Primary Care Clinic Appointments Research Articles

A randomized clinical trial of an interactive voice response and text message intervention for individuals with hypertension.

Interactive voice response and text message (IVR-T) technology may improve hypertension control in under-resourced settings. We conducted a randomized clinical trial to determine whether an IVR-T intervention would improve blood pressure (BP), medication adherence and visit keeping among adults with hypertension from multiple racial and ethnic groups in primary care at an Urban Indian Health Organization in Albuquerque, New Mexico. Two hundred and ninety-five participants were randomly assigned to IVR-T (N=148) or to usual care (N=147). The IVR-T arm received reminders for clinic visits, messages to reschedule missed clinic visits, monthly medication refill reminders, weekly motivational messages, and a blood pressure cuff. The usual care arm received no messages. The primary outcome was change in systolic BP (SBP) between baseline and 12months. Secondary outcomes included change in SBP between baseline and 6months, change in diastolic BP (DBP) at 6 and 12months, self-reported adherence at 6months, and the proportion of missed primary care clinic appointments. The intervention did not affect SBP or DBP at 6 or 12months. The 12-month change in SBP/DBP was 1.66/1.10mmHg in usual care and 0.23/1.34mmHg in the intervention group (P values=.57 and .88, respectively). Self-reported medication adherence improved comparably in both groups, and there was no difference in percentage of kept visits. Several features of study design, clinic operations, and data transfer were barriers to demonstrating effectiveness.

Association of Primary Care Clinic Appointment Time With Opioid Prescribing

Time pressure to provide a quick fix is commonly cited as a reason why opioids are frequently prescribed in the United States, but there is little evidence of an association between appointment timing and clinical decision-making. As the workday progresses and appointments run behind schedule, physicians may be more likely to prescribe opioids. To estimate whether characteristics of appointment timing are associated with clinical decision-making about pain treatment. This cross-sectional study of physician behavior used data from electronic health record systems in primary care offices in the United States to analyze primary care appointments occurring in 2017 for patients with a new painful condition who had not received an opioid prescription within the past year. The association between treatment decisions and 2 dimensions of appointment timing (order of appointment occurrence and delay relative to scheduled start time) were assessed. The rates of opioid prescribing were measured and compared with rates of nonopioid pain medication (ie, nonsteroidal anti-inflammatory drugs) prescribing and referral to physical therapy. All rates were estimated within the same physician using physician fixed effects, adjusting for patient, appointment, and seasonal characteristics. Among 678 319 primary care appointments (642 262 patients; 392 422 [61.1%] women) with 5603 primary care physicians, the likelihood that an appointment resulted in an opioid prescription increased by 33% as the workday progressed (1st to 3rd appointment, 4.0% [95% CI, 3.9%-4.1%] vs 19th to 21st appointment, 5.3% [95% CI. 5.1%-5.6%]; P < .001) and by 17% as appointments ran behind schedule (0-9 minutes late, 4.4% [95% CI, 4.3%-4.6%] vs ≥60 minutes late, 5.2% [95% CI, 5.0%-5.4%]; P < .001). Prescribing of nonsteroidal anti-inflammatory drugs and referral to physical therapy did not display similar patterns. These findings suggest that, even within an individual physician's schedule, clinical decision-making for opioid prescribing varies by the timing and lateness of appointments.

Association of Primary Care Clinic Appointment Time With Clinician Ordering and Patient Completion of Breast and Colorectal Cancer Screening

As the clinic day progresses, clinicians may fall behind schedule and experience decision fatigue. However, the association of time of day with cancer screening rates is unknown. To evaluate the association of primary care clinic appointment time with clinician ordering and patient completion of breast and colorectal cancer screening. Retrospective, quality improvement study of 33 primary care practices in Pennsylvania and New Jersey from September 1, 2014, to August 31, 2016. Participants included adults eligible for breast or colorectal cancer screening. Data analysis was conducted from April 24, 2018, to November 8, 2018. Clinic appointment time during each patient's first primary care physician visit in the study period. Primary outcome was clinician ordering of the screening test during the visit. Secondary outcome was patient completion of the tests within 1 year of the visit. Among the 19 254 patients eligible for breast cancer screening, the mean (SD) age was 60.2 (6.9) years; 19 254 (100%) were female, 11 682 (60.7%) were white, and 5495 (28.5%) were black. Screening test order rates were highest at 8 am at 63.7%, decreased throughout the morning to 48.7% at 11 am, increased to 56.2% at noon, and then decreased to 47.8% at 5 pm (adjusted odds ratio [OR] for overall trend, 0.94; 95% CI, 0.93-0.96; P < .001). Trends in screening test completion rates were similar beginning at 33.2% at 8 am and decreasing to 17.8% at 5 pm (adjusted OR, 0.95; 95% CI, 0.94-0.97; P < .001). Among the 33 468 patients eligible for colorectal cancer screening, the mean (SD) age was 59.6 (7.4) years; 18 672 (55.8%) were female, 22 157 (66.2%) were white, and 7296 (21.8%) were black. Screening test order rates were 36.5% at 8 am, decreased to 31.3% by 11 am, increased at noon to 34.4%, and then decreased to 23.4% at 5 pm (adjusted OR, 0.94; 95% CI, 0.93-0.95; P < .001). Trends in screening test completion rates were similar beginning at 28.0% at 8 am and decreasing to 17.8% at 5 pm (adjusted OR, 0.97; 95% CI, 0.96-0.98; P < .001). Clinician ordering of cancer screening tests significantly decreased as the clinic day progressed. Patient completion of cancer screening tests within 1 year of the visit was also lower as the primary care appointment time was later in the day. Future interventions targeting improvements in cancer screening should consider how time of day may influence these behaviors.

