Hospital-based Primary Care Clinic Research Articles

COVID-19 Vaccination in Historically Marginalized Communities: Examining Barriers and Facilitators in a Pediatric Population

ObjectiveCoronavirus disease (COVID-19) hospitalization rates among unvaccinated children are double that of vaccinated children, and this difference is greater among racial and ethnic minority children. Vaccination rates among children remain suboptimal. Few studies have characterized barriers to COVID-19 vaccination among historically marginalized communities. MethodsFrom January 2022 to May 2022, parents, and guardians of children ages 12 months to 18 years presenting for pediatric care at a hospital-based primary care clinic were surveyed about perceptions of COVID-19 vaccines, intentions to vaccinate their child, and trusted sources of information. Results113 parents/guardians participated, with 92% self-identifying with a historically marginalized racial/ethnic group. 54% of respondents either did not plan to vaccinate their child against COVID-19 or were unsure. The obstacles to vaccination most frequently cited were related to: 1) unknown side effects, 2) the rapid development of the vaccine, and 3) unsafe ingredients. Worries about being used as experimental subjects and potential impacts on fertility were also reported. Parents who planned to vaccinate their child reported higher rates of trust in doctors, local clinics, hospitals, and health departments. ConclusionsHigh rates of COVID-19 vaccination hesitancy exist among parents/guardians from historically marginalized groups. Barriers to vaccination were frequently related to side effects, while a high level of trust in healthcare providers as sources of information may be a facilitator. Strategies to improve health outcomes and boost vaccination rates should focus on equipping pediatric healthcare providers with the knowledge and skills necessary to address these known barriers to COVID-19 vaccination.

COVID-19 Disruptions to Social Care Delivery: A Qualitative Study in Two Large, Safety-Net Primary Care Clinics

BackgroundSocial care integration refers to the incorporation of activities into health systems that assist patients with health-related social needs (HRSNs) that negatively impact the health outcomes of their patients, such as food insecurity or homelessness. Social care integration initiatives are becoming more common. The COVID-19 pandemic strained health systems while simultaneously increasing levels of unmet social needs.ObjectiveTo describe the effects of the COVID-19 pandemic on established social care delivery in a primary care setting.DesignWe used qualitative semi-structured interviews of stakeholders to assess barriers and facilitators to social care delivery in the primary care setting during the COVID-19 health emergency. Data was analyzed using a hybrid inductive/deductive thematic analysis approach with both the Consolidated Framework for Implementation Research (CFIR) and the Screen-Navigate-Connect-Address-Evaluate model of social care integration.SettingTwo safety-net, hospital-based primary care clinics with established screening for food insecurity, homelessness, and legal needs.ParticipantsSix physicians, six nurses, six members of the social work team (clinical social workers and medical case workers), six community health workers, and six patients (total N = 30) completed interviews.ResultsFour major themes were identified. (1) A strained workforce experienced challenges confronting increased levels of HRSNs. (2) Vulnerable populations experienced a disproportionate negative impact in coping with effects of the COVID-19 pandemic on HRSNs. (3) COVID-19 protections compounded social isolation but did not extinguish the sense of community. (4) Fluctuations in the social service landscape led to variable experiences.ConclusionsThe COVID-19 pandemic disrupted established social care delivery in a primary care setting. Many of the lessons learned about challenges to social care delivery when health systems are strained are important considerations that can inform efforts to expand social care delivery.

Implementation of an EHR-integrated web-based depression assessment in primary care: PORTAL-Depression.

To integrate a computerized adaptive test for depression into the electronic health record (EHR) and establish systems for administering assessments in-clinic and via a patient portal to improve depression care. This article reports the adoption, implementation, and maintenance of a health information technology (IT) quality improvement (QI) project, Patient Outcomes Reporting for Timely Assessment of Life with Depression (PORTAL-Depression). The project was conducted in a hospital-based primary care clinic that serves a medically underserved metropolitan community. A 30-month (July 2017-March 2021) QI project was designed to create an EHR-embedded system to administer adaptive depression assessments in-clinic and via a patient portal. A multi-disciplinary team integrated 5 major health IT innovations into the EHR: (1) use of a computerized adaptive test for depression assessment, (2) 2-way secure communication between cloud-based software and the EHR, (3) improved accessibility of depression assessment results, (4) enhanced awareness and documentation of positive depression results, and (5) sending assessments via the portal. Throughout the 30-month observational period, we collected administrative, survey, and outcome data. Attending and resident physicians who participated in the project were trained in depression assessment workflows through presentations at clinic meetings, self-guided online materials, and individual support. Developing stakeholder relationships, using an evaluative and iterative process, and ongoing training were key implementation strategies. The PORTAL-Depression project was a complex and labor-intensive intervention. Despite quick adoption by the clinic, only certain aspects of the intervention were sustained in the long term due to financial and personnel constraints.

