homeless from 2014 to 2021. Homelessness was defined by the presence of the Z-code for homelessness (Z59), the listed address matching to the address of a homeless shelter or other transitional housing or a positive screen for homelessness. A matched cohort of 10,000 non-PEH was generated for comparison. Univariate chi-square analysis and multivariate logistic regression were performed to evaluate variables associated with PSA testing. A total of 1,605 PEH and 3,413 non-PEH were eligible for PSA screening within the study timeframe. Half of PEH were Black (50%). Medicaid was the most common insurance (51%), followed by Medicare (18%). PEH were less likely to have a PCP (58% v 81%, P < .001) and had a significantly lower PSA testing rate (13% v 34%, P < .001) compared with non-PEH. Univariate analysis revealed that PSA testing was more common in PEH who were employed (P < .001), had private insurance or Medicare (P < .001), or had an established primary care provider (PCP; P < .001). Multivariate analysis confirmed that having a PCP (OR, 2.54; 95% CI, 1.62 to 4.00; P < .001) significantly increased the likelihood of PSA testing in PEH. PEH experience low rates of prostate cancer screening. Interventions to increase screening in this population, including increased PCP access, are needed.

Access to Care Limits Lung Cancer Screening Eligibility in an Urban Safety Net Hospital.

Purpose:Lung cancer screening (LCS) results in earlier detection of malignancy and decreases mortality but requires access to care to benefit. We assessed factors associated with timing of lung cancer diagnosis in the absence of systematic LCS in an urban safety net hospital.Patients and Methods:Retrospective chart review was performed of patients with pathologic diagnosis and/or staging of lung cancer at our institution between 2015 and 2018. Patient socio-demographics, disease characteristics, factors associated with access to medical care, and time point and process by which the patient accessed care were collected and analyzed.Results:In total, 223 patients were identified with median age of 63 years and 57.8% male predominance. Racial distribution was 22.9%, 20.2%, 17.1%, and 9.4% for Black, White, Asian, and Hispanic, respectively. Stage at diagnosis was 8.1%, 4.5%, 17.0%, and 60.5% for stages I, II, III, and IV, respectively. Medicaid (59.6%) and Medicare/Medicaid (17.1%) were the most common insurance types, while 16.1% had no insurance. A majority (54.3%) had no established primary care provider (PCP), and only 17.9% had an in-network PCP. Patients without PCPs were more likely to have diagnostic evaluation initiated from Emergency Department or Urgent Care settings (95.0% vs 50.1%, P < .01) and present with later stage disease (92.7% vs 77.8%, P < .01). Of the 83 patients that met age and smoking history LCS criteria, only 33.7% (12.6% of total) also had an in-network PCP.Conclusion:Absence of established PCPs is associated with later stage presentation of lung cancer and may limit system- level benefits of LCS implementation.

Aging through the time of COVID-19: a survey of self-reported healthcare access

BackgroundChronic conditions are common and require ongoing continuous management and preventive measures. The COVID-19 pandemic may have affected the management of chronic conditions by delaying care. We sought to understand the impact of personal characteristics (i.e., age) and healthcare factors (i.e., access to a provider) on healthcare access in a sample of Americans 50 years of age or older during COVID-19.MethodParticipants completed an online survey at the start of the COVID-19 pandemic – the Aging in the Time of COVID Survey. Questions focused on health status, health care access, COVID-19 fear, and social connectedness. Participants were recruited through social media advertisements, list serves, and snowball sampling. Data collection started in early April 2020 and concluded in late May 2020. Logistic regression models examined the results of two key access points: healthcare provider/doctor (n = 481) and medication (n = 765), with 56 and 93% of participants reporting access to a provider and medications, respectively.ResultsIndividuals with an established primary care provider were much more likely to obtain access to a healthcare provider, OR = 3.81 (95% CI: 1.69, 8.77), and to receive medication, OR = 4.48 (95% CI: 1.61, 11.48), during the time of COVID-19. In addition, access to medication was (a) higher for those who were older, OR = 1.05 (95% CI: 1.01, 1.09), had a higher income (greater than 100 k compared to less than 50 k, OR = 3.04 (95% CI: 1.11, 8.98), and (b) lower for those having caregiving responsibilities, OR = 0.41 (95% CI: 0.21, 0.78), or greater social isolation, OR = 0.93 (95% CI: 0.87, 0.98).ConclusionsAlthough most participants had access to medication, just over half had access to a healthcare provider when needed. Notably, health-seeking behaviors for individuals who do not have an established primary care providers as well as those who provide unpaid care, are socially isolated, and younger may require more proactive approaches to care monitoring, management, and maintenance.

