Primary Care Clinic Population Research Articles

Glucagon-like peptide-1 receptor agonist therapy effects on glycemic control and weight in a primary care clinic population.

Glucagon-like peptide-1 receptor agonist (GLP-1a) medications have been shown in randomized controlled trials (RCTs) to have consistent and impressive effectiveness in lowering hemoglobin A1c (HbA1c) and weight, but limited data exist on the efficacy of GLP-1a medications in clinical practice. We studied the association between GLP-1a therapy and changes in weight and HbA1c in a real-world patient population. In this retrospective cohort study of patients seen in a primary care clinic between 2012 and 2021, we examined the change in weight and HbA1c over 12 months in a cohort of patients with at least one prescription for a GLP-1a. Within this cohort, treatment was defined as having ≥2 GLP-1a prescriptions at a therapeutic dosage separated by ≥10 months. The cohort included 693 patients of whom 393 (57%) were treated with GLP-1a therapy. The treatment group had a mean change in body mass index (BMI) of -0.83 kg/m2 (±2.88) compared to -0.70 kg/m2 (±2.99) in the without GLP-1a group (p = 0.57). Treated patients had a mean change in HbA1c of -1.00% (±2.07) compared to -0.83% (±1.92) in the without GLP-1a group (p = 0.27). For treated and without GLP-1a patients, respectively, the proportion of patients with a decrease in BMI was 65 versus 64% (p = 0.86), and the proportion with a decrease in HbA1c was 73 versus 69% (p = 0.28). In clinical practice, GLP-1a therapy was associated with more modest reductions in weight and HbA1c than shown in prior RCTs. As GLP-1a use continues to expand throughout primary care, the real-world impact of this pharmacotherapy will require further evaluation.

Assessment of ISTH-BAT Scores in a Primary Care Clinic Population of Menstruating Adolescents

Background Accurate assessment of bleeding severity is critical for timely diagnosis and appropriate management of inherited bleeding disorders. To achieve standardized and reliable evaluation, the International Society on Thrombosis and Haemostasis (ISTH) developed the Bleeding Assessment Tool (BAT). The ISTH-BAT is a comprehensive questionnaire designed to systematically evaluate bleeding symptoms in both children and adults. A crucial aspect of utilizing the ISTH-BAT in clinical practice is determining the normal range of bleeding scores in the general population. Defining this baseline aids in distinguishing abnormal bleeding tendencies from variations within the healthy population. The ISTH-BAT Merging Project established a normal range of BAT scores for children age <18 years as 0-2 and for adult females age ≥18 years as 0-5. However, the normal range of BAT scores for adolescent females remains undetermined. This population is unique because they have undergone the bleeding challenge of menarche but are less likely to have experienced childbirth or multiple surgeries. Furthermore, while prior studies have shown age-related increases in BAT scores in individuals with von Willebrand Disease, there are limited data on the effect of aging on BAT scores in a healthy adolescent population. This study aims to determine the range of BAT scores in a diverse menstruating adolescent population, compare bleeding scores to published reference ranges from the ISTH-BAT Merging Project and assess potential age-related variations in BAT scores. Methods In an ongoing large population study, 10-20 year-old menstruating adolescents presenting for routine care are recruited from primary care clinics across Nationwide Children's Hospital (Columbus, OH, USA). Patients with a prior diagnosis of a bleeding disorder are excluded. The ISTH-BAT is administered by trained study personnel. Data analyses were completed using nonparametric methods such as Wilcoxon signed-rank or rank sum tests and Spearman's correlation. Means and 95% confidence intervals (CI) were calculated and compared to historical estimates. Results In a preliminary analysis of the first 150 participants, the median age was 15 years (IQR: 13-18). Participants represented a diverse range of backgrounds, with 69% of participants identifying as Black/African American, 19% as White, and 12% as other races. 94% identified as non-Hispanic, while 6% identified as Hispanic/Latino. The mean BAT score was 1.06 (95% CI: 0.87-1.25), with scores ranging from 0-5. The data exhibited a non-normal distribution, with most scores concentrated at 0 or 1, accounting for 72% of the dataset. The mean BAT score is significantly higher than the ISTH-BAT Merging Project pediatric mean score of 0.34 (p<0.0001), but not significantly different from the adult female mean of 1.28 (p=0.99). When analyzed by age group, participants aged 10-17 years had a mean BAT score of 0.96, significantly higher than the published pediatric mean (p<0.0001) but similar to the published adult mean (p=0.99). Similarly, participants aged 18-20 years had a mean BAT score of 1.33. To assess if BAT score increased with age, we compared participants aged 10-14 years to adolescents 15-20 years, and identified a small, but significant increase in mean BAT score with age (p=0.001). Participants aged 10-14 years had a mean score of 0.69 (95% CI: 0.45-0.94), falling between the published pediatric and adult means, with no significant difference from either one (p=0.003 and p=0.99, respectively) (Figure 1). However, participants aged 15-20 had a mean BAT score of 1.30 (95% CI: 1.03-1.56), which remained significantly higher than the published pediatric mean (p<0.0001) but still showed no significant difference from the published adult mean (p=0.81). There was a weak, but statistically significant positive correlation between age and bleeding score, indicating that as age increases, bleeding scores tend to rise (Spearman's correlation r s= 0.21, p=0.001) (Figure 2). Similarly, a weak positive relationship exists between years post-menarche and bleeding score (r s=0.23, p=0.005). Conclusion This study provides insight on ISTH-BAT scores in a population of healthy menstruating adolescent females, suggesting that after the onset of menstruation, the adult female bleeding score range may be more suitable for adolescents than the pediatric range.

