Network Of Primary Care Practices Research Articles

Abstract P336: Severe Hypoglycemia as an Independent Coronary Artery Disease Risk Factor in Diabetes Patients of Different Vascular Risk: A Retrospective Longitudinal Cohort Study

Background: Previous studies have suggested an association between severe hypoglycemic events (i.e. requiring external assistance) and coronary artery disease (CAD). However, whether this association varies across patients with different vascular risk remains unclear. We tested the hypothesis that prior severe hypoglycemia was independently associated with incident CAD in diabetes patients cared for in primary care, and that this association was increased for those with elevated vascular risk. Methods: We identified a diabetes cohort within a primary care practice network using electronic health records (EHR, N=9,173). Patients with severe hypoglycemic events at baseline (before 1/1/2006) were identified via ICD-9 codes, including 251.0-251.2, from emergency department, inpatient and outpatient visits. Incident CAD, including myocardial infarction, acute coronary syndrome, percutaneous transluminal coronary angiography and coronary artery bypass grafting, occurring after the hypoglycemic event, were determined through problem and procedure lists. Patients were followed until incident CAD, death, their last visit within the network, or 6/30/2012. We used Cox regression with time interaction to determine the association between hypoglycemia and CAD, with significance set at P <0.05. We also tested this association among high vascular risk patients (age ≥55 years, Hemoglobin A1c [HbA1c] ≥7.5% and ≥2 risk factors [dyslipidemia, hypertension or obesity]), and a subset aged ≥65 years. Results: A total of 285 (3%) patients had a history of severe hypoglycemia at baseline and 1,098 (12%) developed CAD during follow-up. Severe hypoglycemia was associated with a twofold increase in CAD risk [HR 1.90 (95%CI 1.09-3.31)], adjusting for time interaction, vascular risk factors, diabetes duration and HbA1c; the hypoglycemia-CAD association weakened over time (time interaction P=0.06). Further adjustment for microvascular complications and medication exposures attenuated the association [HR 1.67 (0.96-2.92)]. Among 1,823 (20% of the cohort) high vascular risk patients aged ≥55 years, CAD risk was elevated threefold [HR 3.01 (1.15-7.91)], and in those aged ≥65 years (N=996, 11%), fourfold [HR 4.62 (1.65-12.90)]. The association was not significant among lower vascular risk patients [HR 1.61 (0.97-3.75), N=7,350]. Conclusions: Prior severe hypoglycemic episodes were strongly associated with incident CAD, especially among high vascular risk patients who were similar to those studied in the ACCORD trial. Whereas severe hypoglycemia was not as strongly associated with CAD in patients with fewer vascular risk factors. Results of studies like ACCORD only apply to a fifth of diabetes patients in this primary care cohort. Careful evaluation of diabetes treatment and close monitoring for CAD are especially needed in older high vascular risk patients with severe hypoglycemia.

Clinic variation in recruitment metrics, patient characteristics and treatment use in a randomized clinical trial of osteoarthritis management.