Established Primary Care Provider Improves Odds of Survival to Discharge for Injured Patients

The average age and number of comorbidities is increasing among trauma patients. Primary care providers (PCPs) provide pre-injury diagnosis and management of comorbidities that may affect outcomes for injured patients. The role of primary care in trauma systems is currently unknown. Observational retrospective review of an institutional trauma databank from 2013 - 2019. PCP was extracted from the electronic medical record and combined with trauma data. Case-control matching was performed to compare outcomes between patients with and without primary care based on age, injury severity score, sex, and injury mechanism. Mann-Whitney U test, chi-square test, and multivariate regression described differences between subgroups. Primary outcome was difference in mortality rate for injured patients with and without PCPs. Within the study period, 19,096 patients were included. 6,626 (34.7%) had a PCP recorded. Of these, 2,158 were matched in a case-control design. Patients with PCPs had a lower mortality rate (1.6%) compared to patients without PCPs (3.6%, P < 0.01). PCP retention was associated with longer length of stay overall, equivalent rates of complications (5.4% vs. 5.7%, P=0.63), and similar numbers of ICU and ventilator days. Multivariate logistic regression controlling for case-control factors, insurance, and comorbidities conferred an odds ratio of 2.58 (95% Confidence Interval: 1.59 - 4.19, P < 0.001) for survival to discharge. Pre-injury primary care significantly improves the odds of survival to discharge for injured patients. Prospective study of this relationship may identify strategies to promote primary care within health systems.

Cardiovascular Screening and Lipid Management in Breast Cancer Survivors.

Cardiovascular disease (CVD) is the leading cause of death among breast cancer (BC) survivors. BC survivors are at increased risk of CVD due to a higher prevalence of risk factors. Current data are limited on the cardiovascular screening practices and lipid management in this population in primary care settings. A retrospective case control study was performed with 105 BC survivors and 210 matched controls (based on age and medical comorbidities of diabetes, hypertension, and hyperlipidemia). BC survivors were established with primary care practices within a large academic institution and had completed primary cancer treatment. Data on screening for CVD and lipid management were collected via a retrospective chart review. The average BC survivor was 63 years old, with 9 years since diagnosis. Compared with matched controls, BC survivors had more cholesterol screening (88% vs 70%, P < .001) and active statin prescriptions (63% vs 40%, P < .05) if indicated by the Atherosclerotic Cardiovascular Disease Calculator. There were no differences in CVD screening in White and African American BC survivors. However, African American BC survivors were more likely to have hypertension (P < .01) and have a body mass index in the overweight and obese category (P < .001) than White BC survivors. Older BC survivors were more likely to receive cholesterol screening. This study demonstrates that BC survivors who have an established primary care provider have improved cholesterol screening and statin therapy based on their risk of developing chronic diseases.

146 Evaluating the Effectiveness of Providing New Primary Care Appointments Prior to Discharge from a Community Hospital Emergency Department