Design of a study to implement population-based risk assessment for hereditary cancer genetic testing in primary care

Identifying patients with high genetic risk for cancer has important clinical ramifications, but hereditary cancer risk is often not identified because of testing barriers at both the provider and patient level. It is unknown how to best implement appropriate genetic testing and follow-up care into an operating primary care clinic. Implementation studies to date have been conducted in high resourced facilities under optimal conditions, often not at the clinic level. This study aims to compare and evaluate two population-wide engagement strategies for identifying members of a primary care clinic's population with a family or personal history of cancer and offering high-risk individuals genetic testing for cancer susceptibility mutations. The two engagement strategies are: 1) point of care screening (POC), conducted when a patient is scheduled for an appointment and 2) direct patient engagement (DPE), where outreach provides the patient an opportunity to complete screening online on their own time. The study will identify changes, problems, and inefficiencies in clinical flow during and after the implementation of risk assessment and genomic testing for cancer risk across primary care clinics. It will also evaluate the effects of the two engagement strategies on patient, provider, and clinic leader outcomes, including perceptions of benefits, harms, and satisfaction with the engagement strategy and process of cancer risk assessment and genetic testing, across gender, racial/ethnic, socioeconomic, and genetic literacy divides. Finally, the study will evaluate the cost-effectiveness and budget impact of each engagement strategy.

Prevalence and Characteristics of Low Back Pain in a Rural Ghana Primary Care Clinic Population.

Low back pain (LBP) is the leading cause of disability in the developed world. Less is known about the impact of LBP in the developing world, and particularly the rural developing world. In 2015, the World Health Organization (WHO) issued an urgent call for additional research into the prevalence and effect of LBP on developing world populations. To calculate the prevalence of LBP in a rural Ghana primary care clinic population. Survey of LBP prevalence and severity. Primary care mission clinic in rural Southeastern Ghana. Six hundred eighty-four adult patients. All adult patients were screened for LBP using the definition "any pain occurring within the region between the lower margin of the 12th ribs and the gluteal folds." The Oswestry Disability Index (ODI) was used to further characterize LBP in those screening positive. Chi-square test was used to assess statistical significance of difference in prevalence between groups, and ordinary least squares regression was used to assess the relationship between LBP severity and gender and age. LBP prevalence and LBP severity as assessed using the ODI. Overall LBP prevalence was 15.7%, with no statistically significant differences observed by age or gender. The activities of standing, traveling, and walking were most severely affected. Of those with LBP, 10.3% were considered "crippled" based on ODI responses, whereas a further 31.8% were "severely disabled." No statistically significant relationship between LBP severity and age or gender was found. LBP is a cause of significant disability within this region of rural Ghana; however, prevalence appears to be lower than in the developed world and parts of the urbanized developing world. Increased attention to screening and treatment of LBP represents an opportunity to improve the health of rural Africans. IV.

