Primary Care Internal Medicine Research Articles

Annual HIV screening rates for HIV-negative men who have sex with men in primary care.

Men who have sex with men (MSM) account for most new HIV diagnoses in the US. Annual HIV testing is recommended for sexually active MSM if HIV status is negative or unknown. Our primary study aim was to determine annual HIV screening rates in primary care across multiple years for HIV-negative MSM to estimate compliance with guidelines. A secondary exploratory endpoint was to document rates for non-MSM in primary care. We conducted a three-year retrospective cohort study, analyzing data from electronic medical records of HIV-negative men aged 18 to 45 years in primary care at a large academic health system using inferential and logistic regression modeling. Of 17,841 men, 730 (4.1%) indicated that they had a male partner during the study period. MSM were screened at higher rates annually than non-MSM (about 38% vs. 9%, p<0.001). Younger patients (p-value<0.001) and patients with an internal medicine primary care provider (p-value<0.001) were more likely to have an HIV test ordered in both groups. For all categories of race and self-reported illegal drug use, MSM patients had higher odds of HIV test orders than non-MSM patients. Race and drug use did not have a significant effect on HIV orders in the MSM group. Among non-MSM, Black patients had higher odds of being tested than both White and Asian patients regardless of drug use. While MSM are screened for HIV at higher rates than non-MSM, overall screening rates remain lower than desired, particularly for older patients and patients with a family medicine or pediatric PCP. Targeted interventions to improve HIV screening rates for MSM in primary care are discussed.

Barriers and Facilitators to Lung Cancer Screening: A Physician Survey.

To describe barriers to lung cancer screening (LCS) among family medicine and general internal medicine primary care physicians (PCPs) and assess the association of barriers with discussion and referral for screening. Cross-sectional survey. Random sample of primary care physicians (PCPs) in California. PCP practices for discussion and referral for LCS and ratings of LCS barriers. We performed exploratory factor analysis to identify four barrier constructs: (1) Physician Visit-Level Barriers to screening referral; (2) Physician System and Evidence Barriers; (3) Patient Cost Barrier; and (4) Other Patient Barriers. We then performed multivariable logistic regression adjusted for physician and practice characteristics to assess the association between the physician-reported barriers and whether PCPs discussed or referred for LCS. 368 physicians responded (response rate 42%). Most worked in large metropolitan areas (80%) and large health systems (59%). After adjusting for physician and practice characteristics, we found that physician-reporting of System and Evidence Barriers was associated with lower odds of discussion or referral for LDCT (aOR .18, 95% CI 0.09-0.37), while physician-reported Visit-Level Barriers were associated with increased odds discussion or referral (aOR 2.65, 95% CI 1.30-5.04). While physicians reported numerous barriers to LCS, we found that barriers were differentially associated with discussion or referral for screening. As new LCS guidelines broaden screening eligibility, it is critical to address these barriers to achieve higher rates of evidence-based LCS.

Specialty Care Utilization Among Adults with Limited English Proficiency.

People with limited English proficiency (LEP) face greater barriers to accessing medical care than those who are English proficient (EP). Language-related differences in the use of outpatient care across the full spectrum of physician specialties have not been studied. To compare outpatient visit rates to physicians in 28 specialties by people with LEP vs EP. Multivariable negative binomial regression analysis of nationally representative data from the Medical Expenditure Panel Survey (pooled 2013-2018) with adjustment for age, sex, and self-reported health status. 149,611 survey respondents aged 18 and older. LEP, defined as taking the survey in a language other than English. Annual per capita adjusted visit rate ratios (ARRs) comparing visit rates by LEP and EP persons to individual specialties, and to three categories of specialties: (1) primary care (internal or family medicine, geriatrics, general practice, or obstetrics/gynecology), (2) medical-subspecialties, or (3) surgical specialties. Patients with LEP were underrepresented in 26 of 28 specialties. Disparities were particularly large for the following: pulmonology (ARR, 0.26; 95% CI, 0.20-0.35), orthopedics (ARR, 0.35; 95% CI, 0.30-0.40), otolaryngology (ARR, 0.40; 95% CI, 0.27-0.59), and psychiatry (ARR, 0.43; 95% CI, 0.32-0.58). Among individuals with several specific common chronic conditions, LEP-EP disparities in visits to specialties in those conditions generally persisted. Disparities were larger for medical subspecialties (ARR, 0.41; 95% CI, 0.36-0.46) and surgical specialties (ARR, 0.46; 95% CI, 0.42-0.50) than for primary care (ARR, 0.76; 95% CI, 0.72 to 0.79). Patients with LEP are underrepresented in most outpatient specialty practices, particularly medical subspecialties and surgical specialties. Our findings highlight the need to remove language barriers to physician services in order to ensure access to the full spectrum of outpatient specialty care for people with LEP.