Pediatric behavioral health care utilization in integrated primary care and hospital-based clinics during the pandemic – Implications for virtual care

Introduction: The COVID-19 pandemic forced health care organizations and providers to adapt innovative approaches to ensure patient care needs are met. In particular, improving patient access to behavioral health services is essential to improving population health. 
 Methods and Aims: Clinical visit volume and utilization data were analyzed via the Tableau platform for behavioral health visits by providers within the division of Pediatric Psychology at the University of Michigan Health (UM) during the pandemic through the present. UM is a publicly funded academic medical center that manages a total of approximately 2.5 million patient visits per year. Psychologists provide care within hospital-based specialty clinics or primary care clinics, both of which utilize integrated models of care. Unprecedented changes were made with regards to care delivery format and workforce allocation, and the present paper examines the corresponding impact on patient behavior health care. 
 Results: During Fiscal Year 22 (July 2021 to June 2022), 24 pediatric psychology providers completed a total of 8,252 visits within 12,802 available patient slots, a utilization rate of 64.5%. Utilization was significantly higher in primary care clinics (80.9%) than in hospital-based clinics (51.6%), Z = 34.47, p < .00001. Services were delivered virtually in 100% of the 4549 visits completed in primary care and 72.6% of the 3703 completed hospital visits. These data are currently being analyzed for the present Fiscal Year 23. Patient satisfaction data revealed barriers impacting access to care, including scheduling issues, setting up virtual care and managing, technology problems. 
 Conclusions: Utilization data provides strong support for delivery of behavioral health services in primary care via virtual care means. However, patients area likely to encounter significant barriers to initiating and participating in care when systems are designed to exclusively or primarily support remote users. 

Prevalence and burden of diabetes mellitus-related symptoms in patients with type 2 diabetes mellitus: A cross-sectional study.

Type 2 diabetes mellitus (T2DM) is a significant non-communicable disease in Malaysia, with a prevalence of 18.1%, per the National Health and Morbidity Survey. This study aimed to determine the prevalence and burden of diabetes mellitus-related symptoms and whether these symptoms were addressed by primary care doctors. This 1-month cross-sectional study was conducted at an urban hospital-based primary care clinic in Malaysia. Patients with T2DM were recruited using systematic random sampling. Participants answered a self-administered questionnaire adapted from the Diabetes Symptom Checklist-Revised, which evaluated the sociodemographic characteristics, burden of diabetes mellitus-related symptoms in the past month and post-consultation feedback about symptoms. Data were analysed using SPSS. Four hundred eighteen participants were included, yielding a response rate of 97.7%. Hyperglycaemia was the most prevalent symptom, with 48.1% of the participants reporting a frequent need to empty their bladder. Most participants experienced a low symptom burden, so 56.7% did not report their symptoms to their doctors. The participants who reported their symptoms had a higher symptom burden. Among them, 97.5% indicated that their doctors addressed their symptoms. Approximately 78% reported satisfaction and good coping skills when their symptoms were addressed. Hyperglycaemia was the most prevalent diabetes mellitus-related symptom among the patients with T2DM. The symptom burden was generally low, so most patients did not report their symptoms to their doctors. Those who reported their symptoms had a higher symptom burden. Further studies must explore why patients do not report their symptoms and how doctors address patients' symptoms.

Factors Associated with Utilization of Teleretinal Imaging in a Hospital-Based Primary Care Setting.