Peer-led Group Sessions to Improve Healthful Eating and Physical Activity in a Low-income Primary Care Clinic Population

Peer-led Group Sessions to Improve Healthful Eating and Physical Activity in a Low-income Primary Care Clinic Population

Food security is related to adult type 2 diabetes control over time in a United States safety net primary care clinic population

Background/Objectives:Successful Type 2 diabetes management requires adopting a high nutrient-density diet made up of food items that both meet dietary needs and preferences and can be feasibly obtained on a regular basis. However, access to affordable, nutrient-dense foods often is lacking in poorer neighbourhoods. Therefore, low food security should directly impair glucose control, even when patients have full access to and utilize comprehensive medical management. The present study sought to determine whether food security is related longitudinally to glucose control, over-and-above ongoing medication management, among Type 2 diabetes patients receiving comprehensive care at a Midwestern multi-site federally qualified health centre (FQHC).Subjects/Methods:In this longitudinal observational study, we completed a baseline assessment of patients’ food security (using the US Household Food Security Module), demographics (via Census items), and diabetes history/management (using a structured clinical encounter form) when patients began receiving diabetes care at the health centre. We then recorded those patients’ A1C levels several times during a 24-month follow-up period. Three hundred and ninety-nine patients (56% with low food security) had a baseline A1c measurement; a subsample of 336 (median age=52 years; 56% female; 60% Hispanic, 27% African American, and 9% White) also had at least one follow-up A1c measurement.Results:Patients with lower (vs higher) food security were more likely to be on insulin and have higher A1c levels at baseline. Moreover, the disparity in glucose control by food security status persisted throughout the next 2 years.Conclusions:Although results were based on one multi-site FQHC, potentially limiting their generalizability, they seem to suggest that among Type 2 diabetes patients, low food security directly impairs glucose control—even when patients receive full access to comprehensive medical management—thereby increasing their long-term risks of high morbidity, early mortality, and high health-care utilization and cost.

Points for Improvement: Performance Measurement for Glycemic Control in Diabetes Patients in a Safety-Net Population

Diabetes complications account for significant worldwide morbidity and mortality. Improving glycemic control decreases microvascular complications, particularly among patients with the worst control. Current performance measures fail to prioritize such individuals. The categorization of glycemic control within a safety-net clinic population was compared using a common performance measure against one derived from a metric accounting for change in glycated hemoglobin (A1c) over time. Retrospective cohort analysis of all patients in a safety-net primary care clinic population quality registry with confirmed diabetes mellitus who had at least two A1c values between 2007 through 2011. Patients were stratified into five groups' on the basis of maximum and earliest A1c level (< 7%, 7% to < 8%, 8% to < 9%, 9% to < 10%, and > 10%). The change in Alc was assessed over time and compared with standard healthcare effectiveness data and information set (HEDIS) performance measures. Some 1122 patients were included in the analysis, with mean A1c of 7.9%. There was a modest annual decrease in the average A1c, and > 19% of patients improved by 1% or more during each of the previous three years. For patients who had maximum A1c values > or = 10%, there was a significantly greater reduction in A1c (p < .01), which was not reflected in the standard performance measure. It is feasible for safety-net clinics to analyze their patients with diabetes by level of disease control on the basis of change in A1c over time. Patients with the worst glycemic control tend to have the greatest improvement but are often overlooked by conventional performance measures. Improved performance measures should focus on longitudinal diabetes control and emphasize reducing risk of complications among patients at highest risk.