The Adverse Event Unit (AEU): A novel metric to measure the burden of treatment adverse events.

ObjectiveTo design a physician and patient derived tool, the Adverse Event Unit (AEU), akin to currency (e.g. U.S. Dollar), to improve AE burden measurement independent of any particular disease or medication class.Patients/MethodsA Research Electronic Data Capture (REDCap) online survey was administered to United States physicians with board certification or board eligibility in general neurology, subspecialty neurology, primary care internal medicine or family medicine, subspecialty internal medicine, general pediatrics, and subspecialty pediatrics. Physicians assigned value to 73 AE categories chosen from the Common Terminology Criteria of Adverse Events (CTCAE) relevant to neurologic disorder treatments. An online forced choice survey was administered to non-physician, potential patients, through Amazon Mechanical Turk (MTurK) to weight the severity of the same AE categories. Physician and non-physician data was combined to assign value to the AEU. Surveys completed between 1/2017 and 3/2019.Results363 physicians rated the 73 AE categories derived from CTCAE. 660 non-physicians completed forced choice experiments comparing AEs. The AEU provides 0–10, weighted values for the AE categories studied that differ from the ordinal 1–4 CTCAE scale. For example, CTCAE severe diabetes (category 4) is assigned an AEU score of 9. Although non-physician input changed physician assigned AEU values, there was general agreement among physicians and non-physicians about severity of AEs.ConclusionThe AEU has promise to be a useful, practical tool to add precision to AE burden measurement in the clinic and in comparative efficacy research with neurology patients. AEU utility will be assessed in planned comparative efficacy clinical trials.

Mother-Infant Dyad program in primary care: evidence-based postpartum care following gestational diabetes

Background Gestational diabetes mellitus (GDM), a common complication of pregnancy, is associated with a 10-fold increased risk of type 2 diabetes mellitus (T2DM) compared to the general population. Evidence-based guidelines recommend that patients with GDM receive postpartum care for T2DM risk reduction including an oral glucose tolerance test (OGTT) 4-12 weeks after delivery, yet half of patients with GDM did not return for their postpartum visits by 12 weeks postpartum. Additionally, only 10% utilize primary care within 12 months of delivery and one-third of GDM patients receive timely postpartum OGTT. Objective To determine if the Mother-Infant Dyad postpartum primary care program provides a framework to link well-child visits with postpartum primary care visits to increase postpartum clinical interactions promoting longitudinal care, such as postpartum visit attendance and T2DM screening. Study design All patients with a diagnosis of GDM that received care at a postpartum mother-infant dyad program at a Midwestern academic medical center internal medicine and pediatrics primary care clinic were enrolled. Clinic level data was obtained by baseline and 6-month post-enrollment surveys and chart review. A comparison population was identified from Medicaid claims data using propensity score matching to enable a comparison of program participants’ outcomes to a population comprised of similar individuals diagnosed with GDM that received care at sites not participating in the Dyad program. Our primary outcome was completion of T2DM screening in the 4–12 week postpartum period. The secondary outcomes were postpartum visit attendance with a prenatal provider, and prediabetes diagnoses. Results A total of 75 mother-infant dyads were seen by the clinic. Of the enrolled women, 43% were Non-Hispanic White and 30% were Non-Hispanic Black; mean age was 30.75 years. The matched comparison group (n = 62) had a mean age of 30.75 years, were 43% Non-Hispanic White and 30% Non-Hispanic Black. Women who participated in the program were more likely to receive T2DM screenings than women who did not participate (87 vs. 79%, p<.001) and complete postpartum visits (95 vs. 58%, respectively; p<.001). Additionally, a higher rate of new prediabetes diagnoses was observed (12 vs. 6%, p < .001). Conclusion The Mother-Infant Dyad postpartum primary care program improved T2DM screenings and postpartum visit attendance. In addition, a greater proportion of Dyad program participants experienced new prediabetes diagnoses that those in the comparison group. Our findings suggest that the dyad care model, in which women with GDM engage in postpartum primary care concurrent with well-child visits, can improve longitudinal postpartum care after a GDM diagnosis.