Regular eye examinations to screen for the initial signs of diabetic retinopathy (DR) are crucial for preventing vision loss. Teleretinal imaging (TRI) offered in a primary care setting provides a means to improve adherence to DR screening, particularly for patients who face challenges in visiting eye care providers regularly. The present study evaluates the utilization of TRI to screen for DR in an outpatient, hospital-based primary care clinic. Patients with diabetes mellitus (DM) but without DR were eligible for point-of-care screening facilitated by their primary care provider, utilizing a non-mydriatic, handheld fundus camera. Patient demographics and clinical characteristics were extracted from the electronic medical record. Patients who underwent TRI were more likely to be male, non-White, and have up-to-date monitoring and treatment measures, including hemoglobin A1c (HbA1c), microalbumin, and low-density lipoprotein (LDL) levels, in accordance with Healthcare Effectiveness Data and Information Set (HEDIS) guidelines. Our findings demonstrate that TRI can reduce screening costs compared to a strategy where all patients are referred for in-person eye examinations. A net present value (NPV) analysis indicates that a screening site reaches the break-even point of operation within one year if an average of two patients are screened per workday.

Nurse-Sensitive Indicators in the Care of Individuals With Opioid Use Disorder.

Patients with opioid use disorder (OUD) seek care in primary care settings where nurses support the provision of medication-assisted treatment. Office-based opioid treatment (OBOT) that includes buprenorphine hydrochloride administration under the supervision of a nurse for stabilization and maintenance therapy has the potential to improve outcomes for patients with OUD in primary care settings. However, the first step is to determine if OBOT nurses provide nurse-sensitive care, which consists of activities that have been shown to make a difference in patient outcomes. Content analysis of 368 nursing notes from 100 patients enrolled in an OBOT program in an urban hospital-based primary care clinic was conducted. Data were analyzed descriptively according to quantity and qualitatively according to the content. Entries indicative of care coordination and transition management were extracted. Seven content categories within care coordination were identified, including harm reduction, medication management, symptom management, communication between providers, promoting adherence, self-management goal setting, and patient education. Four areas within transition management were identified including supporting connections to resources, referrals for care, medication reconciliation, and communication with other facilities. Care coordination was documented more frequently than transition management. The presence of nurse-sensitive indicators provides evidence for and distinguishes the role of the nurse in OUD care.

Implementing the Digital Diabetes Questionnaire as a Clinical Tool in Routine Diabetes Care: Focus Group Discussions With Patients and Health Care Professionals.

BackgroundThe Diabetes Questionnaire is a digital patient-reported outcome and experience measure for adults living with diabetes. The Diabetes Questionnaire is intended for use in routine clinical visits in diabetes care and to enable patient perspectives to be integrated into the Swedish National Diabetes Register. The Diabetes Questionnaire was developed on the basis of patients’ perspectives, and evidence for its measurement qualities has been demonstrated. Patients receive an invitation to complete the questionnaire before clinical visits, and the patient and health care professional (HCP) can discuss the findings, which are instantly displayed during the visit. Implementation processes for new tools in routine care need to be studied to understand the influence of contextual factors, the support needed, and how patients and HCPs experience clinical use.ObjectiveThe aim of this study was to describe patients’ and HCPs’ experiences of initiating the use of the digital Diabetes Questionnaire as a clinical tool in routine diabetes care, supported by a structured implementation strategy involving initial education, local facilitators, and regular follow-ups.MethodsIn this qualitative study, semistructured focus group discussions were conducted 12 months after the use of the Diabetes Questionnaire was initiated. Participants were diabetes specialist nurses and physicians (20 participants in 4 groups) at hospital-based outpatient clinics or primary health care clinics and adults with type 1 or type 2 diabetes (15 participants in 4 groups). The audiotaped transcripts were analyzed using inductive qualitative content analysis.ResultsThe results revealed 2 main categories that integrated patients’ and HCPs’ experiences, which together formed an overarching theme: While implementation demands new approaches, the Diabetes Questionnaire provides a broader perspective. The first main category (The Diabetes Questionnaire supports person-centered clinical visits) comprised comments expressing that the digital Diabetes Questionnaire can initiate and encourage reflection in preparation for clinical visits, bring important topics to light during clinical visits, and broaden the scope of discussion by providing additional information. The second main category (The process of initiating the implementation of the Diabetes Questionnaire) comprised comments that described differences in engagement among HCPs and their managers, challenges of establishing new routines, experiences of support during implementation, thoughts about the Diabetes Questionnaire, need to change local administrative routines, and opportunities and concerns for continued use.ConclusionsThe Diabetes Questionnaire can broaden the scope of health data in routine diabetes care. While implementation demands new approaches, patients and HCPs saw potential positive impacts of using the questionnaire at both the individual and group levels. Our results can inform further development of implementation strategies to support the clinical use of the questionnaire.