Testosterone Concentrations in Diabetic and Nondiabetic Obese Men

OBJECTIVETo determine the prevalence of subnormal testosterone concentrations in patients with obesity and with type 2 diabetes in a primary care clinic population.RESEARCH DESIGN AND METHODSFree testosterone concentrations of 1,849 men (1,451 nondiabetic and 398 diabetic) in the Hypogonadism In Males (HIM) study were analyzed. The HIM study was a U.S.-based cross-sectional study designed to define the prevalence of hypogonadism in men aged >45 years. Free testosterone was measured by equilibrium dialysis.RESULTSThe prevalence of subnormal free testosterone concentrations in lean, overweight, and obese nondiabetic men was 26% (n = 275), 29% (n = 687), and 40% (n = 489), respectively (P < 0.001 for trend), and 44% (n = 36), 44% (n = 135), and 50% (n = 227), respectively, in diabetic men (P = 0.46 for trend within group and P < 0.05 compared with nondiabetic men). The mean free testosterone concentration of diabetic men was significantly lower than that of nondiabetic men. Free testosterone concentrations were negatively and significantly (P < 0.001) related to age (r = −0.37), BMI (r = −0.18), and sex hormone–binding globulin (r = −0.11) in multiple regression analysis. The average decline of free testosterone concentrations was 7.8 pg/ml per decade in nondiabetic men and 8.4 pg/ml per decade in diabetic men.CONCLUSIONSForty percent of obese nondiabetic men and 50% of obese diabetic men aged ≥45 years have subnormal free testosterone concentrations. In view of its high prevalence, obesity is probably the condition most frequently associated with subnormal free testosterone concentrations in males. The concomitant presence of diabetes is associated with an additional increase in the prevalence of subnormal free testosterone concentrations.

Poster 75: The Seasonal Incidence of Dry Eye in a Haitian Primary Care Clinic Population

Poster 75: The Seasonal Incidence of Dry Eye in a Haitian Primary Care Clinic Population

Correlates of Co-Occurring Depressive Symptoms and Alcohol Use in an Older Primary Care Clinic Population

ABSTRACT Objective: This report describes the prevalence and correlates of co-occurring depressive symptoms and alcohol use in an older Veteran's Affairs primary care clinic population. Methods: Participants include 8,782 older primary care patients (age 65 +) who responded to a self-report, mailed survey. Patients were classified into six mutually exclusive groups based upon screening indicators for problem drinking (quantity/frequency questions) and depressive symptoms (General Health Questionnaire). Groups included: (a) neither problem drinking nor depressive symptoms (n = 6,415, 73.0%); (b) at-risk alcohol use (n = 761; 8.7%); (c) heavy alcohol use (n = 201; 2.3%); (d) depressive symptoms (n = 1,234, 14.1%); (e) depressive symptoms and at-risk alcohol use (n = 120; 1.4%); and (f) depressive symptoms and heavy alcohol use (n = 51; 0.6%). Chi-square and ANOVA were used to test for equality of demographic and clinical characteristics across groups. Results: 12.9% of patients reported alcohol use consistent with problem drinking (including 10.0% with at-risk alcohol use and 2.9% with heavy alcohol use) and 16.1% screened positive for possible depressive symptoms (including 2.0% with co-occurring at-risk or heavy alcohol use). The combination of heavy alcohol use and depressive symptoms was associated with the highest rates of death and suicidal ideation; living alone; being divorced, separated, or widowed; and regular cigarette smoking. The presence of depressive symptoms (regardless of amount of alcohol use) was associated with worse perceived health, and perceived lack of social support. Finally, individuals with at-risk alcohol use alone were younger and had better perceived health compared to those with non-problem alcohol use or no alcohol use. However, there were no differences between those with at-risk drinking and depressive symptoms and those with depressive symptoms alone. Conclusions: Self-reported heavy alcohol use combined with depressive symptoms identifies a subgroup of older primary care patients at especially high risk with respect to suicidal ideation and poor mental and physical well-being. In contrast, older adults with depressive symptoms and self-reported “at-risk” alcohol use were not differentiated from older persons with depressive symptoms reporting non-problematic or nonuse of alcohol.