Abstract 9161: Referral Patterns Do Not Contribute to Racial Differences in Catheter Ablation for Atrial Fibrillation

Introduction: Non-Hispanic Black (NHB) adults with atrial fibrillation (AF) are less likely to undergo catheter ablation (AFCA) compared with non-Hispanic White (NHW) adults even among those with heart failure and even though previous studies have shown that NHB patients with AF were more symptomatic. Hypothesis: We hypothesize that differences in outpatient referrals to Cardiology and Electrophysiology (EP) contribute to the racial disparity in AFCA. Methods: Using data from the Northwestern Medicine Enterprise Data Warehouse, we curated a retrospective cohort of NHB and NHW patients with newly diagnosed AF between 1/1/2011 and 12/31/2019 in an outpatient office visit to Internal Medicine/Primary Care (IM/PC), Cardiology, or Heart Failure (HF). Rates of AFCA and referral rates from IM/PC to Cardiology or EP and from Cardiology and HF to EP were compared between NHB and NHW patients using logistic regression models adjusted for demographic characteristics and comorbidities. Results: Of the 5,555 included patients, the mean age was 68 years (SD 13.4), 61% were male, 15% were NHB, and the mean CHA 2 DS 2- VASc score was 3.5 (SD 2.0). 373 patients (6.7%) underwent AFCA. NHB patients had a higher prevalence of comorbidities. NHB patients were significantly less likely to undergo AFCA compared with NHW patients (OR 0.61, 95% CI 0.40-0.92, p = 0.02), and this difference persisted even when limited to the subset of patients who had visited EP (N=1,840, OR 0.65, CI 0.42-0.98, p = 0.04). Among patients diagnosed in IM/PC, NHB patients were 1.47 times more likely to be referred to Cardiology than NHW patients (CI 1.09-1.97, p = 0.01), but the rates of referral to EP were similar (OR 0.94, CI 0.72-1.24, p = 0.68) ( Figure ). Conclusion: NHB patients diagnosed in the outpatient setting are less likely to undergo AFCA compared with NHW patients, but referral patterns do not explain these findings. Exploration of other factors should be considered to mitigate disparities in care related to AFCA.

Abstract 14545: Prevalence of Medication Non-Adherence via Therapeutic Drug Monitoring in Patients With Uncontrolled Hypertension Treated at a Safety Net Hospital

Background: Medication nonadherence presents one of the greatest challenges to hypertension management. Previous studies from our group have shown therapeutic drug monitoring (TDM), biochemical monitoring of drug levels, is more accurate than self-report, detailed questionnaires, or prescription fill rate in detecting nonadherence. Prior studies have also shown a prevalence of nonadherence from 45% to 80% among insured patients with uncontrolled hypertension despite having been prescribed a multi-drug regimen. Previous studies have not assessed adherence to antihypertensive drugs in a safety net population by TDM. Methods: We performed a cross-sectional study in patients with uncontrolled hypertension in the primary care Internal Medicine and Cardiology Clinics at Parkland Health&amp; Hospital System (PHHS). Patients with BP of ≥130/80 mmHg, prescribed ≥2 antihypertensive medications, and self-reporting medication adherence were enrolled after informed consent. Plasma samples were obtained for measurement of 44 cardiovascular drugs using liquid chromatography mass spectrometry. Results: Among 77 patients with uncontrolled hypertension (57% female, 65% Black, 12% Hispanic), 13 (17%) were nonadherent to at least one anti-hypertensive drug by TDM. The adherent and nonadherent groups had similar systolic (146±13 vs 148±18, p=0.67) and diastolic (83±9 vs 88±10 mmHg, p=0.13) BP. All patients had either medical insurance or some form of prescription financial assistance. Sixty two patients had insurance, while 15 had prescription financial assistance. Nonadherence rates for patients on financial assistance programs did not significantly differ from patients with medical insurance (13% vs 18%, p&gt;0.999). Conclusions: We found a surprisingly low prevalence of anti-hypertensive medication nonadherence in this uncontrolled hypertension population despite many barriers to treatment. Our study suggests a lesser role of medication nonadherence in uncontrolled hypertension in the safety net population.