Emergency departments (EDs) across the United States are frequently used to address medical needs that are better suited for the outpatient setting. A key factor that has been noted to increase use of the ED for low-acuity needs is the lack of an established primary care provider (PCP). To help facilitate the process of establishing PCP care after an ED visit, the Swedish Hospital ED (SHED) in northern Chicago can arrange follow up appointments for patients at a partner federally qualified health center (FQHC), Erie Family Health Centers (EFHC), located on its hospital campus. This study analyzes the effectiveness of eliminating logistical barriers by comparing two-week PCP follow up rates between patients given a written referral only versus an appointment on SHED discharge. This was a retrospective chart review of four months from August 1 to November 30, 2018. The investigators compared two-week follow-up rates for patients without established PCPs who were given referrals to EFHC on SHED discharge and patients who were given an actual appointment on discharge. The investigators cross-referenced SHED electronic medical record (EMR) patient data with EFHC EMR data to determine if/when follow up occurred. A successful follow-up visit was defined as a non-established patient being seen at EFHC within two weeks of their ED visit at SHED. Patients were excluded from the study if there was documentation of a visit at EFHC prior to their SHED visit, constituting previously established care. Primary outcome data was subsequently compared using chi square analysis to assess for statistical significance. Additionally, secondary data including demographics and discharge diagnosis were compared using descriptive statistics to assess factors that may correlate with better or worse clinic follow-up. In total, 980 patient encounters occurred during the study period where patients were either referred to or had an appointment scheduled at the EFHC on SHED discharge. After EMR review, 783 patients given a written referral had already established care within the EFHC system and were excluded from the study, leaving 66 patients in the control group. Six (9%) control group patients followed up within two weeks of their ED visit, while 60 patients (91%) did not follow up in the two week window. Of the 131 patients given appointments prior to their SHED discharge, 34 had already established care at the EFHC system and were thus excluded from the study leaving 97 patients in the study group. Fifty-six (58%) study group patients followed up successfully while the other 41 patients (42%) did not (chi-square 39.4272, p-value < 0.00001), indicating statistical significance. This study demonstrates that eliminating barriers to follow up does increase patient follow-up after an ED visit. It validates the tangible benefits of having a supportive collaboration between a FQHC primary care clinic and community hospital ED with many uninsured or underserved patients. Because the ED is a key health care access point for our health system, especially for patients without regular access to care, it is well suited for interventions to increase establishment of primary care which may in turn decrease unnecessary ED visits and promote regular access to care in the clinic setting.

Evaluating the impact of influenza and streptococcus point-of-care testing and collaborative practice prescribing in a community pharmacy setting

ObjectivesTo determine if a difference in the use of point-of-care (POC) testing and treatment under a collaborative pharmacy practice agreement exists between insured and uninsured patients and also between patients established with a primary care provider (PCP) and those who are not established. A secondary objective was to assess patient satisfaction with a new, pharmacist-provided service. SettingTwo independent community pharmacies. Practice descriptionPerkins Drugs is an independent community pharmacy practice that operates 2 sites in Gallatin, Tennessee. Practice innovationThis practice innovation was pharmacist-provided POC influenza and group A Streptococcus (GAS) pharyngitis testing and associated treatment when appropriate. Pharmacists entered into a collaborative pharmacy practice agreement with a physician at a nearby primary care clinic, which allowed for the testing and prescribing of medication under a predetermined decision tree. EvaluationPatient demographics and satisfaction levels with the service were collected. The service, while continuing, was implemented in December 2018, and cumulative data were collected until April 2019. ResultsPharmacists tested a total of 73 patients for influenza or GAS. Of the total, 24 patients (33%) did not have an established PCP, and 31 (42.5%) were uninsured. No significant difference was found in the use of the service when comparing the insured and uninsured groups, and participants were more likely to have an established PCP than not have. Of the patients who were contacted for follow-up, 98% reported satisfaction with the delivery of the service stating they would use it again. ConclusionCommunity pharmacy–based POC testing provides access to urgent care services for patients regardless of insurance status. In our experience, the service was well liked by patients and provided a nondispensing source of revenue. This service could potentially be duplicated, as state-based pharmacist scope of practice allows, to provide both a needed service to patients and elevate the pharmacist’s role within the health care system.