The Role of Child and Adolescent Adjustment Problems and Sleep Disturbance in Parent Psychological Distress

The goal of this study was to examine the moderating role of youth sleep disturbance on the relationship between youth internalizing and externalizing symptoms and parent psychological distress. Participants were 225 youth (ages 8–17) and parent dyads attending a primary care clinic appointment. Participants completed questionnaires that assessed parent psychological distress, youth internalizing symptoms, youth externalizing symptoms, and youth sleep disturbance. Moderation analyses were conducted to examine whether youth sleep disturbance moderated the relationship between youth internalizing and externalizing symptoms and parent psychological distress. The interaction between youth internalizing symptoms and youth sleep disturbance was significantly related to parent psychological distress, such that having increased sleep disturbance amplified the positive relationship between internalizing symptoms and parent psychological distress. The moderation model explained 52% of the variance in parent psychological distress. The interaction between youth externalizing symptoms and youth sleep disturbance was also significantly related to parent psychological distress, such that increased sleep disturbance amplified the positive relationship between externalizing symptoms and parent psychological distress. This model accounted for 53% of the variance in parent psychological distress. Greater youth sleep disturbance strengthens the positive relationship between youth internalizing/externalizing symptoms and parent psychological distress. Accordingly, reducing youth sleep disturbance may serve as an appropriate intervention target in families experiencing increased parent psychological distress.

The effects of media, self-esteem, and BMI on youth's unhealthy weight control behaviors

PurposeYouth engage in a variety of methods to manage their weight, including unhealthy weight control behaviors (UWCBs). The purpose of this study was to examine factors associated with youth's engagement in UWCBs, including media influence, youth's BMI z-score and self-esteem. MethodsParticipants were 179 youth, aged 10–17, attending a primary care clinic appointment. Youth completed questionnaires assessing frequency of UWCBs, global self-worth, and perception of media influence to lose weight. BMI z-score was calculated based on height and weight measurements obtained from medical charts. The SPSS macro, PROCESS, was used to conduct moderation analyses. ResultsOver 40% of youth endorsed using at least one UWCB in the past year. Girls reported using more UWCBs and engaging in UWCBs more frequently than boys. For boys, media influence to lose weight was only related to UWCB frequency for those with a BMI z-score of 1.23 and above. For girls, media influence was only related to UWCB frequency for those with low to average levels of global self-worth. ConclusionsGirls' and boys' use of UWCBs is impacted by different factors. Prevention efforts should consider targeting factors, such as weight status and self-esteem, which are uniquely associated with gender.

Youth Safety Perceptions of Weight Control Behaviors.

Youth attempting to lose weight may engage in a variety of weight control behaviors (WCBs), some of which are viewed as healthy WCBs (HWCBs), whereas others are viewed as unhealthy WCBs (UWCBs). This study sought to examine youth perceptions of which WCBs are safe versus unsafe ways to lose weight. Furthermore, youth safety perceptions of WCBs and body mass index (BMI) z-scores were examined in relation to how often youth engage in these WCBs. Participants were 219 youth (aged 10-17 years) attending a primary care clinic appointment. Participants completed questionnaires about the frequency of their own WCB use and whether they perceived each WCB as a safe way to lose weight. Results revealed differences in safety perceptions across weight status groups for certain HWCBs and UWCBs. Youth perception of WCBs as safe ways to lose weight was associated with more frequent engagement in WCBs. Furthermore, an interaction between youth safety perception of HWCBs and youth BMI z-scores was related to greater engagement in HWCBs, such that the relationship between safety perception and engagement was only significant for youth who are overweight/obese. The moderation model explained 36.95% of the variance in engagement in HWCBs. The moderation model was also significant for UWCBs (r = .35). This study identifies youth safety perception of WCBs as a mechanism that may lead to increased youth engagement in WCBs. Health care providers should educate both youth and family members about safe versus unsafe WCBs.

