Hospital-based Primary Care Clinic Research Articles

Capsule Commentary of Shah et al., Targeted Reminder Phone Calls to Patients at High Risk to No-Show for Primary Care Appointment: A Randomized Trial.

T his randomized controlled trial of a telephone intervention in a hospital-based primary care clinic found that a reminder phone call reduced the no-show rate. This is timely and important because empirical evidence suggests that expanded health insurance coverage would potentially increase appointment wait time because of constraints on medical capacity, raising concern regarding efficient appointment coordination in health care services. For example, the average appointment wait time to see an internist increased from 33 days to 52 days when health care reform was initially implemented in Massachusetts. Medical practitioners and policymakers have recognized that delayed appointments could result in discontinuities of care and declines in health status and have performed various interventions such as same-day appointment. However, many interventions have emphasized the role of medical providers and have paid relatively less attention to the obstacles from patients although patient no-shows and last-minute cancellations also significantly interrupt medical providers’ productivity and other patients’ access to health care. This study implies that efficient appointment coordination would be critical to improve timely access to health care and that interventions would be more cost-effective if we identify patients at high risk to no-show and tailor interventions to them. The soundness of a randomized controlled trial warrants careful discussion, as approximately a quarter of patients in the intervention group did not receive at least one reminder call and the differences in the baseline characteristics between the treatment and control groups were not examined statistically. Descriptions of the statistical analysis and estimation results also need further explanations. For example, the authors did not mention the core options (e.g., link function) of a generalized estimating equations model (GEE), even though a GEE yields a wide array of estimation models depending on these options. As a result, it is hard to understand exactly which estimation model was employed and how absolute risk reductions were defined and obtained after estimation. Further studies investigating variations in appointment wait time and no-show (e.g., by physician specialty, patient employment status, and rurality) would provide valuable insights to facilitate efficient health care delivery in the Patient Protection Affordable Care Act era.

Does screening and brief intervention for drug use in primary care increase receipt of substance use disorder treatment?

Material and methods Adults presenting to a hospital-based primary care clinic with recent drug use (Alcohol, Smoking and Substance Involvement Screening Test [ASSIST] drug specific scores of ?4) were enrolled in a randomized clinical trial comparing: (1) a 10-15 minute structured interview conducted by health educators (BNI), (2) a 30-45 minute intervention based on motivational interviewing by Masters-level counselors (MOTIV), or 3) no brief intervention. All received information on treatment resources. We assessed receipt of any SUD treatment in a statewide database. Logistic regression analyses adjusted for main drug (self-identified), drug dependence, and past SUD treatment.

Family history of drug problems as a marker for other health risks in primary care patients

Aims: The study aim is to determinewhether risk behaviors and mental health history differ by family history of drug problems. Methods:N=3253participantswere recruited from thewaiting room of a hospital-based primary care clinic as part of a larger drug and alcohol Screening Brief Intervention and Referral to Treatment (SBIRT) study. Using a small tablet computer in the clinic waiting room participants completed an interactive, computer-delivered screening and assessment, including questions about demographics,mental health history, partner violence exposure, substanceuse behaviors and family history of substance use. Participants were classified into 4 groups based on their report of family members’ history of problems with drugs: (1) no family history; (2) second degree only (grandparents); (3) first degree only (parents and siblings); and (4) first and second degree. Logistic regression analyses were used to compare the four groups on multiple risk factors, with no family history as the reference group. Age, gender, and race were added as covariates in adjusted models. Results: Participants were predominantly mid 40’s (mean 46.6, SD 12.25), women (73%), and Black (72%). Family history of drug problems was associated with current smoking [1◦ AOR 1.8 (1.54, 2.11)], positive alcohol CAGE [1◦ AOR 2.6 (2.02, 3.36); 1◦ & 2◦ AOR 7.5 (3.72, 15.21)], positive drug CAGE [1◦ AOR 4.2 (3.06, 5.76); 1◦ & 2◦ AOR 7.0 (3.04, 15.99)], past year violence victimization [1◦ AOR 1.8 (1.37, 2.28); 1◦ & 2◦ AOR 5.5 (2.99, 10.08)], and previous diagnoses of anxiety [1◦ AOR 1.8 (1.37, 2.28); 1◦ & 2◦ AOR 5.5 (2.99, 10.08)] and depression [1◦ AOR 1.8 (1.37, 2.28); 1◦ & 2◦ AOR 5.5 (2.99, 10.08)]. Conclusions: Family history of drugproblems is associatedwith increased odds for substance use, violence exposure, and mental healthdiagnoses inprimary carepatients. This risk appears additive as high density family history of drug problems (first and second degree relatives) was associated with the highest risk. Financial support: RO1 DA026091, 5K23AA020316-02.