Improving Incidental Finding Documentation in Trauma Patients Amidst Poor Access to Follow-up Care

BackgroundIncidental findings (IFs) are common among injured patients and create a complex problem with no standardized solution. Materials and methodsThis is a retrospective review of adult trauma patients admitted to a level I trauma center from January to May 2017. IFs from abdominal, chest, and neck imaging were categorized based on previously published guidelines focused on clinically significant IFs. Patient demographics related to access to care were collected. Outcome measures included documentation and patient notification of IFs. A univariate analysis was performed to identify characteristics that were associated with these outcomes. ResultsOf 1671 patients, 682 met inclusion criteria, and 418 (61.3%) had any IF based on the a priori categorization scheme. In total, 67 (9.8%) were homeless, 58 (8.5%) had no health insurance, and 115 (16.9%) had no established primary care provider prior to admission. Documentation of IFs was included in discharge summaries and instructions 76.5% and 40.2% of the time, respectively. Physicians were statistically more likely to appropriately document IFs when radiologists provided specific recommendations. Transfer to another hospital service prior to discharge and discharge to another acute care facility were associated with reduced rates of successful documentation. No factors significantly affected documentation of patient notification. ConclusionsTrauma patients are at risk for poor access to follow-up care of IFs. Expanding IF-specific guidelines, collaborating with radiologists to facilitate their inclusion in reports, and ensuring that IFs are part of patient hand-offs could provide systematic methods of improving their documentation.

A Randomized Controlled Trial of Financial Incentives to Increase Colorectal Cancer Screening: Presidential Poster Award

Introduction: Mailing fecal immunochemical test (FIT) kits to patients’ homes has been shown to boost colorectal cancer (CRC) screening rates, but response rates remain limited, and organized programs typically require repeated outreach attempts. Behavioral economics has shown that offering salient financial incentives to patients may increase participation in preventive health. We compare the impact of different financial incentives for mailed FIT outreach. Methods: This is a four-arm pragmatic randomized controlled trial conducted between December 2015 and February 2018 at urban primary care practices at an academic health system (clinicaltrials.gov NCT02594150). Patients aged 50-75 were included who had an established primary care provider, at least 2 visits in the prior two years, and were eligible for CRC screening. Through automated data extraction and chart review, patients were excluded if they were up-to-date with screening or had a history of CRC, polyps, inflammatory bowel disease, symptoms of gastrointestinal bleeding, a family history of CRC, or advanced illness that may compromise life expectancy. Eligible patients received a letter from their primary care provider that included a mailed FIT kit and instructions for use. They were randomized in a 1:1:1:1 ratio to receive: (1) no financial incentive; (2) an unconditional $10 incentive included with the mailing; (3) a $10 incentive conditional on FIT completion; or (4) a conditional lottery with a 1-in-10 chance of winning $100 after FIT completion. The primary outcome was FIT completion within 2 months of initial outreach, and the secondary outcome was FIT completion within 6 months. Results: 897 patients were included in the intent-to-treat analysis with a median age (IQR) of 56 (52-63) years and average household income of $40,817; 56% were female and 69% were black (Table 1). The overall completion rate across all arms was 23.4% at 2 months and 28.5% at 6 months. No incentive arm was statistically superior to the arm without incentive (Table 2). The completion rate also did not differ across arms at 6 months. We found no difference in completion across arms based on sex or race. Conclusion: Mailed FIT was effective at increasing CRC screening rates in this population, but different forms of financial incentives of the same expected value ($10) did not increase FIT completion rates. The incentive value may be too small or financial incentives may not be effective in this context.250_A Figure 1. Demographic characteristics by group assignment250_B Figure 2. Response to outreach and completion of FIT

Pediatric Provider Education and Use of Long-Acting Reversible Contraception in Adolescents

Pediatric primary care providers prescribe the majority of contraception to adolescents, but they often lack training in long-acting reversible contraception (LARC). Our objective was to assess whether a provider education initiative was associated with a change in LARC use for adolescents. Using electronic medical records, we examined LARC use for 7,331 women ages 15 to 21 years with an established primary care provider before and after a provider education initiative on LARC. We used an interrupted time series design to examine trends in LARC use related to the intervention. Before the intervention, 3.4% to 3.8% of adolescents were using a LARC method, and LARC use was declining by 4 devices/10,000 adolescents per month (95% confidence interval = [-5, -2] per 10,000 adolescents). After the intervention, LARC use stabilized. The number of adolescents using a LARC method increased nonsignificantly at 3, 6, 9, and 12 months after the intervention. Education of pediatric primary care providers reversed a trend toward decreased use of long-acting reversible contraception.