Health Beliefs and Co-morbidities Associated with Appointment-Keeping Behavior Among HCV and HIV/HCV Patients.

Appointment-keeping behavior is an important requisite for HCV linkage and treatment initiation. In this study we examine what impact hepatitis C (HCV) knowledge and attitudes has on appointment-keeping behavior among a cohort of HCV and HCV/HIV patients. Knowledge scores and attitude scales, obtained from a cross-sectional survey, were correlated with proportion of appointments kept 1 year prior to taking the survey. Independent risk factors for missing appointments were examined by multiple regression analysis. 292 HCV patients completed the survey, and 149 (51%) were co-infected with HIV. HCV patients kept 67.5 ± 17.4% of their total appointments and a similar proportion (67 ± 38.2) of Liver Clinic appointments, but they attended a higher proportion (73 ± 24.4) of Primary Care Clinic appointments. However, certain health beliefs, psychiatric illness, and HIV co-infection were independently associated with lower levels of appointment-keeping behavior. HCV knowledge was not associated with appointment-keeping behavior. Health beliefs, psychiatric illness, and HIV co-infection are associated with missing appointments, but no link between knowledge and appointment keeping behavior is apparent. In order to increase engagement into HCV care, HCV care coordination programs need to focus on addressing health beliefs and providing resources to those at highest risk for missing appointments.

Communicating about opioids for chronic pain: a qualitative study of patient attributions and the influence of the patient-physician relationship.

Chronic pain poses numerous challenges for patients and providers, particularly when opioid treatment is discussed. Despite accounts of antagonistic patient-provider communication, little is known about how communication about opioids unfolds during clinic visits and, importantly, how the relationship history of a patient and physician shapes this communication. This study's objective was to advance understanding of communication about opioid treatment by recording primary care clinic visits and conducting in-depth interviews with patients to gain insight into the patient–provider relationship and its influence on clinical communication. Forty patients with chronic pain were audio recorded during their primary care clinic appointments and then interviewed about their pain care and relationships with their providers. Ten patients were excluded from analysis because pain was not discussed during the clinic visit. Qualitative analysis revealed that patients responded in markedly different ways to similar physician treatment decisions about opioids. Some patients attributed limiting or denying opioids to physicians' distrust or lack of caring. Others attributed these limitations to acting out of genuine concern for patients' health. These attributions appeared to be shaped by features of the patient–physician relationship as described by patients. Results are discussed within the framework of attribution theory. Understanding how patients and providers discuss opioid treatment is critical for optimal pain treatment. Physicians might be able to improve communication by re-framing treatment discussions about opioids around external factors, such as benefits and harms, and engaging in communication that fosters a strong therapeutic alliance and emphasizes concern for the patient.

Implementation of a hypertension clinic using a streamlined treatment algorithm

The implementation of a pharmacist-managed clinic based on the Simplified Treatment Intervention to Control Hypertension (STITCH) algorithm is described, with insights on physician acceptance and implementation challenges. After a medical records review indicating gaps in the follow-up care of emergency department (ED) patients found to have elevated blood pressures (BPs), the ED of a large public hospital sought to create a "bridge" to ongoing primary care by applying a modified version of the STITCH algorithm, which aims to address compliance barriers to adequate BP control through a streamlined stepped-care approach derived from national consensus guidelines. Following the guidelines of the STITCH algorithm, the goals of the clinic implemented in this project were to (1) coordinate initial pharmacotherapy, (2) monitor patients pending their first primary care clinic appointment, (3) assess for potential antihypertensive-related complications, and (4) provide comprehensive and ongoing patient education. Physician support for the clinic (staffed by one pharmacist one day weekly) was cultivated through both broad and individually targeted education to allay concerns about initiating BP-lowering therapy in the ED setting, especially given patients' typical one- to six-month wait time for a primary care clinic appointment. Early experience at the clinic indicated increased physician willingness to initiate hypertension treatment in the ED due to the availability of appropriate follow-up services within a shorter time frame (about two weeks). One hospital's experience suggests that a hypertension-focused clinic using a streamlined treatment algorithm can serve as a bridge from urgent care to ongoing primary care, facilitating adequate BP control in a transient, low-income patient population.

Routine Screening for HIV Infection in a Low Risk Population

Context: Despite advances in therapy for HIV infection, treatment is often compromised by delayed diagnosis. Strate-gies are needed to improve broad based testing in all medical settings. Objective: To compare HIV screening rates in a primary care setting following implementation of an electronic reminder system to rates produced solely by provider educational efforts. Design: Prospective, observational study of HIV screening, comparing rates during implementation of strategies. Setting: Multiple clinic healthcare system affiliated with a tertiary care medical center. Patients: Veterans receiving care in the clinics affiliated with the Department of Veterans Affairs-Eastern Colorado Healthcare System. Intervention: Provider education and a provider clinical reminder system embedded in the electronic medical record. Main Outcome Measure: Proportion of primary care clinic appointments at which the veteran was screened for HIV infection. Results: The proportion of visits at which screening occurred increased from 2.7% during the provider edu-cation period to 16.7% during the provider clinical reminder period (p < 0.0001). All of the cases identified by the re-minder were antiretroviral therapy candidates, and there was a trend to earlier diagnosis in the screening group than in the diagnostic testing group (CD4 count 329 vs. 109, p = 0.13). Conclusions: An electronic clinical reminder system in a primary care setting is an effective strategy to increase testing for HIV infection, and may lead to fewer delayed diag-noses.