1.7 Screening Adolescents for Trauma and Traumatic Stress Symptoms at Annual Pediatric Wellness Visits: Implementation of a Standardized Screening Process

Routine screening for childhood trauma in the pediatric primary care setting is recommended to identify youth at risk for negative physical and mental health sequelae. We sought to improve adolescent trauma screening in our urban, hospital-based pediatric primary care clinic by implementing the use of the Pediatric Traumatic Stress Screening Tool (PTSST), a validated screening tool for trauma and traumatic stress symptoms in children and adolescents. A survey to assess current resident practices established the need for a standardized trauma screening process in our clinic, because none existed. A clinical workflow was implemented to screen adolescents aged 11 years and older for trauma and traumatic stress symptoms using the self-complete adolescent version of the PTSST during well visits. Additional interventions included: 1) provider educational sessions; 2) a provider decision-making algorithm; 3) standard language for documentation of screening; and 4) a list of patient resources. We reviewed adolescent well visits conducted during the first 6 weeks postimplementation (n = 103) to gather data on weekly rates of documented PTSST screening and screening results. We also reviewed visits during the 6 weeks pre-implementation (n = 120) to compare pre- and postimplementation rates of referrals to mental health services and reports to the Administration for Children's Services (ACS) for safety concerns. Residents documented trauma screening using the PTSST at 19.4% of visits postimplementation (weekly range: 7%-46%). Of those adolescents screened, 25% reported a prior trauma (n = 5) with 80% of these endorsing moderate or severe symptoms of traumatic stress. All youth screening positive for trauma were referred for mental health services (n = 4) or already engaged in care (n = 1). Rates of adolescent mental health referrals were similar pre- and postimplementation (18.3% vs 15.5%). Screening resulted in the only ACS report made pre- or postimplementation. Our initiative to standardize and increase trauma screening using the PTSST led to the detection of adolescents with prior traumatic experiences and facilitated the identification of youth in need of mental health services. Future interventions will aim to increase provider engagement and education on in-office interventions for traumatic stress symptoms.

Hepatitis C treatment outcomes among patients treated in co-located primary care and addiction treatment settings

BackgroundPersons with substance use disorders face major barriers to hepatitis C virus (HCV) treatment. Co-location of addiction and HCV treatment is appealing, yet there are limited data on outcomes using this model. This study evaluated HCV outcomes of patients treated with direct-acting antivirals (DAAs) by primary care providers in two sites of co-located addiction/HCV care. MethodsThe study conducted a retrospective chart review for all patients receiving DAA treatment from 2016 to 2018 at 1) a hospital-based primary care clinic with an office-based buprenorphine program, and 2) a primary care clinic within an opioid treatment program (i.e. methadone clinic). The study classified patients into 3 groups according to treatment status: buprenorphine maintenance, methadone maintenance, or neither. Descriptive analyses compared patient demographics, clinical characteristics, adherence to monitoring and treatment, and the primary outcome of sustained virologic response at 12 weeks (SVR12), defined as an undetectable HCV viral load at least 12 weeks after completing treatment. ResultsThis study included 50 patients who initiated DAA treatment. The majority of patients were unemployed (74.0%), did not smoke tobacco (54.0%), and had psychiatric comorbidities (80.0%). Many also experienced homelessness during treatment (22.0%) and experienced previous incarceration (36.0%). Only a few had recently injected drugs (4.0%). Seven of 7 (100%) patients were treated with buprenorphine, 21 of 24 (87.5%) patients were treated with methadone, and 17 of 19 (89.5%) patients receiving no opioid addiction treatment fully completed HCV DAA treatment. When including patients with missing SVR12 data with the cohort that did not achieve cure, we observe that 44 of 50 patients (88.0%) achieved SVR12. Excluding patients missing SVR12 data, we observed that 44 of 46 patients (95.7%) achieved SVR12. ConclusionPersons with substance use disorders treated with DAAs in co-located primary care and addiction treatment settings can achieve high rates of cure despite significant comorbidities and barriers. DAA treatment should be expanded to co-located HCV and addiction settings.