Screening Patterns and Mortality Differences in Patients With Lung Cancer at an Urban Underserved Community

BackgroundThe landmark National Lung Screening Trial demonstrated significant reduction in lung cancer-related mortality. However, European lung cancer screening (LCS) trials have not confirmed such benefit. We examined LCS patterns and determined the impact of LCS-led diagnosis on the mortality of newly diagnosed patients with lung cancer in an underserved community. Patients and MethodsMedical records of patients diagnosed with primary lung cancer in 2013 through 2016 (n = 855) were reviewed for primary care provider (PCP) status and LCS eligibility and completion, determined using United States Preventative Services Task Force guidelines. Univariate analyses of patient characteristics were conducted between LCS-eligible patients based on screening completion. Survival analyses were conducted using Kaplan-Meier and multivariate Cox regression. ResultsIn 2013 through 2016, 175 patients with primary lung cancer had an established PCP and were eligible for LCS. Among them, 19% (33/175) completed screening prior to diagnosis. LCS completion was associated with younger age (P = .02), active smoking status (P < .01), earlier stage at time of diagnosis (P < .01), follow-up in-network cancer treatment (P = .03), and surgical management (P < .01). LCS-eligible patients who underwent screening had improved all-cause mortality compared with those not screened (P < .01). Multivariate regression showed surgery (hazard ratio, 0.31; P = .04) significantly affected mortality. ConclusionTo our knowledge, this is the first study to assess LCS patterns and mortality differences on patients with screen-detected lung cancer in an urban underserved setting since the inception of United States Preventative Services Task Force guidelines. Patients with a LCS-led diagnosis had improved mortality, likely owing to cancer detection at earlier stages with curative treatment, which echoes the finding of prospective trials.

P2.13-008 Lung Cancer Screening Improves Mortality: Examining Screening Patterns in an Urban Underserved Community

The landmark Lung Cancer Screening (LCS) Trial demonstrated a significant reduction in mortality. However, European LCS trials have not confirmed such benefit. We examined the impact of LCS-led diagnosis on the mortality of newly diagnosed lung cancer patients at an urban medical center. Medical records of patients diagnosed with primary lung cancer for the period 2013-2015 (n=638) were reviewed to identify those who had an established primary care provider (PCP), were LCS-eligible/ non LCS-diagnosed, and LCS-eligible/LCS-diagnosed as per the United States Preventative Services Task Force (USPSTF) guidelines. Baseline characteristics between LCS-eligible/non-diagnosed patients and LCS-eligible/diagnosed patients were analyzed using chi-squared and Wilcoxon-Mann-Whitney tests. Kaplan-Meier curves were generated, and predictors of overall survival were evaluated using Cox proportional hazards modeling. 134 primary lung cancer patients had an established PCP and were LCS-eligible; 19/134 (14%) were LCS-diagnosed. LCS-eligible/LCS-diagnosed patients were of younger age (p=0.03), English-speaking (p=0.03), of higher socioeconomic status (p=0.02), active smokers (p<0.01), and had earlier disease stages (p=0.02) than LCS-eligible/non-diagnosed patients. All-cause mortality was significantly lower in LCS-eligible/diagnosed patients compared to LCS-eligible/non-diagnosed patients (p=0.03). Disease stage was found to be the main factor associated with higher mortality by multivariate regression analysis (HR: 6.13, stage 4 vs. stage 1-2, p<0.01). To our knowledge, this is the first report of lung cancer mortality differences in LCS eligible patients as a function of them undergoing or not LCS in a single-center setting since the inception of the USPSTF guidelines. Patients with an LCS-led diagnosis had a reduced mortality, probably as a result of having an earlier disease stage, which echoes the findings of large prospective LCS trials. LCS-led diagnosis rates remain low among lung cancer patients. Fully implementing the USPSTF guidelines constitutes a great unrealized opportunity to decrease lung cancer mortality.