BackgroundThe Patient and PRovider Interventions for Managing Osteoarthritis (OA) in Primary Care (PRIMO) study is one of the first health services trials targeting OA in a multi-site, primary care network. This multi-site approach is important for assessing generalizability of the interventions. These analyses describe heterogeneity in clinic and patient characteristics, as well as recruitment metrics, across PRIMO study clinics.MethodsBaseline data were obtained from the PRIMO study, which enrolled n = 537 patients from ten Duke Primary Care practices. The following items were examined across clinics with descriptive statistics: (1) Practice Characteristics, including primary care specialty, numbers and specialties of providers, numbers of patients age 55+, urban/rural location and county poverty level; (2) Recruitment Metrics, including rates of eligibility, refusal and randomization; (3) Participants’ Characteristics, including demographic and clinical data (general and OA-related); and (4) Participants’ Self-Reported OA Treatment Use, including pharmacological and non-pharmacological therapies. Intraclass correlation coefficients (ICCs) were computed for participant characteristics and OA treatment use to describe between-clinic variation.ResultsStudy clinics varied considerably across all measures, with notable differences in numbers of patients age 55+ (1,507-5,400), urban/rural location (ranging from “rural” to “small city”), and proportion of county households below poverty level (12%-26%). Among all medical records reviewed, 19% of patients were initially eligible (10%-31% across clinics), and among these, 17% were randomized into the study (13%-21% across clinics). There was considerable between-clinic variation, as measured by the ICC (>0.01), for the following patient characteristics and OA treatment use variables: age (means: 60.4-66.1 years), gender (66%-88% female), race (16%-61% non-white), low income status (5%-27%), presence of hip OA (26%-68%), presence both knee and hip OA (23%-61%), physical therapy for knee OA (24%-61%) and hip OA (0%-71%), and use of knee brace with metal supports (0%-18%).ConclusionsAlthough PRIMO study sites were part of one primary care practice network in one health care system, clinic and patient characteristics varied considerably, as did OA treatment use. This heterogeneity illustrates the importance of including multiple, diverse sites in trials for knee and hip OA, to enhance the generalizability and evaluate potential for real-world implementation.Trial registrationClinical Trial Registration Number: NCT 01435109Electronic supplementary materialThe online version of this article (doi:10.1186/1471-2474-15-413) contains supplementary material, which is available to authorized users.

Association of Antibiotics in Infancy With Early Childhood Obesity

Obesity in children and adults is associated with significant health burdens, making prevention a public health imperative. Infancy may be a critical period when environmental factors exert a lasting effect on the risk for obesity; identifying modifiable factors may help to reduce this risk. To assess the impact of antibiotics prescribed in infancy (ages 0-23 months) on obesity in early childhood (ages 24-59 months). We conducted a cohort study spanning 2001-2013 using electronic health records. Cox proportional hazard models were used to adjust for demographic, practice, and clinical covariates. The study spanned a network of primary care practices affiliated with the Children's Hospital of Philadelphia including both teaching clinics and private practices in urban Philadelphia, Pennsylvania, and the surrounding region. All children with annual visits at ages 0 to 23 months, as well 1 or more visits at ages 24 to 59 months, were enrolled. The cohort comprised 64,580 children. Treatment episodes for prescribed antibiotics were ascertained up to 23 months of age. Obesity outcomes were determined directly from anthropometric measurements using National Health and Nutrition Examination Survey 2000 body mass index norms. Sixty-nine percent of children were exposed to antibiotics before age 24 months, with a mean (SD) of 2.3 (1.5) episodes per child. Cumulative exposure to antibiotics was associated with later obesity (rate ratio [RR], 1.11; 95% CI, 1.02-1.21 for ≥ 4 episodes); this effect was stronger for broad-spectrum antibiotics (RR, 1.16; 95% CI, 1.06-1.29). Early exposure to broad-spectrum antibiotics was also associated with obesity (RR, 1.11; 95% CI, 1.03-1.19 at 0-5 months of age and RR, 1.09; 95% CI, 1.04-1.14 at 6-11 months of age) but narrow-spectrum drugs were not at any age or frequency. Steroid use, male sex, urban practice, public insurance, Hispanic ethnicity, and diagnosed asthma or wheezing were also predictors of obesity; common infectious diagnoses and antireflux medications were not. Repeated exposure to broad-spectrum antibiotics at ages 0 to 23 months is associated with early childhood obesity. Because common childhood infections were the most frequent diagnoses co-occurring with broad-spectrum antibiotic prescription, narrowing antibiotic selection is potentially a modifiable risk factor for childhood obesity.

Practice network-based care management for patients with type 2 diabetes and multiple comorbidities (GEDIMAplus): study protocol for a randomized controlled trial.

