Large Primary Care Research Articles

P-1631. Implementing an Effective Antibiotic Prescribing Feedback Intervention in a Large Primary Care Network with Emphasis on Bacterial Sinusitis

Abstract Background Education and feedback interventions are a key aspect of antibiotic stewardship in outpatient settings. We examined effectiveness of an antibiotic prescribing feedback intervention in a large primary care network with emphasis on bacterial sinusitis.Figure 1.Letter Template for Prescribing and Benchmarking Feedback to Primary Care Network Providers Methods We examined prescriptions written by 237 network primary care clinicians between 9/1 -11/31/2022 (baseline n=23048) and 12/1/2023 -2/29/2024 (post intervention n=18885). Feedback was given via individualized letters (Fig 1) comparing providers’ antibiotic prescribing rates and guideline concordant prescribing for sinusitis against network peers and national data. Guideline concordance was defined from local antibiograms and national guidelines. Primary outcomes were rate of antibiotic prescriptions and percentage of guideline concordant sinusitis prescriptions. Data were analyzed in GraphPad and SAS v9.4 with generalized linear mixed model to account for correlation between repeated provider data.Table 1.Rates of Antibiotic Prescriptions by Provider Designation Before and After Feedback Intervention Results Average rates of antibiotic prescriptions before and after intervention were 13.9 and 13.4/100 visits, a 0.5% absolute reduction and 4.0% relative reduction (p = 0.13). Among providers with baseline >1 standard deviation (SD) antibiotic utilization, average prescribing decreased from 27.7 to 19.7/100 visits (p=0.0002), with increase among those with lowest (> 1 SD) utilization, 5.3 to 7.16/100 visits (p = 0.0048). Physicians’ rates remained lower than non-physician providers (p< 0.0001), and reduction post intervention was similar in both provider groups (p = 0.87, Table 1). Bacterial sinusitis remained most common antibiotic indication (Fig 2). Guideline concordant sinusitis prescriptions pre and post intervention were 69.7% and 83.2% respectively, a 13.5% absolute increase and 19% relative increase (p = < 0.0001) Degree of increase did not differ by provider group (p = 0.76). Antibiotic distribution shifted away from azithromycin, with increases in amoxicillin and doxycycline (Fig 3).Figure 2.Most Common Indications for Prescribing Antibiotics within URMC Primary Care Network Before and After Feedback Intervention Conclusion A prescription feedback intervention in a large primary care network reduced antibiotic prescription rates and non-guideline concordant prescriptions for bacterial sinusitis. The impact of the intervention was most pronounced in prescribers with highest antibiotics utilization pre-intervention.Figure 3.Characterization of Most Common Antibiotics Prescribed by PCN Providers Before and After Feedback Intervention Disclosures All Authors: No reported disclosures

EXPERIENCES EMBEDDING MIND AT HOME DEMENTIA CARE COORDINATION PROGRAM IN PRIMARY CARE

Abstract The prevalence of people living with dementia (PLWD) is growing and dementia is one of the highest burden, and highest cost chronic conditions in the US. Care management support within primary care practices is one solution to provide patient- and care partner (CP)-centered care, improve patient care outcomes, e.g., hospitalizations, ED visits, polypharmacy, high care partner strain, and reduce healthcare costs. This session describes a collaborative adaptation and implementation of the MIND at Home Dementia Care Coordination Program into two large primary care clinics in two states (e.g., Iowa and North Carolina). The program pilot expanded the skills of existing primary care staff members to the level of Memory Care Coordinators (MCCs), who worked with larger primary care teams on combining the benefits of clinic-based with home-based services that support PLWD, their families, and CPs. 106 primary care patients and their CPs were recruited for a 3-month intervention period and process measures, including identified and addressed needs of the PLWD and CP, were ascertained. This session will discuss the feasibility of program implementation in a racially, economically, and geographically diverse population of PLWD and provide qualitative and quantitative outcomes on patient, provider and MCC program acceptability, program impact, and barriers and facilitators to implementation from the primary care practice perspective. The presentation will reflect on specific issues important to consider in primary care including underdiagnosis of dementia, patient recruitment and outreach, incorporation of home visits, interdisciplinary collaboration and consultation, and outcomes ascertainment.

Association between demographic, clinical characteristics and severe complications by SARS-CoV-2 infection in a community-based healthcare network in Chile.