Prevalence of Iron Deficiency and Iron Deficiency Anemia in Syrian Infants

Background: Iron deficiency (ID), with or without anemia, is the most common micronutrient malnutrition problem worldwide. Iron deficiency anemia (IDA) in infancy is linked to long-term motor and cognitive deficits. Infants and children in developing countries are particularly vulnerable to ID due to a negative iron balance resulting from increasing demands for growth that surpass dietary supplies. Recently, health reports have emerged on rising child malnutrition due to shortages of children’s foods and medicines in Syria. Nevertheless, factual data on prevalence are lacking.Objective: To estimate the prevalence of ID and IDA in a cohort of non-displaced Syrian infants living in Damascus between November, 2011 and March, 2013.Design/Methods: This was a prospective observational study conducted at the Children’s Hospital-based primary care clinic in Damascus. Information on type of feeding milk (maternal, iron-fortified formula or cow milk), and demographic characteristics was collected by face-to-face interviews with the parents of the study subjects. Hematological profile (complete blood count, reticulocytes and reticulocyte hemoglobin content (CHr)), and biochemical tests including serum ferritin and iron, and total iron-binding capacity were carried out. ID and IDA were diagnosed according to the 2010 American Academy of Pediatrics guidelines.Results: Out of 155 infants assessed for eligibility, 135 infants met the inclusion criteria and were evaluated for iron deficiency. The average age was 12.4 ± 5.5 months (mean ± SD), and female to male ratio was 57:78. Only 31 (23%) of the study subjects were iron sufficient and not anemic, whereas 97 (72%) had ID, 75 (55.5%) had IDA, and 7 (5.2%) had non-iron deficiency anemia (thalassemia, hemolytic anemia, and macrocytic anemia). Prevalence of ID was statistically higher in males than females (85.33% vs. 62.26% respectively) (P=0.003). IDA was more prevalent in infants living in the countryside (76.25%) in comparison with their urban peers (53.84%) (p=0.04). Unexpectedly, ID and IDA were similarly prevalent regardless of the predominant type of milk fed to the infants (P >>0.05).Conclusion: Our results unveil high prevalence of ID and IDA in Syrian infants between 2011 and 2013. Higher rates are expected in displaced infants and in remote regions of the country. These alarming findings call for immediate national and international collaborative efforts to provide iron supplementation and correct other existing malnutrition in Syrian children. DisclosuresNo relevant conflicts of interest to declare.

Duplicate Publication

Objective:Insufficient and poor quality sleep is prevalent in children, and is a significant public health concern due to the negative consequences for health. Certain sleep-related behaviours are associated with improved sleep, and sleep behaviours are amenable to efforts targeted towards behaviour change. Parental educational interventions have been successful at improving parents’ knowledge and children’s health outcomes in some areas of health, but no population-based educational interventions have been designed to improve parents’ knowledge of healthy children’s sleep. This study aimed to design and test an educational tool to increase caregivers’ knowledge of healthy children’s sleep in a primary care setting.Setting:A hospital-based pediatric primary care clinic where children attend for well-child and sick visits.Method:Parents of 95 children aged three months to 12 years completed two surveys, one prior to and one after receiving the intervention. The surveys assessed children’s sleep habits (pre...

Blood Pressure Status During Consultation: A Primary Care Study

Blood pressure control needs to be assessed at a primary care level, which is the first contact with patients. To evaluate blood pressure readings among patients visiting a primary care clinic at a teaching university hospital in Riyadh, Saudi Arabia. A cross-sectional study was conducted in a primary care clinic at the King Khalid University Hospital from April to September 2013. Blood pressure readings were measured by trained nurses working in a primary care clinic during patients' visits. The study showed that only 33.6 % of participants had a normal blood pressure reading, and 49.3 % of participants were diagnosed as hypertensive patients. The study showed that 74.7 % do not exercise, and 45 % have high stress levels in their life. Uncontrolled blood pressure was common at this hospital-based primary care clinic, so it is recommended to educate primary care physicians to take care of blood pressure management and to educate and encourage patients about non-pharmacological advice like losing weight and coping with stress.