BackgroundCare management interventions in the German health-care system have been evaluated with promising results, but further research is necessary to explore their full potential in the context of multi-morbidity. Our aim in this trial is to assess the efficacy of a primary care practice network–based care management intervention in improving self-care behaviour among patients with type 2 diabetes mellitus and multiple co-occurring chronic conditions.Methods/DesignThe study is designed as a prospective, 18-month, multicentre, investigator-blinded, two-arm, open-label, individual-level, randomized parallel-group superiority trial. We will enrol 582 patients with type 2 diabetes mellitus and at least two severe chronic conditions and one informal caregiver per patient. Data will be collected at baseline (T0), at the primary endpoint after 9 months (T1) and at follow-up after 18 months (T2). The primary outcome will be the differences between the intervention and control groups in changes of diabetes-related self-care behaviours from baseline to T1 using a German version of the revised Summary of Diabetes Self-Care Activities (SDSCA-G). The secondary outcomes will be the differences between the intervention and control groups in: changes in scores on the SDSCA-G subscales, glycosylated haemoglobin A level, health-related quality of life, self-efficacy, differences in (severe) symptomatic hypoglycaemia, cost-effectiveness and financial family burden. The intervention will be delivered by trained health-care assistants as an add-on to usual care and will consist of three main elements: (1) three home visits, including structured assessment of medical and social needs; (2) 24 structured telephone monitoring contacts; and (3) self-monitoring of blood glucose levels after T1 in 3-month intervals. The control group will receive usual care. The confirmatory primary analysis will be performed following the intention-to-treat (ITT) principle. The efficacy of the intervention will be quantified using two-level linear regression stratified by type of medical treatment adjusted for baseline values on the SDSCA-G. Secondary analyses will be performed according to the ITT principle. In health economic evaluations, we will estimate the incremental cost-effectiveness ratios.DiscussionWe hope that the results of this study will provide insights into the efficacy of practice network–based care management among patients with complex health-care needs.Trial registrationCurrent Controlled Trials ISRCTN 83908315 (ISRCTN assigned 25 February 2014).

Results of the Northern Manhattan Diabetes Community Outreach Project: A Randomized Trial Studying a Community Health Worker Intervention to Improve Diabetes Care in Hispanic Adults

OBJECTIVEThe Northern Manhattan Diabetes Community Outreach Project evaluated whether a community health worker (CHW) intervention improved clinically relevant markers of diabetes care in adult Hispanics.RESEARCH DESIGN AND METHODSParticipants were adult Hispanics, ages 35–70 years, with recent hemoglobin A1c (A1C) ≥8% (≥64 mmol/mol), from a university-affiliated network of primary care practices in northern Manhattan (New York City, NY). They were randomized to a 12-month CHW intervention (n = 181), or enhanced usual care (educational materials mailed at 4-month intervals, preceded by phone calls, n = 179). The primary outcome was A1C at 12 months; the secondary outcomes were systolic blood pressure (SBP), diastolic blood pressure, and LDL-cholesterol levels.RESULTSThere was a nonsignificant trend toward improvement in A1C levels in the intervention group (from unadjusted mean A1C of 8.77 to 8.40%), as compared with usual care (from 8.58 to 8.53%) (P = 0.131). There was also a nonsignificant trend toward an increase in SBP and LDL cholesterol in the intervention arm. Intervention fidelity, measured as the number of contacts in the intervention arm (visits, phone contacts, group support, and nutritional education), showed a borderline association with greater A1C reduction (P = 0.054). When assessed separately, phone contacts were associated with greater A1C reduction (P = 0.04).CONCLUSIONSThe trend toward A1C reduction with the CHW intervention failed to achieve statistical significance. Greater intervention fidelity may achieve better glycemic control, and more accessible treatment models, such as phone-based interventions, may be more efficacious in socioeconomically disadvantaged populations.