Most of the evidence on risk factors for COVID-19 complications comes from North America or Europe with very little research from Latin-America. We aimed to evaluate the association between sociodemographic, clinical factors and the risk of COVID-19 complications among adults in Chile, the fifth Latin-American country with more COVID-19 reported cases since de beginning of the Pandemic. A retrospective population-based cohort study using data from electronic health records from a large Primary Care Network, linked to national hospital, immunization, Covid-19 PCR surveillance, mortality and birth records. We included people 18+ years old enrolled in the Primary Care Network between 1st January 2020 and 31st December 2021. Using Multivariate Cox proportional hazard models, we evaluate the association between sociodemographic, clinical characteristics with three COVID-19 complications: (1) a hospital admission, (2) an ICU admission, and (3) death due to a COVID-19 infection that occurred between the 1st January 2020 and the 31st December 2021. 44,674 people were included. The mean age was 44.30 (sd 17.31), 55.6% were female, 15.9% had a type of healthcare insurance for people from the lowest category of income, 11.6% and 9.4% had a record of hypertension or diabetes mellitus diagnosis. Among the 44,674 people, 455 (1.02%) had a hospital admission due to a COVID-19 infection and 216(0.48%) of them also had an ICU admission. Among the 44,674 people,148(0.33%) died due to COVID-19 infection. Older age and male sex were consistently associated with a higher risk of the three COVID-19 complications. Hypertension and diabetes were associated with a higher risk of a hospital admission and death, but not with an ICU admissions due to COVID-19 infection. Having two or more COVID-19 vaccine doses compared with no doses was associated with a lower risk of any hospital admission (HR 0.81; 95% CI 0.77-0.84), an ICU admission (HR 0.60; 95% CI 0.57-0.63) and death (HR 0.50; 95% CI 0.46-0.54). Pregnant or puerperal women were more likely to be admitted to hospital (HR 2.89; 95% CI 1.41-5.89) or ICU (HR 3.04; 95% CI 1.01-9.14). Sociodemographic and clinical factors associated with COVID-19 complications such as age, sex and pre-existing conditions were comparable to those reported in similar studies from higher-income countries, and can be used to predict severity in COVID-19 patients.

Identifying patients with cognitive impairment in a large health system: an innovative initiative to facilitate detection in primary care

AbstractThe prevalence of Alzheimer’s disease and related disorders (ADRD) is rising, and primary care providers (PCPs) will increasingly play a role in its detection. We developed an evidence‐based intervention to facilitate cognitive evaluation in primary care. We then implemented it as a set of web‐based trainings which were combined with specific tools embedded in the electronic health record (EHR) for PCPs to use in their practices. The model was adapted from the Gerontological Society of America’s KAER (Kickstart, Assess, Evaluate, Refer) Toolkit, and rolled out across 14 community‐based primary care clinics in a large health system. Outcome measures included: 1) the number of cognitive assessments entered into the EHR; 2) the number of patients diagnosed with mild cognitive impairment (MCI); and 3) change in PCP confidence and attitudes in identifying and managing dementia assessed by a validated survey tool, the General Practitioner’s Attitudes and Confidence Scale for Dementia (GPACS‐D). The number of cognitive assessments entered into the EHR in the six months before the intervention compared to the six months after increased from a mean of 5.2 to 21.2 per month (p<0.01); the number of patients newly diagnosed with MCI increased from a mean of 23.5 to 32.2 per month (p = 0.03); and fifty PCPs who completed the GPACS‐D survey reported significant improvement in confidence and attitudes (mean total attitude and confidence score increase from 3.33 to 4.09, p<0.01). This data suggests an initiative like this can improve cognitive evaluation and increase identification of MCI across a large primary care network. The initiative’s methods are designed to be easy to replicate, without requiring hiring new staff or building new services, making it highly scalable. The educational videos and EHR tools developed are available at no charge to anyone who wants to adapt this approach. Easy to deploy, with clear, reproducible outcomes, it has the potential to improve ADRD care. As new therapeutics for ADRD become available, initiatives such as this will increasingly be needed to improve referrals to specialists, foster an engaged primary care workforce for collaboration, and improve the lives of patients living with ADRD.