What can Europe learn from HCP knowledge and attitudes towards hepatitis A vaccination in the US?

Abstract Background An estimated &amp;gt;100 million new hepatitis A (hepA) infections occur annually worldwide. Centres for disease control and prevention reported 38795 hepA cases in the US since 2016, and 4475 outbreak-confirmed cases in Europe between 2016-2018. HepA outbreaks resulted mainly from person-to-person contact, especially among homeless, illegal drug users (IDU) and men who have sex with men (MSM). In 2020, we surveyed US health care providers (HCPs) to understand their knowledge and attitudes towards hepA vaccination in these populations at higher risk of infection and complications. Methods This was a cross-sectional, web-based survey of 400 HCPs (primary care providers, nurse practitioners, gastroenterologists, internal medicine and infectious disease specialists [IDs], emergency room physicians [ERs]) who had recommended and/or administered hepA vaccines to ≥ 19-year-olds. Results 85% of 371 HCPs reported recommending hepA vaccine to homeless, 87% of 393 to IDU and 83% of 397 to MSM, although vaccination may not actually occur after recommendation. Results varied by specialty, 16% fewer ERs than IDs reported recommending the vaccine in these at-risk populations. Moreover, 64%, 75% and 71% of all (400) HCPs reported extremely important that homeless, IDU and MSM, respectively, get vaccinated for hepA, while 6%, 7% and 8% of all HCPs reported this as slightly, or not important. Reasons for not recommending hepA vaccine to homeless, IDU and MSM included uncertainty on guidelines (reported by 22/56, 24/50 and 29/66 HCPs, respectively) and low risk of infection (reported by 20/56, 30/50 and 27/66 HCPs, respectively). Conclusions Despite recent hepA outbreaks and strengthened recommendations for vaccination in at-risk populations, knowledge gaps persist among US HCPs. This survey may motivate European countries to reinforce national hepA vaccination recommendations and, in parallel, consider efforts to raise vaccination awareness. Funding GlaxoSmithKline Biologicals SA Key messages Education on hepatitis A vaccination recommendations in at-risk populations is needed. Health care providers’ vaccination knowledge plays a critical role to control the hepatitis A outbreak in the US and preventing hepatitis A in Europe.