An Innovative Model for Providing Dermatology Services Within Primary Care.

ObjectiveDermatologic complaints are common in outpatient pediatrics. However, pediatric dermatology specialty care can be difficult to access. We aimed to test the feasibility of co-locating dermatology services within primary care and increase the proportion of patients treated for basic skin complaints within the medical home while decreasing wait times.MethodsThe Rapid Assessment of Skin Health (RASH) clinic was created within a hospital-based primary care clinic in 11/2013. The clinic was staffed by 2 pediatricians trained in the dermatology department and supported with specialist advice as needed. Referral volume and wait times to dermatology and RASH clinic were tracked for visits between 11/1/12 and 10/31/18. A chart review was also conducted on a subset of RASH clinic visits. Primary care providers (PCPs) were surveyed about their experiences.ResultsFifty-eight percent of patients referred for a dermatologic complaint were scheduled in RASH clinic. Wait times for new patient appointments in RASH clinic were significantly shorter than for new dermatology appointments in the previous 12 months (mean 36 days vs 65 days, P < .001). The monthly number of referrals to dermatology also decreased significantly after the RASH clinic opened (24/month vs 12/month, P < .001). Ten percent of RASH patients were referred on to dermatology. In a survey of PCPs (N = 67), 76% said the RASH clinic was “extremely/very helpful.”ConclusionsProviding dermatologic care to low or moderate complexity patients within the medical home is feasible and leads to better access to care. This innovative model could be spread to other clinics and subspecialties.

An implementation project to expand access to self-administered depot medroxyprogesterone acetate (DMPA)

ObjectiveTo describe the implementation and results of a proactive patient outreach project to offer self-administered, depot medroxyprogesterone (DMPA) subcutaneous (SC) to interested patients at a California safety-net clinic following expanded state Medicaid coverage. Study designWe contacted non-pregnant patients at an urban, safety-net hospital-based primary care clinic who had been prescribed DMPA intramuscular (IM) in the past year to gauge interest in self-administered DMPA-SC. Interested patients received a prescription for DMPA-SC and a telehealth appointment with a clinic provider to learn self-injection. We recorded patient interest in DMPA-SC, completed appointments, and completed first injections. We conducted initial outreach in May, 2020 and recorded appointment attendance and completed injections through August, 2020. ResultsOf 90 eligible patients (age 17–54), we successfully contacted and discussed DMPA-SC with 70 (78%). Twenty-six (37%) patients expressed interest in DMPA-SC and scheduled telehealth appointments to learn to self-administer the medication. Fifteen (58%) of those interested (21% of the total) successfully self-injected DMPA-SC. Of the 44 (63%) patients not interested in DMPA-SC, the three most common reasons were fear of self-injection (n = 23 [52%]), wanting to stop DMPA (n = 11 [25%]), and satisfaction with DMPA-IM (n = 6 [14%]). ConclusionThere is interest in and successful initiation of self-administered DMPA-SC among patients at an urban safety net hospital-based primary care clinic who have used DMPA-IM in the last year. ImplicationsOur data provide evidence for the interest and successful first injection rate after offering self-administered DMPA-SC to patients on DMPA-IM. Expanding coverage of self-administered DMPA-SC could increase patient-centeredness and accessibility of contraception as well as reduce patient anxiety around COVID-19 transmission without losing contraceptive access.