Entry into primary care-based buprenorphine treatment is associated with identification and treatment of other chronic medical problems

BackgroundBuprenorphine is an effective treatment for opioid dependence that can be provided in a primary care setting. Offering this treatment may also facilitate the identification and treatment of other chronic medical conditions.MethodsWe retrospectively reviewed the medical records of 168 patients who presented to a primary care clinic for treatment of opioid dependence and who received a prescription for sublingual buprenorphine within a month of their initial visit.ResultsOf the 168 new patients, 122 (73%) did not report having an established primary care provider at the time of the initial visit. One hundred and twenty-five patients (74%) reported at least one established chronic condition at the initial visit. Of the 215 established diagnoses documented on the initial visit, 146 (68%) were not being actively treated; treatment was initiated for 70 (48%) of these within one year. At least one new chronic medical condition was identified in 47 patients (28%) during the first four months of their care. Treatment was initiated for 39 of the 54 new diagnoses (72%) within the first year.ConclusionsOffering treatment for opioid dependence with buprenorphine in a primary care practice is associated with the identification and treatment of other chronic medical conditions.

Electronic Health Record Components and the Quality of Care

Electronic health records (EHRs) have been promoted as an important tool to improve quality of care. We examined the association between EHR components, a complete EHR, and the quality of care. Using data from the 2005 National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey, we conducted a cross-sectional analysis of all visits with an established primary care provider and examined the association between presence of EHR components and: (1) blood pressure control; and (2) receipt of appropriate therapy for chronic conditions. We examined similar associations for complete EHRs which we defined as one that includes physician and nursing notes, electronic reminder system, computerized prescription order entry, test results, and computerized test order entry. We constructed multivariate models to examine the association between EHR components and each outcome controlling for patient sociodemographic, health, physician practice, and geographic factors. We found no association between electronic physician notes and blood pressure control or receipt of appropriate therapies, with the exception of inhaled steroids among asthmatics (adjusted odds ratio 2.86; 95% confidence interval, 1.12-7.32). We found no association between electronic reminder systems and blood pressure control or receipt of appropriate therapies, with the exception of angiotensin converting enzyme inhibitors or angiotensin receptor blockers in patients with diabetes with hypertension (odds ratio 2.58; 95% confidence interval, 1.22-5.42). We found no association between electronic physician notes and any measure of quality. We found no relationship between having a complete EHR and any of the quality measures investigated. We found no consistent association between blood pressure control, management of chronic conditions, and specific EHR components. Future research focusing on how an EHR is implemented and used and how care is integrated through an EHR will improve our understanding of the impact of EHRs on the quality of care.

Prevalence of Human Immunodeficiency Virus Testing in Patients With Hepatitis B and C Infection

To determine the proportion of patients with hepatitis B virus (HBV) and hepatitis C virus (HCV) who are adequately assessed for human immunodeficiency virus (HIV) and to identify variables associated with absence of HIV testing. We retrospectively reviewed the medical records of patients who had positive serologic test results for reactive HBV and/or HCV between January 1999 and December 1999 and were followed up at a general internal medicine clinic in East Harlem, NY. Data were collected on patient demographics, HIV risk factors, and other variables that might influence the physician's decision to test the patient for HIV. Primary outcomes were HIV tests performed and documented discussions of at-risk HIV behavior. The HIV tests were performed in 40% (95% confidence interval [CI], 32%-49%) of the 141 patients with reactive HBV and/or HCV serologic test results. Predictors of HIV testing on multivariate logistic regression were age younger than 50 years (odds ratio [OR], 25; 95% CI, 13-3.8), male sex (OR, 1.6; 95% CI, 1.1-2.2), and having an established primary care provider (OR, 2.3; 95% CI, 1.2-3.9). Injection drug use was not significantly associated with HIV testing. Although HBV and HCV have clear epidemiological links with HIV, this study shows that a high percentage of these patients are not being tested. Although some of the factors associated with lack of testing were identified, further studies on the barriers to HIV testing are needed to reveal potential approaches to increase rates of HIV testing in this high-risk population.