A health literacy pilot intervention to improve medication adherence using Meducation® technology

ObjectiveTo determine whether antihypertensive medication adherence could improve using a Meducation® technology health literacy intervention. MethodsWe conducted a six-month feasibility study among patients with cardiovascular disease (CVD) risk factors receiving care from hospital-based primary care clinics. All patients received a personalized Meducation® calendar listing CVD-related medications. We evaluated changes in medication adherence and clinical outcomes at six months. ResultsThere was a 42% enrollment rate (n=23). Forty percent had low health literacy, defined as less than 9th grade reading level. At three months, self-reported medication adherence improved. At six months, medication possession ratio improved 3.2%. Also, at six months there were decreases in patients’ average systolic blood pressure (0.5mmHg), diastolic blood pressure (1.5mmHg), and body weight (3.6 pounds) (p>0.05). ConclusionsA health literacy intervention may be a feasible mechanism to improve cardiovascular-related medication adherence and outcomes. Practice implicationsHealth literacy interventions may improve adherence while requiring relatively few resources to implement.

Cost-Effectiveness of a Low-Cost, Hospital-Based Primary Care Clinic.

This study assesses the cost-effectiveness of an insurance administration-free, hospital-based clinic designed to provide a full array of primary care services to low-income individuals at little or no cost. In addition to low/no-cost visits, individuals have the option to purchase a low-cost health insurance plan similar to any traditional health plan (eg, prescriptions, primary care, specialty care, durable medical equipment, radiology, laboratory test results). We used 3 years of data (2009-2012) on emergency department (ED) visits and inpatient hospital admissions from clinic patients and patients at the community’s 2 largest private physician groups to assess the cost-effectiveness of the hospital-based clinic in terms of ED and inpatient admission costs avoided and financial sustainability of the low-cost insurance plan. Estimated annual savings in hospital inpatient and ED costs were approximately 1.4 million. Insurance plan data indicated sound fiscal sustainability with modest provider reimbursement growth and zero annual premium growth.

Improving Immunization Delivery using an Electronic Health Record: The ImmProve Project

ObjectiveThough an essential pediatric preventive service, immunizations are challenging to deliver reliably. Our objective was to measure the impact on pediatric immunization rates of providing clinicians with electronic health record–derived immunization prompting. MethodsOperating in a large, urban, hospital-based pediatric primary care clinic, we evaluated 2 interventions to improve immunization delivery to children ages 2, 6, and 13 years: point-of-care, patient-specific electronic clinical decision support (CDS) when children overdue for immunizations presented for care, and provider-specific bulletins listing children overdue for immunizations. ResultsOverall, the proportion of children up to date for a composite of recommended immunizations at ages 2, 6, and 13 years was not different in the intervention (CDS active) and historical control (CDS not active) periods; historical immunization rates were high. The proportion of children receiving 2 doses of hepatitis A immunization before their second birthday was significantly improved during the intervention period. Human papillomavirus (HPV) immunization delivery was low during both control and intervention periods and was unchanged for 13-year-olds. For 14-year-olds, however, 4 of the 5 highest quarterly rates of complete HPV immunization occurred in the final year of the intervention. Provider-specific bulletins listing children overdue for immunizations increased the likelihood of identified children receiving catch-up hepatitis A immunizations (hazard ratio 1.32; 95% confidence interval 1.12–1.56); results for HPV and the composite of recommended immunizations were of a similar magnitude but not statistically significant. ConclusionsIn our patient population, with high baseline uptake of recommended immunizations, electronic health record–derived immunization prompting had a limited effect on immunization delivery. Benefit was more clearly demonstrated for newer immunizations with lower baseline uptake.