Mild Cognitive Impairment and Dementia Diagnoses after an Annual Wellness Visit in a Large Primary Care Network

Mild Cognitive Impairment and Dementia Diagnoses after an Annual Wellness Visit in a Large Primary Care Network

Rapid rule-out of acute myocardial infarction using the 0/1-hour algorithm for cardiac troponins in emergency primary care: the OUT-ACS implementation study

Abstract Background Acute chest pain in primary care often results in defensive and unnecessary hospital referrals due to the limited ability to rule out an acute myocardial infarction (AMI) outside of hospital. In a previous prospective observational study (OUT-ACS; One-hoUr Troponin in a low-prevalence population of Acute Coronary Syndrome), we demonstrated that the ESC 0/1-hour algorithm for high-sensitivity cardiac troponin T (hs-cTnT) would be safe and cost-effective if implemented to assess low-risk patients with chest pain in emergency primary care. Purpose We evaluated the real-world applicability, personnel adherence, and disposition of low-risk patients with chest pain following the implementation of the ESC 0/1-hour algorithm in emergency primary care. Methods In April 2023, the ESC 0/1-hour algorithm for hs-cTnT was implemented at a large emergency primary care clinic in Norway. The clinic is located close to a hospital, enabling the patient to wait at the clinic while blood samples are analysed for hs-cTnT at the hospital laboratory. For the following six months, all patients ≥18 years with acute non-traumatic chest discomfort, offered hs-cTnT measurements at the clinic, were anonymously registered, including their discharge diagnoses and disposition from the clinic. By applying the ESC 0/1-hour algorithm, patients were assigned to rule-out, rule-in or further observation. Patients in the observation group were offered a 4-hour hs-cTnT measurement before a final decision. Results During the six-month period, 10.3% (n=3,053/29,631) of the clinic's consultations involved chest complaints. Hs-cTnT measurements were conducted in 32.6% (n=995/3,053) with a median age of 58 years (IQR 45-68), 50.6% being female. A single hs-cTnT <5 ng/L, sampled ≥3 hours since symptom onset, triaged 24.1% (n=240/995) of the patients towards the rule-out group, increasing to 63.8% after adding a 1-hour measurement. In the rule-in group (n=42/995, 4.2%), 16 patients were diagnosed with an AMI. The intermediate observation group (n=318/995, 32.0%, 4 AMIs) was reduced to 23.0 % after a 4-hour hs-cTnT measurement. Healthcare personnel adhered well to the algorithm, with a median sampling interval of 63 minutes (IQR 60-66) and 4.5 hours (IQR 4.1-5.5) for the 1- and 4-hour measurements, respectively. The algorithm was misinterpreted or overruled in 8.8% of the cases. Ultimately, only 14.8% required hospital transfer following troponin assessment at the clinic. The remaining patients were sent home or managed in the outpatient setting. Conclusions The OUT-ACS strategy, utilizing a 0/1/4-hour algorithm for hs-cTnT measurements in emergency primary care, is safe, effective and applicable, and the strategy contributes to reduced hospital referrals for low-risk patients with chest pain.0/1/4-hour algorithm for hs-cTnTDisposition

The Utility of Multitarget Stool DNA Testing for Colorectal Cancer Screening After a Normal Colonoscopy.

Multitarget stool DNA (MT-sDNA) tests (here, Cologuard®) are currently used in average-risk patients as a primary method of screening for colorectal cancer. However, MT-sDNA testing has also been used in patients who previously underwent colonoscopy who wish to avoid repeat colonoscopy. Here, in a large primary care practice setting, our aim was to evaluate the diagnostic performance of MT-sDNA testing in patients with a previously normal colonoscopy. This retrospective cohort study included 5827 patients from 35 different primary locations in South Carolina. Patients aged 45 and above with a previously documented normal, high-quality colonoscopy prior to the MT-sDNA test date were included. High-risk patients and those with a previous negative MT-sDNA result were excluded. Of 5827 ordered MT-sDNA tests, 248 patients had a prior normal colonoscopy. The average time from initial colonoscopy to MT-sDNA testing was 7.3years. Of the 63 patients who had a positive MT-sDNA test, 41 patients (65%) completed follow-up colonoscopy and 40 patients had complete colonoscopy data. Of these 40 patients, 12 patients (30%) had advanced adenomas and none had colorectal cancer. Compared to patients without a previous colonoscopy, patients with prior colonoscopies had fewer adenomas of all types (1.6 vs 2.4) and fewer advanced adenomas (1.4 vs 2.0). Patients with a previously negative colonoscopy and subsequent positive MT-sDNA test were found to have a high rate of advanced adenomas on follow-up colonoscopy (30%). Thus, in patients with a previously negative colonoscopy, MT-sDNA testing may be a reasonable alternative screening option.