Regional differences in outpatient care of peripheral artery diseases in Germany

Abstract Background Peripheral arterial disease (PAD) is one of the most common diseases worldwide and affected patients have an increased risk for cardiovascular events. The main goals of PAD treatment include modification of risk factors and prevention of cardiovascular events by means of guideline-recommended and specialized ambulatory care. Knowledge on treatment regimens and outpatient care structures in different German states is essential to improve the overall quality of medical care as well as patient outcome. Aim The aim of this study was to analyze the care of PAD patients with emphasis on pharmacotherapy and outpatient treatment patterns with special focus on regional differences in Germany. Methods This study included data of 17.633.970 patients collected in Germany between 2009 and 2018. This data was provided by analyzing all statutory health insured patients with PAD in Germany. Ambulatory care structure included treatments by vascular surgeons, angiologists, cardiologist, internal medicine physician and primary care physicians. Furthermore, prescription of guideline-recommended pharmacotherapy (statins and antiplatelets) was analyzed for the period of 2012–2016. For our analysis we used chi-squared test and two-way Anova. Results Nationwide, prescription frequency of statins increased from 40% in 2009 to 50% (p&amp;lt;0,0001) in 2016. Similar results were seen in the prescription frequency of antiplatelet agents, which increased from 26% in 2009 to 30% (p&amp;lt;0,0001) in 2016. In fact, prescription frequency of both statins and antiplatelet drugs remained insufficient in every federal state (p&amp;gt;0,05), despite wide access to general practitioners. Nevertheless, there is a significant difference between rural and urban regions (Bavaria 46% vs. North Rhine-Westphalia 44%, p&amp;lt;0,05). However, in every federal state, treatment by the vascular specialist is low. In 2018 only 10% of patients were treated by vascular surgeons and 9% by angiologists. Conclusion Our study shows that, for PAD patients, outpatient care as well as prescription frequency of guideline-based therapy is insufficient in every federal German state. According to our data, there is a need to establish regional structures for PAD patients that can improve current care and ultimately reduce mortality in this high-risk population. Funding Acknowledgement Type of funding sources: None.

Disease Modifying Treatment of Osteoarthritis with Triple Combination Anti-Microbial Therapy

Background: The study author, while still a medical student, observed microscopic evidence of chronic inflammation in joint tissue of patients suffering with osteoarthritis and hypothesized that osteoarthritis was caused by an infectious process. After graduating from medical school and entering into private practice, the study author had several patients who informed him that when they were on tetracycline therapy, for reasons other than arthritis, their arthritis symptoms diminished to some extent. After reporting improvement of arthritic symptoms with tetracycline, one of these patients subsequently received metronidazole and while taking both tetracycline and metronidazole reported that his arthritic symptoms improved to an even greater extent, as his joint pain further diminished but did not resolve. Subsequent treatment of osteoarthritis in other patients included the combination of tetracycline, metronidazole, other antibiotics and some natural products but only when L-lysine was added to the tetracycline and metronidazole combination therapy did the author observe yet further improvement in arthritic pain. Since L-lysine was reported to inhibit the growth of herpes simplex virus, the author and another colleague concluded that acyclovir might be a beneficial addition to the tetracycline, metronidazole, L-lysine combination. This four-component combination treatment resulted in total resolution or a marked diminution of osteoarthritis joint pain, joint tenderness and joint stiffness in most patients treated. It was further determined that L-lysine could be eliminated; that acyclovir could be replaced with valicyclovir; and that tetracycline could be replaced with minocycline or doxycycline.&#x0D; Preliminary studies of patients diagnosed with osteoarthritis and treated with tetracycline alone or the combination of tetracycline and metronidazole demonstrated improvement in their osteoarthritic symptoms. However the triple combination of doxycycline (broad spectrum antibiotic), metronidazole (antiprotozoal and antibacterial imidazole) and acyclovir (antiviral purine nucleoside) administered orally twice daily for eight weeks showed marked success in a group of patients suffering with osteoarthritis by substantially eliminating their joint pain, joint tenderness and joint stiffness while overcoming their fatigue and increasing their energy level. The data in this report substantiate that this triple combination is a disease modifying therapy that eliminates or markedly diminishes the symptomatology of osteoarthritis and further supports the hypothesis that osteoarthritis is an infectious disease. Objective: To evaluate the effect of the triple combination therapy of doxycycline, metronidazole, and acyclovir on the joint pain, joint stiffness and functionality in patients suffering with osteoarthritis. Design: Non-blinded study of treatment of patients suffering with osteoarthritis Setting: Primary care internal medicine practice in Alameda County, California. Sample: Six adult individuals suffering with osteoarthritis. Patients: Six patients, ages 53 through 82 years. Patient 1 was treated for 28 days and Patients 2 through 6 were treated for 56 days. Method: After obtaining informed consent, six patients suffering with osteoarthritis were prescribed a 56 day course of treatment with the triple combination of doxycycline, metronidazole, and acyclovir for treatment of their osteoarthritis. Utilizing the WOMAC index for assessment of the effectiveness of treatment of osteoarthritis, pre-treatment pain, stiffness and functional limitation, were compared to post-treatment pain, stiffness and functional limitations. Results: Three patients demonstrated total resolution of pain and stiffness and greater than 95% improvement in functional limitations. One of the remaining three patients demonstrated a 70% improvement in pain, total resolution of stiffness, and an 85% improvement in functional limitations; another one of the three remaining patients demonstrated an 86% improvement in pain, total resolution of stiffness, and a 79% improvement in functional limitations; while the last of the three remaining patients demonstrated at least an 85% improvement in pain, 67% improvement in stiffness, and a 63% improvement in functional limitations.&#x0D; Limitations: No randomization. No placebo. No control group. Small sample size. Conclusion: The results of treatment of these patients suffering the osteoarthritis support the hypothesis that osteoarthritis is an infectious disease. These results further suggest that osteoarthritis is, at a minimum, modifiable with the triple combination therapy of doxycycline, metronidazole, and acyclovir and is even curative of with this breakthrough treatment in many cases. The medical treatment reported in this article represents the first truly Disease Modifying medication therapy developed for osteoarthritis. &#x0D; Keywords: WOMAC index