The Comprehensive Care Clinic

Management of chronic diseases has been a recent focus of health care because of its effect on quality of life, health care use, and cost (Holman & Lorig, 2000). However, most of the interventions geared toward chronic disease management have been disease specific and do not address the issue of comorbidity, defined as an additional disease beyond the condition under study that increases a patient's total burden of (Klabunde, Warren, & Legler, 2002, p. 26). Previous studies of older adults have demonstrated the importance of comorbidity in affecting the number and type of health care services sought (Westert, Satariano, Schellevis, & van den Bos, 2001), functional abilities (Dunlopp, Manheim, Sohn, Liu, & Chang, 2002), and general health (Wensing, Vingerhoests, & Grol, 2001). In a review of current management strategies for chronic diseases, Davis, Wagner, and Groves (2002) stated that people with chronic comorbid diseases have common concerns and face similar challenges, such as coping with anger and dealing with role function changes, that are not often addressed in disease-specific self-management programs (Lorig et al., 1996). Disease-management vendors, such as case managers, who provide services specific to a disease or syndrome, are now finding it necessary to merge with other companies to provide comprehensive all-disease management to patients with multiple chronic comorbid conditions (Carroll, 2002). The problem of comorbidity is well represented in the elderly veteran population. Given its rapid growth, an important goal for the Department of Veterans Affairs (VA) is to develop effective interventions to help elderly veterans better cope with their chronic comorbid conditions. This article describes a clinical demonstration project, the Comprehensive Care Clinic (CCC) in the West Los Angeles VA Medical Center, implemented by its Geriatric Research, Education, and Clinical Center (GRECC) outpatient clinic staff that aimed to serve this need. The CCC was an interdisciplinary team effort to serve the psychosocial and medical needs of a population of elderly veterans with chronic comorbid conditions and who were perceived as high users of health services by their GRECC providers. The CCC consisted of a monthly group clinic supplemental to the patients' outpatient primary care clinic appointments and provided increased access to their health care team, closer monitoring of chronic illness symptoms, and education for self-care and encouraged social support among its members. It began in January 2001 and ended in December 2001. METHOD Sample The sampling method for the CCC was based on the Kaiser Permanente Cooperative Health Care Clinic model (Kaiser Permanente, 1993). The GRECC clinic interdisciplinary staff, composed of physicians, a nurse practitioner, a social worker, a pharmacist, a psychologist, a nutritionist, and a program assistant, was given rosters of the clinic patients and asked to recommend patients for the CCC based on eligibility criteria developed from the Kaiser Permanente model: * Frequent flyers or those who sought unscheduled care at least 10 times per year (phone calls, emergency room visits, urgent care, unscheduled primary care visits) as determined by GRECC interdisciplinary staff * Minimum of two chronic disorders * No terminal illness * No cognitive impairment as measured by a Mini-Mental State Examination (Folstein, Folstein, & McHugh, 1975) score of at least 24 * Able to transfer and toilet independently * No active substance abuse problem * Living in the community (no nursing home residents) * Primary care providers were GRECC staff Twenty-two patients were identified by the clinic staff as potential participants from a roster of 200. Procedures and Interventions Telephone Needs Assessment. The identified patients were contacted by telephone, introduced to the concept of the CCC, and asked about their health care needs, patterns of VA services use, and interest in attending a group clinic, using a needs assessment instrument developed for this pilot program (see Table 1). …

Toward Smoke-Free VA Hospitals

To the Editor. — The letter by Drs Joseph and Korn 1 in the Sept 16 issue of JAMA discusses the attitudes of veterans toward smoking restrictions in a Veterans Administration (VA) hospital and the feasibility of smoke-free VA hospitals. We were encouraged and delighted to hear that the Minneapolis VA Medical Center has become a totally smoke-free hospital. All other VA hospitals, on the other hand, still allow smoking by patients and staff in a number of areas. The number of places where smoking is allowed in the Denver VA Medical Center has been reduced significantly in the last few years, but further efforts to restrict smoking have met with considerable resistance. To determine the extent of this resistance among patients, we gave a questionnaire (June through August 1987) to outpatients awaiting primary care clinic appointments. Completed questionnaires were received from 84% (468/553); 40% were current smokers, 45% were