Incidence of Hospitalizations Involving Alcohol Withdrawal Syndrome in a Primary Care Population

Alcohol withdrawal syndrome (AWS) is an important cause and complication of hospitalizations. Although common and preventable, the incidence of AWS during hospitalizations is poorly described. To evaluate the incidence and proportional incidence of hospitalizations involving AWS in an adult primary care population overall and across patient characteristics. This retrospective cohort study used electronic health records and insurance claims from Kaiser Permanente Washington (KPWA) between July 1, 2018, and June 30, 2022. The study included adults with 1 or more primary care visits during this period or the year prior, where primary care included annual standardized alcohol screening using the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C). Age, sex, race, Hispanic ethnicity, AUDIT-C scores, and comorbid diagnoses. Hospitalizations involving AWS were defined by diagnosis codes documented during hospitalizations (incidence numerator). Time enrolled in KPWA determined person-enrolled-years (incidence denominator). Proportional incidence was calculated as the incidence of hospitalizations involving AWS divided by the incidence of all-cause hospitalizations. Proportional incidence was also estimated for hospitalizations involving other common chronic conditions (chronic obstructive pulmonary disease, diabetes, heart failure, and hypertension), which were also defined using hospital diagnosis codes. Among 544 825 adults engaged in primary care (mean [SD] age, 47.0 [17.9] years; 310 069 [56.9%] female; 3656 [0.7%] American Indian or Alaska Native, 55 206 [10.1%] Asian, 25 406 [4.7%] Black, 5204 [1.0%] Native Hawaiian or Other Pacific Islander, 365 780 [67.1%] White, 19 791 [3.6%] multiracial, 15 963 [2.9%] other races, and 53 819 [9.9%] unknown race; 33 987 [6.2%] Hispanic, 414 269 [76.0%] not Hispanic, and 96 569 [17.7%] unknown ethnicity), incidence of hospitalizations involving AWS was 169 (95% CI, 159-179) per 100 000 person-enrolled-years overall but as high as 15 347 (95% CI, 13 502-17 331) in patients with other alcohol-attributable diagnoses. The proportional incidence of hospitalizations involving AWS was 2.3% overall, with variation by age, sex, and AUDIT-C scores (eg, 9%-11% in male patients aged 30-49 years and 23%-44% in patients with high-risk AUDIT-C scores of 7-12 points). In most cases, among adults younger than 60 years, proportional incidence of hospitalizations involving AWS matched or surpassed that of other common chronic conditions (chronic obstructive pulmonary disease, diabetes, heart failure, and hypertension). In this cohort study of a large primary care population served by an integrated health system, AWS hospitalizations were common, especially in male patients, younger age groups, and individuals with high-risk alcohol use. During hospitalizations, the burden of AWS was similar to or exceeded complications of other chronic diseases that receive greater medical attention.

The “Inboxologist” — A Novel Approach to In-Basket Management in Primary Care

Primary care providers are spending more time responding to electronic patient requests and completing other tasks in their digital in-basket that do not require their level of expertise. This contributes to job dissatisfaction and burnout. Last year, at two large primary care practice sites, Corewell Health West implemented a pilot program that introduced a new in-basket triage system involving a registered nurse completing initial triage and an advanced practice provider serving as an “inboxologist.” Under this model, primary care providers handled 41% fewer in-basket messages than before the pilot and spent an average of 47% less time on the messages they did receive. Self-reported time spent on the in-basket during office hours and after office hours decreased by an average of 37% and 32%, respectively. The number of messages that were resolved by the nonphysician staff member who initially triaged the message increased by 14.2% from pre-pilot to the end of the pilot period. Time to resolution of patient-generated messages decreased by 93%, with subsequent improvement in patient satisfaction scores. Given the favorable reception by physicians, patients, and staff, Corewell plans to expand the inboxologist program to all of its primary care sites and to selected specialty practices.

Levels of plasma 25-hydroxy vitamin D and risk of developing type 2 diabetes in a large Danish primary health care population.