Engaging a Network of Primary Care Practices in an Effort to Better Assist Patients in Quitting Tobacco Use

Engaging a Network of Primary Care Practices in an Effort to Better Assist Patients in Quitting Tobacco Use

Integrating Palliative Care Information and Hospice Referral in Medicaid Primary Care

Hospice and palliative care (PC) remain underutilized by Medicaid patients. Our aim was to evaluate an intervention to improve communication about advance care planning (ACP) and symptom distress, and to facilitate referral to PC and hospice. We conducted a study in a statewide Medicaid primary care network with 510 Medicaid care managers (CMs). PC experts collaborated with leaders in the statewide primary care network on a quality improvement intervention. Training components included education and engagement with local hospice and PC providers. Quality improvement components included feedback of quality measures and a practice toolkit. Evaluation used participant surveys and tracking of key quality measures: 1) percent of at-risk subset of aged, blind, and disabled (ABD) Medicaid patients asked about ACP or symptom distress; 2) cumulative number of ABD Medicaid PC or hospice referrals; and 3) the percent of all nondual ABD Medicaid decedents enrolled in hospice. After training, CMs identified the following areas for expected practice change: ACP (29%), identifying/referring patients for hospice or PC (25%), supporting patients and families (21%), toolkit utilization (10%), and engaging medical providers (10%). Over one-year follow-up the percent of moderate and high-risk ABD Medicaid patients asked about ACP or symptoms increased from 7% to 31% and 8% to 41%, respectively (p<0.001). The cumulative number of PC or hospice referrals increased from 8 to 155. Hospice enrollment at death was unchanged (29% to 30%, p=NS [nonsignificant]). A statewide intervention targeting CMs in a Medicaid primary care practice network is effective to increase communication and hospice and PC referrals; longer follow-up may be required to determine effect on hospice use.

A Statewide Intervention to Improve Access to Hospice and Palliative Care for Seriously Ill Medicaid Enrollees (416-A)

1.Discuss training and quality improvement components of a statewide intervention to improve access to hospice, palliative, and supportive care for seriously ill Medicaid enrollees.2.Discuss a model program that may guide future community-based interventions to facilitate collaboration between primary care providers and palliative care experts. Hospice, palliative care, and other support services improve pain, symptom management, and quality of life for seriously ill patients but remain underutilized by the low income population enrolled in Medicaid. We evaluated a systems intervention in a statewide network of primary care practices to improve access to hospice, palliative care, and other supportive resources for Medicaid recipients. Experts in palliative care, primary care, and quality improvement designed and delivered a prospective educational and quality improvement intervention, administered to 495 care managers serving seriously ill aged, blind, and disabled (ABD) Medicaid enrollees. Quality improvement components included feedback of practice quality measures, engagement with local hospice and palliative care, and a toolkit for practice change. Outcome measures included surveys to evaluate the educational components and change in care manager practices using two key quality measures: (a) percentage of at-risk ABD patients asked at least one palliative care question and (b) percentage of at-risk ABD Medicaid enrollees referred to receive palliative care services and hospice. Of 495 care managers, 471 responded to the survey (95.2%). Expected practice changes included more active role in advance care planning (28.6%); supporting patients and families (21.4%); identifying patients for discussion of hospice/palliative care (18.0%); using practice toolkit (10.4%); engaging medical providers (9.9%); hospice/palliative care referrals (7.4%). From June 2010 to June 2011, the percent of at-risk Medicaid enrollees asked palliative care questions increased (7.7% vs. 29.2%), as did the cumulative number of palliative care and hospice referrals (3 vs. 134). A statewide intervention targeting care managers in a primary care practice network is effective to improve access to hospice, palliative care, and other supportive resources for seriously ill, Medicaid recipients.

Measuring Diabetes Care in the National Interdisciplinary Primary Care Practice‐Based Research Network (NIPC‐PBRN)