MAKING OLD BONES: QUALITY IMPROVEMENT IN OSTEOPOROSIS MANAGEMENT IN A GERIATRIC PRIMARY CARE CLINIC

Osteoporotic fractures and their sequelae are a leading cause of morbidity and mortality in older adults. In the United States, nearly 50% of white women and 20% of black women and white men will suffer a fragility fracture in his or her lifetime. Osteoporosis medications reduce the risk of major fragility fracture by 31-62%, but numerous care gaps exist, including screening rates as low as 1-47% and treatment rates as low as 16-30% even after a fracture has already occurred. From January to August 2019, we conducted a multi-faceted quality improvement project at a university hospital-based geriatric primary care clinic, with a goal of improving our rates of osteoporosis screening and treatment. We designed and tested electronic health record-based registries of eligible patients, and developed patient outreach workflows and physician “inreach” workflows. We piloted a bone health clinic. While we did not meaningfully affect the rate of osteoporosis screening, our efforts resulted in an increase in treatment of osteoporosis from 49% to 53%. Documentation of osteoporosis decision making among eligible patients improved from 66% to 80%. In our clinic, ongoing barriers to evidence-based osteoporosis management include competition for time with other medical issues, patient mistrust of medications, and the complexity of decision making around osteoporosis in older adults with polypharmacy and limited life expectancy. Future work must balance the broad application of treatment guidelines via population health tools with the need to individualize treatment decisions for each patient’s overall health and goals of care.

Evaluation of Direct Oral Anticoagulant Dosing and Monitoring in Two Geriatric Outpatient Clinics

OBJECTIVE: This study was conducted to evaluate direct oral anticoagulants (DOACs) prescribed to elderly patients in an outpatient setting, specifically evaluating if Food and Drug Administration (FDA) -approved dosing recommendations are followed.<br/> DESIGN: This study was a retrospective quality improvement project.<br/> SETTING: This study was conducted at geriatric hospital-based primary care clinics at the University of Pittsburgh Medical Center (UPMC), UPMC Senior Care Institute and UPMC Benedum Geriatric Center.<br/> PATIENTS: Subjects included were 65 years of age or older; had an office visit at UPMC Senior Care Institute or UPMC Benedum Geriatric Center from September 1, 2015, to August 31, 2017; and had a DOAC on their home medications.<br/> INTERVENTIONS: Data were obtained through retrospective chart review.<br/> MAIN OUTCOME MEASURE: The primary objective of the study was to evaluate the appropriateness of dosing of DOACs based on FDA-labeled recommendations.<br/> RESULTS: Of 232 patients included in analysis, 42.7% were found to have dosing inconsistent with FDAlabeled recommendations (47.3% apixaban, 35.8% rivaroxaban, and 31.6% dabigatran). No patients were prescribed edoxaban. The majority (72.7%) were dosed lower than FDA-recommended doses. Of all patients, the most frequent parameter (54.5%) for inappropriate dosing was patients meeting only 1 of 3 dose-reduction criteria when prescribed reduced-dose apixaban. Geriatrician and nongeriatrician prescribers had similar rates of prescribing DOACs with doses inconsistent with FDA-labeled recommendations (44.0% vs. 40.8%; P = 0.62).<br/> CONCLUSION: Results suggest that DOACs used in outpatient geriatric patients are frequently dosed inconsistent with FDA-approved dosing recommendations. Further research is needed regarding clinical outcomes in older patients receiving DOACs and in those with dose adjustments inconsistent with FDA-labeled recommendations.<br/>.

The willingness of Saudi men with type 2 diabetes to discuss erectile dysfunction with their physicians and the factors that influence this.

ObjectivesThe study’s objectives were to find out the proportion of Saudi men with type 2 diabetes who have been asked by their physicians about erectile dysfunction (ED) in the last year, to determine the willingness of Saudi men with type 2 diabetes to discuss ED, and to explore the factors that may be related to their willingness to discuss ED with their physicians.MethodsThis study employed a cross-sectional survey design using a quantitative self-administered questionnaire among 309 Saudi men with type 2 diabetes. The study was conducted in hospital-based primary care clinics at King Khalid University Hospital, Riyadh, Saudi Arabia during the period from July to September 2015.ResultsThe mean age of the patients was 60.2 years with the mean duration of diabetes approximately 12.5 years. Few of the patients (9.7%) had been asked by their physicians about ED within the last year of attending the clinics although most patients (84.8%) were willing to discuss this issue. The presence of ED among the respondents was 89%. Two participants’ characteristics were associated with a willingness to discuss ED with the physicians. These characteristics were age above 60 (OR = 0.25, 95% CI: 0.11–0.55), and having severe ED (OR = 0.26, 95% CI: 0.08–0.85). The respondents’ main barriers to discussing ED with their physicians were embarrassing the doctor, ED is a personal issue, too old or too sick to address ED issues now, no effective treatment available, and the doctor is too young to discuss ED with.ConclusionsMost patients who have type 2 diabetes are not asked about ED within the last year of attendance even though most are willing to discuss it with their physicians. Being older and suffering more severe ED will result in being less willing to discuss ED with their doctor. Further research is needed to explore the barriers which prevent physicians from discussing ED with their patients who have diabetes.