Plasma levels of Vitamin D (25(OH)D) have been suggested as a predictor for developing type 2 diabetes. The purpose of this study was therefore to investigate if a measurement of plasma 25(OH)D could predict the development of type 2 diabetes in a cohort of 222,311 individuals from primary healthcare in Denmark. The CopD-study database containing data from the Copenhagen General Practitioners Laboratory on blood tests conducted from April 2004 to January 2012 was used for identification of the study population. Incident type 2 diabetes was then defined as having at least two redeemed prescriptions of antidiabetics or at least two hospital contacts due to type 2 diabetes or one redeemed prescription and one hospital contact regarding type 2 diabetes. A total of 222,311 individuals were included in the study, of whom 7652 (3.4%) developed type 2 diabetes during the follow-up period of minimum one year. Individuals who developed type 2 diabetes had a significantly lower median 25(OH)D level than persons in the non-diabetes group. The hazard ratio for development of type 2 diabetes increased by 15% per 10nmol/L decrease in 25(OH)D level. In this study of 222,311 persons from primary health care in Denmark, we found a clear inverse relationship between 25(OH)D and the risk of developing type 2 diabetes. Further studies should be conducted to clarify the mechanisms behind the relationship between 25(OH)D and type 2 diabetes and the effect of oral vitamin D supplementation on the development of type 2 diabetes.

A Clinician and Electronic Health Record Wearable Device Intervention to Increase Physical Activity in Patients With Obesity: Formative Qualitative Study.

The number of individuals using digital health devices has grown in recent years. A higher rate of use in patients suggests that primary care providers (PCPs) may be able to leverage these tools to effectively guide and monitor physical activity (PA) for their patients. Despite evidence that remote patient monitoring (RPM) may enhance obesity interventions, few primary care practices have implemented programs that use commercial digital health tools to promote health or reduce complications of the disease. This formative study aimed to assess the perceptions, needs, and challenges of implementation of an electronic health record (EHR)-integrated RPM program using wearable devices to promote patient PA at a large urban primary care practice to prepare for future intervention. Our team identified existing workflows to upload wearable data to the EHR (Epic Systems), which included direct Fitbit (Google) integration that allowed for patient PA data to be uploaded to the EHR. We identified pictorial job aids describing the clinical workflow to PCPs. We then performed semistructured interviews with PCPs (n=10) and patients with obesity (n=8) at a large urban primary care clinic regarding their preferences and barriers to the program. We presented previously developed pictorial aids with instructions for (1) providers to complete an order set, set step-count goals, and receive feedback and (2) patients to set up their wearable devices and connect them to their patient portal account. We used rapid qualitative analysis during and after the interviews to code and develop key themes for both patients and providers that addressed our research objective. In total, 3 themes were identified from provider interviews: (1) providers' knowledge of PA prescription is focused on general guidelines with limited knowledge on how to tailor guidance to patients, (2) providers were open to receiving PA data but were worried about being overburdened by additional patient data, and (3) providers were concerned about patients being able to equitably access and participate in digital health interventions. In addition, 3 themes were also identified from patient interviews: (1) patients received limited or nonspecific guidance regarding PA from providers and other resources, (2) patients want to share exercise metrics with the health care team and receive tailored PA guidance at regular intervals, and (3) patients need written resources to support setting up an RPM program with access to live assistance on an as-needed basis. Implementation of an EHR-based RPM program and associated workflow is acceptable to PCPs and patients but will require attention to provider concerns of added burdensome patient data and patient concerns of receiving tailored PA guidance. Our ongoing work will pilot the RPM program and evaluate feasibility and acceptability within a primary care setting.

Abstract P315: Using Home Blood Pressure Monitors in the Office Setting as an Alternative to Automated Office Blood Pressure: A Quality Improvement Project