S1182 Assessing Comfort with Hepatitis C Screening, Education, and Treatment in Internal Medicine Primary Care Clinics

S1182 Assessing Comfort with Hepatitis C Screening, Education, and Treatment in Internal Medicine Primary Care Clinics

Abstract P133: Prevalence Of Medication Non-adherence Via Therapeutic Drug Monitoring In Patients With Uncontrolled Hypertension Treated At A Safety Net Hospital

Background: Medication nonadherence presents one of the greatest challenges to hypertension management. Previous studies from our group have shown therapeutic drug monitoring (TDM), biochemical monitoring of drug levels, is more accurate than self-report, detailed questionnaires, or prescription fill rate in detecting nonadherence. Prior studies have also shown a prevalence of nonadherence from 45% to 80% among insured patients with uncontrolled hypertension despite having been prescribed a multi-drug regimen. Previous studies have not assessed adherence to antihypertensive drugs in a safety net population by TDM. Methods: We performed a cross-sectional study in patients with uncontrolled hypertension in the primary care Internal Medicine and Cardiology Clinics at Parkland Health&amp; Hospital System (PHHS). Patients with BP of 130/80 mmHg, prescribed ≥2 antihypertensive medications, and self-reporting medication adherence were enrolled after informed consent. Plasma samples were obtained for measurement of 44 cardiovascular drugs using liquid chromatography mass spectrometry. Results: Among 77 patients with uncontrolled hypertension (57% female, 65% Black, 12% Hispanic), 13 (17%) were nonadherent to at least one anti-hypertensive drug by TDM. There was no difference in baseline characteristics between the two groups. The adherent and nonadherent groups had similar systolic (146±13 vs 148±18, p=0.67) and diastolic (83±9 vs 88±10 mmHg, p=0.13) BP. All patients had either medical insurance or some form of prescription financial assistance. 15 patients had prescription financial assistance, while 62 patients had medical insurance. Nonadherence rates for patients on financial assistance programs did not significantly differ from patients with medical insurance (13% vs 18%, p&gt;0.999). Conclusions: We found a surprisingly low prevalence of anti-hypertensive medication nonadherence in this uncontrolled hypertension population despite many barriers to treatment. Our study suggests a lesser role of medication nonadherence in uncontrolled hypertension in the safety net population.

Point-of-Care Virtual Radiology Consultations in Primary Care: A Feasibility Study of a New Model for Patient-Centered Care in Radiology.