A Randomized Controlled Trial of an Eczema Care Plan

ObjectiveTo test whether an eczema care plan (ECP) would improve provider documentation and management, decrease eczema severity, and increase patient quality of life (QOL) in the pediatric primary care setting. MethodsWe conducted a randomized controlled trial from June 2015 to September 2016 at a large hospital-based pediatric primary care clinic. Participants included children from 1 month to 16 years of age with a diagnosis of eczema. The intervention group received the ECP and the control group received usual care. Both groups completed a validated eczema severity scale (Patient-Oriented Eczema Measure [POEM]) and a QOL scale (Infant's Dermatitis Quality of Life Index [IDQOL]) or Children's Dermatology Life Quality Index [CDLQI]) before the visit and again ~1 month later. ResultsA total of 211 caregivers completed both the pre- and postintervention surveys (100 control group and 111 intervention group [94% completion]). Intervention group providers were more likely to recommend a comprehensive “step-up” plan (88%) vs 28%; P < .001, bleach baths (45%) vs 9%; P < .001, and wet wraps (50%) vs 7%; P < .001. They were also more likely to document providing a written plan to families (80%) vs 2%; P < .001. In the intervention and control groups, eczema severity and QOL improved between the pre- and postintervention periods. However, there was not a significant difference between the groups on either measure: POEM difference −0.8, 95% confidence interval (CI) −3.2 to 1.7; IDQOL difference −0.1, 95% CI −1.8 to 1.6; CDLQI difference 0.8, 95% CI −0.9 to 2.6. ConclusionsIntervention group providers documented more comprehensive eczema care than control group providers. Although patients improved on all measures in the postintervention period, the ECP did not augment that improvement.

Buprenorphine/Naloxone Maintenance Therapy: an Observational Retrospective Report on the Effect of Dose on 18 months Retention in an Office-Based Treatment Program.

Context and objective:Buprenorphine has been available with few reports of the dose range necessary to adequately maintain patients. We report on the effect of 8 mg/d versus 16 mg/d of buprenorphine on long-term patient retention in office-based opioid maintenance (OBOMT).Design, setting, and participants:Case series, at an urban hospital-based primary care clinic providing OBOMT to 157 opiate-dependent, low socioeconomic status, uninsured, nonhomeless patients.Intervention:The OBOMT program operated by a comprehensive sobriety treatment program experienced State funding cuts. Thus, after 2 years, the program was required by the State funder to decrease the buprenorphine maintenance dose from 16 to 8 mg/d for all new admissions. We report on patient retention before and after dose reduction.Main outcome measures:The primary outcomes of this study were to measure and compare patient retention in the 2 cohorts at each point of treatment transition over the 18 months following OBOMT initiation.Results:No significant differences in patient retention were observed between the 16 and 8 mg/d patient cohorts. Lower dose buprenorphine maintenance (8 mg/d) in uninsured patients enrolled in publicly funded long-term OBOMT combined with comprehensive sobriety counseling was as effective as higher dose therapy (16 mg/d) in promoting patient retention throughout the study period. This lower dose resulted in a substantial saving to the public funding agency.Conclusions:In an observational retrospective report, retention in treatment of opiate-addicted patients was the same at 8 and 16 mg/d buprenorphine doses after 18 months. These data have implications for public and managed care funding of OBOMT, for the general prescribing of buprenorphine in outpatient care, and may be instructive in the ongoing debate about the relationship between buprenorphine dose.

Making the cut: Depression screening in urban general hospital clinics for culturally diverse Latino populations.