Background: Accurate blood pressure (BP) measurement is key to the diagnosis and effective treatment of hypertension (HTN). The U.S. HTN guideline recommends having patients rest for 5 minutes before measuring BP and obtaining at least two measurements 1-2 minutes apart. This is difficult to achieve in a busy primary care practice, and while automated office BP (AOBP) has been advanced as a solution, the required device may be cost-prohibitive. As home BP monitors are much less expensive, a protocol employing them in the office setting could prove to be an attractive alternative to AOBP. Objective: To promote the recording of multiple BP readings in primary care visits by using home BP monitors for measurement. Methods: Our primary care practice hosts 110 internal medicine residents and completes more than 35,000 patient visits annually. Prior to the intervention, medical assistants (MAs) obtained vital signs (VS) at every visit using a VS cart. In the first version of the new protocol, MAs measured all VS except BP using the VS cart, then measured BP once using an Omron 5 series BP monitor and recorded that reading in the chart. MAs left the cuff on the patient’s arm and instructed him/her to rest quietly for 5 minutes before taking a second BP reading him/herself while waiting for the provider after the MA exited the room. The patient took a third reading 1-2 minutes after the second. The provider recorded the second and third readings in the chart. Results: We implemented the new protocol in November 2023. In February 2024, we met with MAs to solicit feedback. They found the protocol easy to follow overall but had two concerns: (1) It was cumbersome to use two different devices to obtain a full set of VS; and (2) since many patients had normal BP, it did not seem worthwhile to obtain multiple BP measurements for all patients. After this meeting, we began measuring heart rate and oxygen saturation with a portable pulse oximeter instead of the VS cart, which is now only used in special circumstances. We also modified the protocol so that patients with systolic BP < 120 mm Hg and diastolic BP < 80 mm Hg are not required to obtain any repeat BP measurements. Conclusions: A new BP measurement protocol using home BP monitors to obtain multiple readings at each visit was feasible in our large academic primary care practice. We plan to investigate its effect on frequency of repeat BP measurement and likelihood of intensifying therapy for uncontrolled HTN.

Enhancing community-oriented care: Implementation of social prescribing within a family health team.

High quality comprehensive primary care is essential for the health and well-being of individuals and communities, but the provision of health services is inadequate to fully address these needs. Social isolation and loneliness are associated with poor health outcomes and are increasingly prevalent among older adults. The St. Michael's Hospital Academic Family Health Team, a large interdisciplinary primary care organization that serves approximately 55,000 people in the downtown east of Toronto, Ontario, developed and implemented a social prescribing program to support socially isolated and lonely older adults. This article reports the development of that program-called SEED (Seniors, Equity, Engagement, and Dignity)-and describes opportunities and challenges and some preliminary results from the first year. By supporting people in new ways, this program aims to reduce loneliness and social isolation, increase capacity within the family health team, and support diverse older adults to live fulfilling lives.

The effect of the US Child Tax Credit advance payments in 2021 on adolescent mental health: Changes in depression symptoms and suicidality

ObjectiveChild poverty is associated with poor adolescent mental health. Changes to the Child Tax Credit (CTC) in 2021 in the U.S. were historic and introduced a new model of distributing the credit in advance of tax filing, providing families with stable, supplemental monthly income. This policy shift offers a unique opportunity to examine the mental health effects for adolescents. MethodsWe use electronic health record data from a large pediatric primary care network in Columbus, Ohio, which collected adolescent depression screening scores in real time as the CTC advance payments were introduced. We utilized differences in age of eligibility for the CTC to examine the changes in the probability of depression screening outcomes (positive depression screen, any depression symptom, any suicidal ideation), for adolescents eligible for the credit (turned 18 first quarter of 2022), relative to those not eligible (turned 18 last quarter of 2021) (n = 1,423). ResultsWe did not observe a significant association between the policy change and study outcomes in the overall sample. However, the percentage of adolescents with a positive depression screen significantly declined for Non-Hispanic Black (13.4 percentage point reduction, p = 0.01) and publicly insured (9.7 percentage point reduction, p = 0.04) adolescents. ConclusionsOur findings suggest reductions in depression symptoms for subgroups of adolescents who were age-eligible for the CTC compared to their counterparts who were not eligible. The CTC advance payments were a brief experiment in universal basic income and may offer a policy solution for addressing both poverty and a growing adolescent mental health crisis.

Ultra-processed food and drink consumption and lipoprotein subclass profiles: A cross-sectional study of a middle-to older-aged population