The goal of this study is to assess the value of point-of-care virtual consultations in radiology. We conducted an institutional review board-approved feasibility study of video-based radiology consultations in an internal medicine primary care clinic at a quaternary academic medical center. The study included 3 primary care providers (PCPs) and enrolled 43 patients. Inclusion criteria consisted of the following: age > 18 years, English speaking, recent radiology examination at our institution, and patient consenting to participate. Patients completed a pre- and postvisit survey. PCPs completed a postvisit survey. Primary study end points included the effect on patient and provider satisfaction, effect on patient experience and understanding of medical condition, and impact on PCP's management decisions. Statistical significance was assessed using Fisher's exact test. Of the enrolled patients, 93% (n= 40 of 43) indicated that they were satisfied with the virtual consultation visit. The PCPs were satisfied with the virtual consultation in 97% of consultations (n= 42 of 43). In addition, 88% (n= 38 of 43) of patients indicated improved understanding of their medical condition as a result of the virtual consultation, and 91% of patients (n= 39 of 43) were interested in similar consultations in the future. The participating PCPs indicated that the consultation was helpful in their management decisions in 83% of visits. Patient's interest in receiving their imaging results from radiologist increased from 56% to 88% when comparing pre- and post-virtual consultation survey results (P= .03). Initial experience with virtual radiology consultations show high rates of patient and provider satisfaction. Virtual radiology consultations have the potential to advance radiology's value in care delivery.

Implementation and Evaluation of a Team-Based Approach to Hospital Discharge Transition of Care.

Transitional care management (TCM) programs guide patients from hospital discharge to outpatient follow-up with the goal to decrease hospital readmissions and the cost of care. In 2017, the department of primary care internal medicine (PCIM) at Eastern Virginia Medical Group implemented TCM. We aimed to evaluate the efficacy and self-sustainability of this TCM program. The TCM team contacted patients upon discharge to schedule the follow-up appointment. We coded patient contact as (1) no successful phone-call contact, patient did not attend appointment; (2) successful phone-call contact, patient did not attend appointment; and (3) patient attended appointment. We collected patient demographics, readmissions, and visit costs using manual chart review and electronic health record (EHR) data extraction. We conducted χ 2 analysis, one-way analysis of variance, and unpaired t tests to assess associations between readmission rates or costs and TCM care. Initial analysis did not indicate significant associations between readmission rates and level of TCM care at 30 (χ 2=1.40, P=.50), 60 (χ 2=5.48, P=.06), or 90 (χ 2=4.23, P=.12) days or significant differences in patient charges at 30 (F[2,59]=2.85, P=.06), 60 (F[2,91]=2.00, P=.14), or 90 (F[2,126]=1.39, P=.25) days. Follow-up analysis indicated significant associations between readmission rates and any level of TCM care at 60 (χ 2=5.40, P=.02) and 90 (χ 2=4.21, P=.04) days, but not at 30 days (χ 2=1.39, P=.28). Our TCM program review suggests that the benefits of transitional care extend beyond 30 days by decreasing readmission rates at 60 and 90 days after hospital discharge.

Teaching Telehealth During a Pandemic and Beyond: an Intern's Survival Guide for Virtual Medicine.

BackgroundThe rapid transition to telemedicine at the onset of the COVID-19 pandemic required many providers to learn telemedicine “on the fly.” As virtual care will likely remain a mainstay of outpatient medicine, it is imperative that telemedicine training be incorporated into graduate medical education.AimDesign a telemedicine curriculum for internal medicine residents based on principles of experiential learning.SettingVA-based internal medicine primary care clinic.ParticipantsSixteen first-year internal medicine residents participated in the curriculum.Program DescriptionThe curriculum included a didactic session followed by four simulated patient encounters focused on troubleshooting technical issues, performing the virtual physical exam, coordinating team-based care, and tackling emergencies.Program EvaluationParticipants reported minimal previous experience with telemedicine. After completing the training, resident confidence in conducting video visits increased from an average score of four to seven (on a 10-point scale). Residents were more likely to agree that video visits would allow them to build bonds and effectively address their patients’ needs. This increased confidence persisted at 3 months after training.DiscussionUsing experiential learning, we identified strategies which increased the confidence of internal medicine trainees in conducting telemedicine visits. Further research is needed to validate our findings across different practice settings.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-021-07009-8.