To assess diabetes care in a network of primary care practices that include pharmacist support by using a scoring system designed for the National Committee for Quality Assurance (NCQA) Diabetes Recognition Program (DRP) measures. Retrospective medical record review. Subset of the National Interdisciplinary Primary Care Practice-Based Research Network (NIPC-PBRN). A total of 1309 adults who were seen at 17 practices for an outpatient diabetes mellitus visit between January 1 and June 30, 2008. Patient demographic data and NCQA DRP process and outcome measures (hemoglobin A(1c) [A1C], blood pressure, and low-density lipoprotein cholesterol [LDL] level measurements; eye and foot examinations; nephropathy assessment; and smoking status and cessation advice or treatment) were recorded. Points for each measure were compiled, and practices achieving a sufficient score for NCQA recognition (≥ 75.0 points) were identified. Pharmacists were also surveyed regarding their services, participation in quality improvement initiatives, use of electronic medical records, and methods of data extraction. The relationships between DRP measures and quality improvement activities, pharmacist involvement in diabetes care, and use of electronic medical records were analyzed. The DRP outcome measures were satisfactory: mean ± SD A1C 7.6% ± 1.9%, LDL level 99.1 ± 35.1 mg/dl, and systolic and diastolic blood pressures 130.2 ± 18.1 and 74.4 ± 10.8 mm Hg, respectively. Five practices (29%) achieved a sufficient score for NCQA recognition. No significant relationships were noted between DRP measures and participation in quality improvement, type of clinical pharmacy services, or use of electronic medical records (p>0.05). In a regression analysis, only electronic medical record use was significantly related to DRP measures (p=0.02). Diabetes care in the NIPC-PBRN appears satisfactory, but improvements are necessary if NCQA recognition is the goal. Use of electronic medical records was associated with better DRP measures.

Organizational factors and depression management in community-based primary care settings.

BackgroundEvidence-based quality improvement models for depression have not been fully implemented in routine primary care settings. To date, few studies have examined the organizational factors associated with depression management in real-world primary care practice. To successfully implement quality improvement models for depression, there must be a better understanding of the relevant organizational structure and processes of the primary care setting. The objective of this study is to describe these organizational features of routine primary care practice, and the organization of depression care, using survey questions derived from an evidence-based framework.MethodsWe used this framework to implement a survey of 27 practices comprised of 49 unique offices within a large primary care practice network in western Pennsylvania. Survey questions addressed practice structure (e.g., human resources, leadership, information technology (IT) infrastructure, and external incentives) and process features (e.g., staff performance, degree of integrated depression care, and IT performance).ResultsThe results of our survey demonstrated substantial variation across the practice network of organizational factors pertinent to implementation of evidence-based depression management. Notably, quality improvement capability and IT infrastructure were widespread, but specific application to depression care differed between practices, as did coordination and communication tasks surrounding depression treatment.ConclusionsThe primary care practices in the network that we surveyed are at differing stages in their organization and implementation of evidence-based depression management. Practical surveys such as this may serve to better direct implementation of these quality improvement strategies for depression by improving understanding of the organizational barriers and facilitators that exist within both practices and practice networks. In addition, survey information can inform efforts of individual primary care practices in customizing intervention strategies to improve depression management.

Prevalence of Positive Substance Abuse Screen Results Among Adolescent Primary Care Patients

To measure the prevalence of positive substance use screen results among adolescent primary care patients and to estimate the prevalence of substance-related problems and disorders. Cross-sectional survey. A network of primary care practices in New England. A consecutive sample of 12- to 18-year-old patients (N = 2133), with a study participation rate of 92.7%. The CRAFFT substance abuse screening test (a full description of this screen is given in the "Introduction"). Frequencies of positive screen results were computed for the entire sample, each practice, visit type (well-child care, sick visit, follow-up, or other), and patient status (new vs established). Generalized estimating equation modeling was used to test for difference in proportions. CRAFFT scores, demographic data, and Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) diagnostic data from a previous study were used to estimate the prevalence of problematic substance use, abuse, and dependence. Overall, 14.8% of adolescents had positive results on the CRAFFT screen. Prevalence rates differed significantly across practices (P < .001) after adjusting for demographic factors. The highest positive rates on the CRAFFT screen were at school-based health centers (29.5%) and the rural family practice (24.2%), the middle rate was at the adolescent clinic (16.6%), and the lowest rates were at the health maintenance organization (14.1%) and pediatric clinic (8.0%). Sick visits had the highest rate (23.2%). Well-child care visits had a significantly lower rate (11.4%, P < .001). Statistical modeling estimated that 11.3% of all patients had problematic use, 7.1% had abuse, and 3.2% had dependence. Substance abuse screening should occur whenever the opportunity arises, not at well-child care visits only.