Background and aimsStudies have consistently demonstrated associations between ultra-processed food and drink (UPFD) consumption and an increased risk of non-communicable diseases. However, there is a lack of data investigating relationships between UPFD intake and intermediate cardiometabolic disease markers. In this study we explored UPFD associations with lipoprotein subclasses. MethodsThis was a cross-sectional study of 1,986 middle- to older-aged men and women randomly selected from a large primary care centre. The percentage contribution of UPFDs to total energy intake was calculated for each participant using the NOVA classification. Lipoprotein particle subclass concentrations and size were determined using nuclear magnetic resonance spectroscopy. Correlation and multivariate-adjusted linear regression analyses were performed to examine UPFD intake relationships with lipoprotein subclasses. ResultsIn fully adjusted regression models, higher UPFD consumption was associated with reduced high-density lipoprotein (HDL) cholesterol concentrations (β = -0.024, p = 0.001), large low-density lipoprotein (LDL) levels (β = -18.645, p = 0.002), total and medium HDL concentrations (β = -0.328, p = 0.012; β = -0.510, p < 0.001), smaller LDL and HDL size (β = -0.026, p = 0.023; β = -0.023, p = 0.024), and increased medium very low-density lipoprotein levels (β = 0.053, p = 0.022), small LDL and HDL concentrations (β = 20.358, p = 0.02; β = 0.336, p = 0.011), and higher lipoprotein insulin resistance scores (β = 0.048, p = 0.012), reflecting greater lipoprotein-related insulin resistance. ConclusionsFindings from this research suggest that increased intake of UPFDs is associated with a more pro-atherogenic, insulin-resistant metabolic profile in middle- to older-aged adults which may be a potential mechanism underlying reported associations between UPFD consumption and chronic disease risk and mortality.

Agile implementation of alcohol screening in primary care

BackgroundDespite the United States Preventive Services Task Force recommendation to screen adults for unhealthy alcohol use, the implementation of alcohol screening in primary care remains suboptimal.MethodsA pre and post-implementation study design that used Agile implementation process to increase screening for unhealthy alcohol use in adult patients from October 2021 to June 2022 at a large primary care clinic serving minority and underprivileged adults in Indianapolis.ResultsIn comparison to a baseline screening rate of 0%, the agile implementation process increased and sustained screening rates above 80% for alcohol use using the Alcohol Use Disorders Identification Test – Consumption tool (AUDIT-C).ConclusionsUsing the agile implementation process, we were able to successfully implement evidence-based recommendations to screen for unhealthy alcohol use in primary care.

Electronic medical information and analytical system (EMIAS) as a tool for the new level of understanding and diagnosis of medication adherence in patients with myocardial infarction in primary care practice in Moscow

Introduction. The global community is increasingly using patients' prescription claims data as a dominant method for assessing medication adherence, which encouraged us to conduct this study.Aim. To adapt the existing international experience of using digital technologies to measure medication adherence to the routine practice of domestic health care at the outpatient level.Methods. We conducted a retrospective study of adherence to statin therapy in patients with myocardial infarction (MI) at a large primary care clinic in Moscow, which included 2 stages: 1st stage — compilation of international experience on medication adherence studies using pharmacy dispensing records; 2nd stage — testing the method of electronic prescription refill record to measure adherence. We calculated the proportion of days covered (PDC) by statin therapy over a 12‑month period following MI. Data on demography, anamnesis, lipid profile, and statin prescriptions were obtained from the electronic medical records of patients with acute MI from January 1 — December 31, 2022. A total of 109 patients were included according to the prespecified selection criteria.Results. An analysis of international experience demonstrated that the pharmacy dispensing record method has become widespread in recent decades in foreign countries and has established itself as an objective, noninvasive, and inexpensive method for measuring medication adherence. The study of adherence to statin therapy in post-MI patients using the electronic prescription refill record method revealed a mean PDC = 63.0±29.7 %. Optimal adherence (PDC≥80 %) throughout the 12‑month follow-up period was noted in 38 % of patients. When PDC was calculated separately for the 1st and 2nd half year, it was found that the proportion of patients with optimal adherence decreased by 17.6 % (p=0.04). Adherence correlated with the efficacy of statin therapy — a more pronounced reduction of LDL–C was observed in patients with PDC≥80 % compared with those who were insufficiently adherent (–1.47±1.09 vs –0.96±1.16 mmol/L; p=0.043).Conclusion. This study demonstrated the efficiency and information value of an electronic prescription refill record system for domestic primary care. After operational tuning, the proposed method can be integrated into EMIAS for routine medication adherence assessment.

Substance Use Screening in a Large Pediatric Primary Care Network: A Quality Improvement Project.