Can a brief educational intervention improve parents’ knowledge of healthy children’s sleep? A pilot-test

Objective: Insufficient and poor quality sleep is prevalent in children, and is a significant public health concern due to the negative consequences for health. Certain sleep-related behaviours are associated with improved sleep, and sleep behaviours are amenable to efforts targeted towards behaviour change. Parental educational interventions have been successful at improving parents’ knowledge and children’s health outcomes in some areas of health, but no population-based educational interventions have been designed to improve parents’ knowledge of healthy children’s sleep. This study aimed to design and test an educational tool to increase caregivers’ knowledge of healthy children’s sleep in a primary care setting. Setting: A hospital-based pediatric primary care clinic where children attend for well-child and sick visits. Method: Parents of 95 children aged three months to 12 years completed two surveys, one prior to and one after receiving the intervention. The surveys assessed children’s sleep habits (pre-intervention) and parental sleep beliefs and sleep knowledge (pre- and post-intervention). The intervention was a short, informational brochure. Results: Following the intervention there was a significant increase in parents’ knowledge regarding children’s healthy sleep, and in the number of parents who planned to make positive behaviour changes regarding their child’s sleep practices. Conclusion: Simple written educational interventions may be effective tools with which to increase parents’ knowledge and promote healthy sleep behaviours in children.

Prevalence, Risk Factors, and Predictors of Female Sexual Dysfunction in a Primary Care Setting: A Survey Finding

Female sexual dysfunction (FSD) is a highly prevalent sexual health problem but poorly investigated at the primary care level. This article examines the prevalence of sexual dysfunction and its possible risk factors associated with women at high risk of FSD in a hospital-based primary practice. A validated Malay version of the Female Sexual Function Index (MVFSFI) was utilized to determine FSD in a cross-sectional study design, involving 163 married women, aged 18-65 years, in a tertiary hospital-based primary care clinic in Kuala Lumpur, Malaysia. Sociodemographic, marital profile, health, and lifestyle for women at high risk of FSD and those who were not at high risk were compared and their risk factors were determined. Prevalence of FSD in Malaysian women based on the MVFSFI, and its risk factors for developing FSD. Some 42 (25.8%) out of 163 women had sexual dysfunction. Prevalence of sexual dysfunction increased significantly with age. Sexual dysfunctions were detected as desire problem (39.3%), arousal problem (25.8%), lubrication problem (21.5%), orgasm problem (16.6%), satisfaction problem (21.5%) and pain problems (16.6%). Women at high risk of FSD were significantly associated with age (OR 4.1, 95% CI 1.9 to 9.0), husband's age (OR 4.3 95% C.I 1.9 to 9.3), duration of marriage (OR 3.3, 95% CI 1.6 to 6.8), medical problems (OR 8.5, 95% CI 3.3 to 21.7), menopausal status (OR 6.6, 95% CI 3.1 to 14.3), and frequency of sexual intercourse (OR 10.7, 95% CI 3.6 to 31.7). Multivariate analysis showed that medical problem (adjusted OR 4.6, 95% CI 1.6 to 14.0) and frequency of sexual intercourse (adjusted OR 7.2, 95% CI 2.1 to 24.0) were associated with increased risk of having FSD. Those who practiced contraception were less likely to have FSD. Sexual health problems are prevalent in women attending primary care clinic where one in four women were at high risk of FSD. Thus, primary care physician should be trained and prepared to address this issue.

Comparing Knowledge of Colorectal and Prostate Cancer Among African American and Hispanic Men

African American and Hispanic men are less likely to participate in prostate and colorectal cancer screening and have poorer outcomes from these diseases. Guided by the Patient/Provider/System Theoretical Model for Cancer Screening, this study compares the relationships among knowledge of prostate and colorectal cancer, perceptions of cancer fatalism, common sources of cancer information, and awareness of cancer resources screening between African American (n = 72) and Hispanic (n = 47) men who attend federally qualified health centers and a hospital-based primary care clinic in a southern state. African American men were older, had higher levels of education, and were more knowledgeable about cancer than Hispanic men were. However, Hispanic men were more fatalistic about cancer. Most men in both groups were more likely to get cancer information from the television and/or radio, with few accessing the Internet for this information. The men were not aware of many of the leading cancer-related organizations and programs. Nurses continue to play a critical role in patient education and enhancing screening rates. These findings suggest that culturally and educationally appropriate intervention strategies are needed to enhance knowledge and that the television/radio may be an effective medium for delivering these strategies.