Peripheral arterial disease symptom subtype and walking impairment

Walking impairment is common in patients with peripheral arterial disease (PAD). The purpose of this study was to compare specific leg symptoms and walking impairment in a racially diverse cohort of patients with PAD. Patients who were receiving care at the Michael E DeBakey Veterans Affairs Medical Center or in the Harris County Hospital District were screened for PAD, which was diagnosed in the office setting by blood pressure measurements that were used to calculate the ankle-brachial index (a level <0.90 was defined as disease). To define leg symptoms, we asked patients to complete the San Diego Claudication Questionnaire. Based on the questionnaire results, leg symptoms were categorized as: asymptomatic, atypical, and intermittent claudication. The patients also completed the Walking Impairment Questionnaire. Among 403 patients screened (136 Caucasians, 136 African Americans and 131 Latinos), 67 were found to have PAD (18 Caucasians, 31 African Americans and 18 Latinos). The mean age of the cohort was 63.8 years (standard deviation (SD) 7.3). Walking distance, speed and stair climbing scores were lower (p < 0.0001) for patients with PAD and leg pain on exertion or at rest when compared with patients with PAD without leg symptoms or with symptoms of intermittent claudication. For patients with PAD and leg pain on exertion and at rest, the walking distance score was 27.1 +/- SD 37.7 compared with 41.0 +/- 38.4 for those with asymptomatic disease who were inactive, and with 38.5 +/- 42.7 for those with intermittent claudication (p = 0.02). In an ethnically diverse primary care clinic population, patients with PAD and leg pain on exertion and at rest had greater compromise in their walking ability when compared with patients with intermittent claudication. The reasons for the significant impairment in walking among patients with PAD and these atypical leg symptoms may stem from coexisting illnesses or other as yet undefined factors. Future research should focus on methods to improve daily walking in patients with PAD and atypical leg symptoms.

Poor Methodology Teaches Us Nothing About Undetected Eye Disease

The recent article Undetected Eye Disease in a Primary Care Clinic Population by Wang et al 1 advanced laudable goals but, unfortunately, the quality of the research and the possibility that it may have been influenced by politically motivated bias necessitates the following critique. The significant limitations and flaws of this study are too numerous to address fully in this venue, so we will focus on what we consider to be its most egregious errors. Pursuit of Incompatible Research Questions. Wang and colleagues stated: This study was designed to determine the value of a battery of screening tests for the detection of four major eye diseases. In addition, the study was designed to address the prevalence of ocular disease in patients attending a general medical clinic, the proportion of prevalent ocular disease that is undetected.... It is inappropriate and illogical for Wang and colleagues to examine the prevalence of detected

Effect of Digital Rectal Examination on Serum Prostate-Specific Antigen in a Primary Care Setting

Background: Measurement of serum prostate-specific antigen (PSA) and digital rectal examination (DRE) are commonly used for prostate cancer screening. Clinicians have been advised to avoid measuring serum PSA after DRE because of the possibility of spurious elevation. However, studies in healthy volunteers have found no change. We sought to determine whether DRE performed by internists affects PSA levels in a primary care clinic population. Methods: Men older than 49 years enrolled in a Veterans Affairs internal medicine clinic were eligible for the study. For all patients, prostate size and nodularity were assessed by DRE. Blood for determination of PSA levels was drawn immediately before DRE and 30 minutes after DRE. All patients completed a questionnaire regarding voiding. Results: Two hundred two men aged 50 to 85 years (mean, 67 years) were enrolled and had complete data. The mean PSA level increased by 0.26 μg/L after DRE (P Conclusions: We conclude, in an elderly veteran population, that DRE causes a statistically significant but clinically insignificant increase in serum PSA level. Additionally, we found that symptoms and physical examination results cannot be used to select a population for whom PSA screening would likely be useful. (Arch Intern Med. 1995;155:389-392)