We examined whether the cut-point 10 for the Patient Health Questionnaire-9 (PHQ9) depression screen used in primary care populations is equally valid for Mexicans (M), Ecuadorians (E), Puerto Ricans (PR) and non-Hispanic whites (W) from inner-city hospital-based primary care clinics; and whether stressful life events elevate scores and the probability of major depressive disorder (MDD). Over 18-months, a sample of persons from hospital clinics with a positive initial PHQ2 and a subsequent PHQ9 were administered a stressful life event questionnaire and a Structured Clinical Interview to establish an MDD diagnosis, with oversampling of those between 8 and 12: (n=261: 75 E, 71 M, 51 PR, 64 W). For analysis, the sample was weighted using chart review (n=368) to represent a typical clinic population. Receiver Operating Characteristics analysis selected cut-points maximizing sensitivity (Sn) plus specificity (Sp). The optimal cut-point for all groups was 13 with the corresponding Sn and Sp estimates for E=(Sn 73%, Sp 71%), M=(76%, 81%), PR=(81%, 63%) and W=(80%, 74%). Stressful life events impacted screen scores and MDD diagnosis. Elevating the PHQ9 cut-point for inner-city Latinos as well as whites is suggested to avoid high false positive rates leading to improper treatment with clinical and economic consequences.

Challenges to Meeting Access and Continuity Performance Measures in a Large Hospital-Based Primary Care Clinic Implementing the Patient-Centered Medical Home: A Qualitative Study

Article-at-a-Glance Purpose Patient-centered medical home (PCMH) performance measures are used to gauge progress towards improving timely access to care and patient-provider continuity. Starting in 2010, the Veterans Health Administration (VHA) PCMH initiative focused on clinics' performance in accommodating urgent access requests from established patients to their usual primary care providers (PCPs). Factors were examined that affected the efforts of a large hospital-based VHA primary care clinic to meet an urgent access PCMH performance measure while implementing other aspects of PCMH. Method Early in PCMH implementation (2012–2013), 20 semistructured interviews were conducted with primary care staff (physicians, residents, nurses, and administrative clerks), and 19 coaching sessions designed to help primary care teams improve access and continuity were observed. Descriptive codes were applied, and findings were developed via consensus. Results This large primary care clinic was challenged in meeting the urgent access performance measure by part-time availability of many PCPs, conflicting with performance measure structure; PCMH-encouragement of processes to increase urgent access that were not recognized by performance measures; high patient volume, overwhelming efforts to increase access; numerous and varied schedulers hindering coordination of scheduling algorithms; and multiple simultaneous access improvement goals that non-hospital-based clinics may not experience. Conclusions Early in VHA PCMH implementation, a performance measure that incentivized same-day access to the usual PCP created unanticipated challenges at a large hospital-based primary care clinic.

Targeted Reminder Phone Calls to Patients at High Risk of No-Show for Primary Care Appointment: A Randomized Trial.

No-shows, or missed appointments, are a problem for many medical practices. They result in fragmented care and reduce access for all patients. To determine whether telephone reminder calls targeted to patients at high risk of no-show can reduce no-show rates. Single-center randomized controlled trial. A total of 2247 primary care patients in a hospital-based primary care clinic at high risk of no-show (>15% risk) for their appointment in 7 days. Seven days prior to their appointment, intervention arm patients were placed in a calling queue to receive a reminder phone call from a patient service coordinator. Coordinators were trained to engage patients in concrete planning. All patients received an automated phone call (usual care). Primary outcome was no-show rate. Secondary outcomes included arrival rate, cancellation rate, reschedule rate, time to cancellation, and change in revenue. The no-show rate in the intervention arm (22.8%) was significantly lower (absolute risk difference -6.4%, p < 0.01, 95% CI [-9.8 to -3.0%]) than that in the control arm (29.2%). Arrival, cancellation, and reschedule rates did not differ significantly. In the intervention arm, rescheduling and cancellations occurred further in advance of the appointment (mean difference, 0.35days; 95% CI [0.07-0.64]; p = 0.01). Reimbursement did not differ significantly. A phone call 7 days prior to an appointment led to a significant reduction in no-shows and increased reimbursement among patients at high risk of no-show. The use of targeted interventions may be of interest to practices taking on increased accountability for population health.