Should an inquiry about sexual health, as a reflection of vascular health, be part of routine physicals for young men? Results from an outpatient study

The objective of this study was to determine the cardiovascular risk factors among men with erectile dysfunction (ED) at a hospital-based primary care clinic in Riyadh, Saudi Arabia. A cross-sectional study was conducted at a primary care clinic in the King Khalid University Hospital (Riyadh, Saudi Arabia), during the period from January to March 2009. Verbal consent was obtained from the attending patients. All patients attending a consultant primary care clinic were interviewed and asked about the presence of ED. Cardiovascular risk factors such as diabetes, hypertension, dyslipidaemia and smoking were determined during consultation. Data entry and analysis were performed using the Statistical Package for Social Sciences (SPSS) version 11.5. A P-value <0.05% was considered significant. A total of 264 men were studied. The estimated prevalence of ED was 18.9%, and only 28% of them had consulted their physician regarding their problem. The prevalence of ED increased with old age, 64% of men with ED were aged > or =60 years. Diabetes mellitus, hypertension, dyslipidaemia and smoking were common cardiovascular risk factors among men with ED. Using medications for chronic illnesses such as diabetes, hypertension and dyslipidaemia was common among men with EDs (98%). Diabetes mellitus, hypertension, dyslipidaemia and smoking are common cardiovascular risk factors among men with ED. Early diagnosis and management of cardiovascular risk factors at an early stage might help to decrease the prevalence of ED. Facilitating patients to talk with their treating physicians regarding sensitive issues such as ED during consultation will help patients to seek proper and safe medical advice. Further research at multi-centres to study the relationship between cardiovascular risk factors and ED is recommended.

Adolescent Preferences for Human Immunodeficiency Virus Testing Methods and Impact of Rapid Tests on Receipt of Results

Rapid human immunodeficiency virus (HIV) tests may be more acceptable to adolescents and may improve receipt of test results. We conducted a study to determine (a) adolescent preferences for different HIV testing methods (rapid oral fluid vs. rapid fingerstick vs. traditional venipuncture), (b) factors associated with choice of a rapid vs. traditional test, and (c) whether those who chose a rapid method were more likely to receive test results. Participants (N=99, 13-22 years old, both genders) were recruited from an urban hospital-based adolescent primary care clinic, agreed to HIV testing with their choice of method, and completed a questionnaire assessing demographic characteristics and attitudes about HIV testing. Logistic regression modeling was used to determine factors associated with choice of a rapid versus traditional test. Half (50.5%) of participants chose rapid oral fluid testing, 30.3% traditional venipuncture testing, and 19.2% rapid fingerstick testing (p < .01). Factors independently associated with choice of a rapid versus traditional method included preference for an oral fluid versus blood test and perceived approval of HIV testing by one's healthcare provider. Participants who chose a rapid test were more likely to receive their test results within the follow-up period than participants who chose a traditional test (91.3% vs. 46.7%, p < .001). In this study, 70% of adolescents preferred rapid to traditional HIV testing, and rapid testers were more likely to receive their results within the follow-up period. Offering rapid testing may lead to improved receipt of results among adolescents in urban primary care settings.

Creating a Medical Home in the San Francisco Department of Public Health

Patients with a medical home tend to fare better. One of the first steps toward establishing a medical home is to create panels by designating a clinic responsible for each patient. In 2006, we defined active clinic panels (all patients assigned to a clinic and seen there for one or more outpatient medical visits during the past 2 years) for the San Francisco Department of Public Health's 13 community- and four public hospital-based primary care clinics and began automatically assigning previously unassigned patients to clinics based on utilization. In 2007, we created a Web-based user interface for managing panels from within the electronic medical record. Providers and medical directors can now view and verify their panels and link to patient demographic and utilization data. Through April 2008, 14 508 patients have been auto-assigned to a clinic; on average 320 patients were assigned monthly. A total of 82,637 primary care patients were on a clinic panel, and 73.6 percent of them were active. Patient demographics, panel size, and productivity vary considerably by clinic. By establishing active panels and providing Web-based access to panel data, we can systematically assign patients a clinical home; enable providers to manage their panels; accurately measure utilization, capacity, and productivity; assess patient characteristics; and generate clinical quality indicators based on an accurate denominator. These management tools will allow us to set policies and work toward our goal of establishing a medical home for San Franciscans who rely on publicly funded care.