Depressive Symptoms Among Adults Visiting an Indian Health Service Primary Care Clinic

Depression is common among patients visiting primary care clinics. In order to describe the prevalence of depressive syndromes in an American Indian primary care clinic population and to help define the clinical correlates of depressive syndromes in this setting, a clinic-based research study of depression was undertaken by the Indian Health Service (IHS). One hundred and six patients from an IHS primary care clinic were systematically enlisted for participation in the study. Participants completed the Inventory for Diagnosing Depression (IDD). Twenty-two (20.7%) responded with answers scoring positive for a depressive syndrome. Nine of these 22 (8.9% of the 106 participants) met IDD criteria for a major depressive syndrome. A diagnosis of depression, a past history of depression, use of mental health facilities, unexplained pains, and antidepressant medication use were associated with the presence of a depressive syndrome.

Undetected Eye Disease in a Primary Care Clinic Population

Population-based data have indicated that a significant proportion of persons with undiagnosed ocular disease in the community are regular users of general medical services. This, combined with the high prevalence of chronic medical disorders known to be risk factors for ocular disease in such clinics, makes them an attractive site for screening. The prevalence of ocular disease was estimated in a sample of 405 general medicine patients attending an adult primary care clinic in an urban teaching hospital. Overall, 205 (50.6%) of 405 patients were found to have clinically important ocular pathology. One third of those affected (n = 68) were unaware of their eye disease, and 26% (n = 18) of these 68 patients required immediate medical or surgical intervention. Patients 65 years or older (odds ratio [OR], 1.76), in fair or poor general health (OR, 1.78), with diabetes mellitus (OR, 2.07), or with self-reported fair or poor vision (OR, 3.03), were at increased risk for the presence of ocular disease. Among patients with eye disease, those who had no insurance coverage for eye care (OR, 3.45), those who had not had an eye examination during the previous 2 years (OR, 4.03), and those whose last eye examination was performed by an optometrist (OR, 7.25, reference ophthalmologist) were more likely to not be aware of their eye disease. Our results underscore the importance of screening for ocular disease in primary health care settings, especially for patients who are older than 65 years, are in poor health, report poor vision, have had infrequent eye examinations, or have inadequate insurance coverage for eye care.

Undetected eye disease in a primary care clinic population

<h3>Background:</h3> Population-based data have indicated that a significant proportion of persons with undiagnosed ocular disease in the community are regular users of general medical services. This, combined with the high prevalence of chronic medical disorders known to be risk factors for ocular disease in such clinics, makes them an attractive site for screening. <h3>Methods:</h3> The prevalence of ocular disease was estimated in a sample of 405 general medicine patients attending an adult primary care clinic in an urban teaching hospital. <h3>Results:</h3> Overall, 205 (50.6%) of 405 patients were found to have clinically important ocular pathology. One third of those affected (n=68) were unaware of their eye disease, and 26% (n=18) of these 68 patients required immediate medical or surgical intervention. Patients 65 years or older (odds ratio [OR], 1.76), in fair or poor general health (OR, 1.78), with diabetes mellitus (OR, 2.07), or with self-reported fair or poor vision (OR, 3.03), were at increased risk for the presence of ocular disease. Among patients with eye disease, those who had no insurance coverage for eye care (OR, 3.45), those who had not had an eye examination during the previous 2 years (OR, 4.03), and those whose last eye examination was performed by an optometrist (OR, 7.25, reference ophthalmologist) were more likely to not be aware of their eye disease. <h3>Conclusions:</h3> Our results underscore the importance of screening for ocular disease in primary health care settings, especially for patients who are older than 65 years, are in poor health, report poor vision, have had infrequent eye examinations, or have inadequate insurance coverage for eye care. (Arch Intern Med. 1994;154:1821-1828)