This project aimed to introduce substance use screening, using the CRAFFT (Car, Relax, Alone, Forget, Family/Friends, Trouble) screening tool, into the routine care of adolescents using quality improvement strategies and tools. We expanded a single-site project showing the successful introduction of CRAFFT screening into adolescent care to include the entire 34-site primary care network of a children's hospital in Northeastern Ohio. We deployed quality improvement methodology to facilitate the acceptance and use of the screener. Data showing the percentage of eligible adolescents screened were collected and shared monthly with network providers. The single-site phase increased the screening rate from 3.5% to 72%. The percentage screened for the network phase rose from 0% to >90% in the first 2 months of the project and remained at that level. Of those screened, 85% were low risk, 3% were medium risk, and 2% were high risk. Ten percent of the results were not recorded in a way that allowed for post hoc risk assessment. During the network phase, 35,750 of 38,427 (93%) eligible patients completed the screening form. This project resulted in the highly reliable use of the CRAFFT screener in a large primary care network.

Screening patients in general practice for advanced chronic liver disease using an innovative IT solution: The Liver Toolkit.

Identifying patients with undiagnosed advanced chronic liver disease (ACLD) is a public health challenge. Patients with advanced fibrosis or compensated cirrhosis have much better outcomes than those with decompensated disease and may be eligible for interventions to prevent disease progression. A cloud-based software solution ("the Liver Toolkit") was developed to access primary care practice software to identify patients at risk of ACLD. Clinical history and laboratory results were extracted to calculate aspartate aminotransferase-to-platelet ratio index and fibrosis 4 scores. Patients identified were recalled for assessment, including Liver Stiffness Measurement (LSM) via transient elastography. Those with an existing diagnosis of cirrhosis were excluded. Existing laboratory results of more than 32,000 adults across nine general practices were assessed to identify 703 patients at increased risk of ACLD (2.2% of the cohort). One hundred seventy-nine patients (26%) were successfully recalled, and 23/179 (13%) were identified to have ACLD (LSM ≥10.0kPa) (10% found at indeterminate risk [LSM 8.0-9.9kPa] and 77% low risk of fibrosis [LSM <8.0kPa]). In most cases, the diagnosis of liver disease was new, with the most common etiology being metabolic dysfunction-associated steatotic liver disease (n=20, 83%). Aspartate aminotransferase-to-platelet ratio index ≥1.0 and fibrosis 4 ≥3.25 had a positive predictive value for detecting ACLD of 19% and 24%, respectively. Patients who did not attend recall had markers of more severe disease with a higher median aspartate aminotransferase-to-platelet ratio index score (0.57 vs. 0.46, p=0.041). This novel information technology system successfully screened a large primary care cohort using existing laboratory results to identify patients at increased risk ACLD. More than 1 in 5 patients recalled were found to have liver disease requiring specialist follow-up.

Factors Correlated with Anticoagulation Choice in Primary Care Patients with Atrial Fibrillation and High Stroke Risk.

The available data on anticoagulation therapy in real-world primary care settings for atrial fibrillation (AF) patients at high risk of stroke is limited. To evaluate anticoagulation therapy and elucidate the factors associated with the selection between direct oral anticoagulants (DOACs) and warfarin. This is a retrospective cohort study that included patients ≥ 18years old at a large primary care outpatient group, a network of twenty clinics in the northeast United States between January 4, 2021 - January 4, 2023. Oral anticoagulation therapy in AF patients with high risk of stroke (CHA2DS2-VASc score of ≥ 2 in men or ≥ 3 in women). Among the 3,118 adult patients with AF and high risk of stroke (median age 77.90, IQR 71.66-84.50years; male 57.6%), we found that older age (aOR 1.40, p = 0.003), greater BMI (25-29.9: aOR 1.32, p = 0.048; ≥ 30 aOR 1.42, p = 0.010), and taking more than five medications (aOR 2.28, p < 0.001) were more likely to be on an oral anticoagulant. Among those taking an OAC, having Medicare as the sole coverage (aOR 0.53, p = 0.032), male gender (aOR 0.69, p = 0.011), worse renal function (aOR 0.80, p = 0.021), and higher CHA2DS2-VASc score (aOR 0.88, p = 0.024) are more likely to be on warfarin than a DOAC. Patients taking more than five medications daily (6-10 medications: aOR 1.92, p = 0.013; ≥ 16: aOR = 2.10, p = 0.006) were more likely to be on an anticoagulant and may receive a DOAC over warfarin. AF with high stroke risk adult patients are more likely to be on an oral anticoagulant if they are older, having BMI ≥ 25, or taking more than five medications. Medicare as the sole coverage, male gender, worse renal function, and higher CHA2DS2-VASc scores are factors associated with greater warfarin usage, while patients taking over five daily medications are more likely to be prescribed DOACs.