Detection of Undiagnosed and Poorly Controlled Asthma in a Hospital-Based Outpatient Pediatric Primary Care Clinic Using a Health Risk Assessment System

Objective. To determine the rate of undiagnosed and poorly controlled asthma detected by a computerized health risk assessment (HRA) survey system in an urban pediatric hospital-based outpatient teaching clinic. Methods. A software-based HRA system uses survey answer patterns to identify children with (1) probable, (2) uncontrolled, and (3) moderate to severe asthma. Parents of patients > 2 years of age were asked by clinic staff to complete the touch screen computer survey before seeing their physician from August 2005 through July 2006. Results. The HRA survey predicted 26% (282/1,098) to have probable asthma. Of these, 51% (144/282) were controlled and the parents reported a previous diagnosis of asthma; 14% (40/282) were controlled and the parents did not report a previous diagnosis of asthma; 25% (71/282) were uncontrolled and the parents reported a previous diagnosis of asthma; and 10% (27/282) were uncontrolled and no previous diagnosis of asthma was reported by the parents. Among active cases completing the baseline version survey (N = 217), 68% reported emergency department (ED) visits / hospitalizations in the last 2 years (44% > 2), while 59% reported missed school days during the previous year (23% > 5 days). Impairment, as defined by the 2007 National Heart, Lung, and Blood Institute/National Asthma Education and Prevention Program (NHLBI/NAEPP) asthma guidelines, tended to be higher in patients without a previous diagnosis of asthma, per parental report, but this trend only achieved significance in two measures: daytime symptoms > 2 days per week in the last 4 weeks (p = 0.028) and more than 5 missed school days in the past year (p = 0.001). Conclusion. A previously validated HRA system can consistently identify a high rate of undiagnosed and poorly controlled asthma in an urban pediatric hospital–based teaching clinic. The utility of such a system would be to reduce missed opportunities for delivery of care and morbidity for the patients who currently have undiagnosed and/or uncontrolled asthma in the pediatric primary care outpatient setting.

Improving Patient Understanding of Prescription Drug Label Instructions

Patient misunderstanding of instructions on prescription drug labels is common and a likely cause of medication error and less effective treatment. To test whether the use of more explicit language to describe dose and frequency of use for prescribed drugs could improve comprehension, especially among patients with limited literacy. Cross-sectional study using in-person, structured interviews. Three hundred and fifty-nine adults waiting for an appointment in two hospital-based primary care clinics and one federally qualified health center in Shreveport, Louisiana; Chicago, Illinois; and New York, New York, respectively. Correct understanding of each of ten label instructions as determined by a blinded panel review of patients' verbatim responses. Patient understanding of prescription label instructions ranged from 53% for the least understood to 89% for the most commonly understood label. Patients were significantly more likely to understand instructions with explicit times periods (i.e., morning) or precise times of day compared to instructions stating times per day (i.e., twice) or hourly intervals (89%, 77%, 61%, and 53%, respectively, p < 0.001). In multivariate analyses, dosage instructions with specific times or time periods were significantly more likely to be understood compared to instructions stating times per day (time periods--adjusted relative risk ratio (ARR) 0.42, 95% Confidence Interval (CI) 0.34-0.52; specific times--ARR 0.60, 95% CI 0.49-0.74). Low and marginal literacy remained statistically significant independent predictors of misinterpreting instructions (low--ARR 2.70, 95% CI 1.81-4.03; marginal--ARR 1.66, 95% CI 1.18-2.32). Use of precise wording on prescription drug label instructions can improve patient comprehension. However, patients with limited literacy were more likely to misinterpret instructions despite use of more explicit language.

Treating Opioid Addiction With Buprenorphine-Naloxone in Community-Based Primary Care Settings

Office-based treatment of opioid addiction with a combination of buprenorphine and naloxone was approved in 2002. Efficacy of this treatment in non-research clinical settings has not been studied. We examined the efficacy and practicality of buprenorphine-naloxone treatment in primary care settings. We studied a cohort of 99 consecutive patients enrolled in buprenorphine-naloxone treatment for opioid dependence at 2 urban primary care practices: a hospital-based primary care clinic, and a primary care practice in a free-standing neighborhood health center. The primary outcome measure was sobriety at 6 months as judged by the treating physician based on periodic urine drug tests, as well as frequent physical examinations and questioning of the patients about substance use. Fifty-four percent of patients were sober at 6 months. There was no significant correlation between sobriety and site of care, drug of choice, neighborhood poverty level, or dose of buprenorphine-naloxone. Sobriety was correlated with private insurance status, older age, length of treatment, and attending self-help meetings. Opioid-addicted patients can be safely and effectively treated in non-research primary care settings with limited on-site resources. Our findings suggest that greater numbers of patients should have access to buprenorphine-naloxone treatment in nonspecialized settings.

Comparison of evidence-based therapeutic intervention between community- and hospital-based primary care clinics

The purpose of this study was to compare the proportion of therapeutic interventions that is supported by scientific evidence between hospital-based and community-based primary care clinics. The study setting is a primary care clinic in university-affiliated tertiary hospital and community-based primary care clinic in a region in Seoul. A retrospective review of patients' medical records was done according to the primary diagnosis and treatment for 890 patients in community-based clinic and 307 in hospital-based clinic. The evidence for the intervention was searched for in Medline (1966-2001) and other evidence-based databases. The evidence was then classified as one of the three categories (i) evidence from randomised controlled trials (RCTs); (ii) convincing non-experimental evidence; and (iii) interventions without substantial evidence. In the hospital-based clinics, out of 356 primary diagnosis and treatment pairs, 59.6% were supported by evidence from at least one RCTs, and 19.4% were supported by convincing non-experimental evidence. In the community-based clinics, 47.1% out of 893 pairs and 10.5% fell into each category. As a result, the proportion of interventions in community settings that were based on evidence meeting our criteria was significantly lower than that of the hospital-based settings. To facilitate evidence-based practice, supportive activity should be focused on the primary care settings based on community where medical practices are less evidence-based.

Utilization and Costs for Children Who Have Special Health Care Needs and Are Enrolled in a Hospital-Based Comprehensive Primary Care Clinic

When deciding how much hospital resources should be allocated to comprehensive primary care clinics for children with multisystem disorders, it is important to consider all of the non-primary care revenue streams associated with these children as well as the effects of a comprehensive primary care program on access and quality. The objectives of this study were, first, to determine costs as well as the payments associated with hospital ambulatory and inpatient services for children with multisystem disorders followed by a comprehensive primary care clinic; and, second, to determine the effect of enrollment in a hospital-based comprehensive primary care clinic on ambulatory and inpatient utilization patterns and expenditures for children with multisystem disorders. The study population for the payment analysis consisted of 1012 children of all ages who were seen in the Special Primary Care Clinic (SPCC) in 2001. For these children, outcomes included direct costs, total (direct plus allocated overhead) costs, and payments per patient per 365 days after their first SPCC visit in 2001. A total of 175 of these patients were 4 years of age or older and had no SPCC visit before their first visit in 2001. We compared utilization and expenditures for the 175 children during the year before enrollment in SPCC with those in the year after enrollment. The Children's Hospital administrative database was used to document direct costs, total costs, and payments by type of service for 365 days after an index visit. Ambulatory services included medical and surgical ambulatory, inpatient, emergency department (ED), and ancillary services. We determined the proportion of children who had visits; the visit rates per 100 child-years; and the average total and direct costs per visit, per child with a visit, and per child-year. Inpatient services data included non-intensive care and intensive care hospitalization rates per 100 child-years; the proportion of children hospitalized; their average length of stay; and the average total and direct costs per hospitalization, per patient hospitalized, and per child-year of total patients in the cohort. For 1012 children who were seen in SPCC in 2001, the hospital overall loss per child-year was $956. The loss per child-year for outpatient services was $1554. This loss was partially offset by a gain from inpatient services of $598. For the 175 patients for whom data were available to compare costs before and after enrollment in the SPCC, there were no significant differences in hospitalization or in direct costs per patient for patients who were hospitalized. The average length of non-intensive care stay was lower after enrollment (4.8 vs 11.7). In the surgical specialty analysis, children were more likely to see a surgeon after enrollment (41% vs 21%) and had a higher rate of visits per 100 child-years (102.3 vs 51.4). Differences in medical subspecialty, ancillary, and ED services did not achieve statistical significance. This study suggests that children with multisystem disorders are medically fragile and require frequent hospitalizations and ED visits even with improved primary care. Enrollment in a comprehensive primary care program was associated with a decreased length of stay for non-intensive care hospitalizations and with increased use of surgical services.