An Ultrasound Screening Exam During Medicare Wellness Visits May Be Beneficial

The physical exam component of a periodic health visit in the elderly has not been considered useful. Standard Medicare Wellness visits require no physical exam beyond blood pressure and most physicians perform limited exams during these visits. The objective of this study was to test the feasibility, potential benefit, and costs of performing a screening ultrasound (US) exam during Medicare Wellness visits. A physician examiner at an academic internal medicine primary care clinic performed a screening US exam targeting important abnormalities of patients 65-85 years old during a Medicare Wellness visit. The primary care physician (PCP) recorded the follow-up items for each abnormality identified by the US examiner and assessed the benefit of each abnormality for the participant. Abnormality benefit, net exam benefit per participant, follow-up items and costs, participant survey results, and exam duration were assessed. Participants numbered 108. Total abnormalities numbered 283 and new diagnoses were 172. Positive benefit scores were assigned to 38.8%, neutral (zero) scores to 59.4%, and negative benefit scores to 1.8% of abnormalities. Net benefit scores per participant were positive in 63.9%, 0 in 34.3%, and negative in 1.8%. Follow-up items were infrequent resulting in 76% of participants without follow-up cost. Participant survey showed excellent acceptance of the exam. The US screening exam identified frequent abnormalities in Medicare Wellness patients. The assessed benefits were rarely negative and often mild to moderately positive, with important new chronic conditions identified. Follow-up costs were low when the PCPs were also US experts.

Impact of an Educational Comic to Enhance Patient-Physician-Electronic Health Record Engagement: Prospective Observational Study.

BackgroundElectronic health record (EHR) use can impede or augment patient-physician communication. However, little research explores the use of an educational comic to improve patient-physician-EHR interactions.ObjectiveTo evaluate the impact of an educational comic on patient EHR self-advocacy behaviors to promote patient engagement with the EHR during clinic visits.MethodsWe conducted a prospective observational study with adult patients and parents of pediatric patients at the University of Chicago General Internal Medicine (GIM) and Pediatric Primary Care (PPC) clinics. We developed an educational comic highlighting EHR self-advocacy behaviors and distributed it to study participants during check-in for their primary care visits between May 2017 and May 2018. Participants completed a survey immediately after their visit, which included a question on whether they would be interested in a follow-up telephone interview. Of those who expressed interest, 50 participants each from the adult and pediatric parent cohorts were selected at random for follow-up telephone interviews 8 months (range 3-12 months) post visit.ResultsOverall, 71.0% (115/162) of adult patients and 71.6% (224/313) of pediatric parents agreed the comic encouraged EHR involvement. African American and Hispanic participants were more likely to ask to see the screen and become involved in EHR use due to the comic (adult P=.01, P=.01; parent P=.02, P=.006, respectively). Lower educational attainment was associated with an increase in parents asking to see the screen and to be involved (ρ=−0.18, P=.003; ρ=−0.19, P<.001, respectively) and in adults calling for physician attention (ρ=−0.17, P=.04), which was confirmed in multivariate analyses. Female GIM patients were more likely than males to ask to be involved (median 4 vs 3, P=.003). During follow-up phone interviews, 90% (45/50) of adult patients and all pediatric parents (50/50) remembered the comic. Almost half of all participants (GIM 23/50, 46%; PPC 21/50, 42%) recalled at least one best-practice behavior. At subsequent visits, adult patients reported increases in asking to see the screen (median 3 vs 4, P=.006), and pediatric parents reported increases in asking to see the screen and calling for physician attention (median 3 vs 4, Ps<.001 for both). Pediatric parents also felt that the comic had encouraged them to speak up and get more involved with physician computer use since the index visit (median 4 vs 4, P=.02) and that it made them feel more empowered to get involved with computer use at future visits (median 3 vs 4, P<.001).ConclusionsOur study found that an educational comic may improve patient advocacy for enhanced patient-physician-EHR engagement, with higher impacts on African American and Hispanic patients and patients with low educational attainment.

Perspectives of internal medicine physicians regarding medication abortion provision in the primary care setting

ObjectiveTo better understand medication abortion attitudes and interest in future provision among Internal Medicine primary care providers (IM PCPs), and to characterize barriers to provision. Study DesignWe conducted a survey with IM attendings and trainees at a large academic medical center in Western Pennsylvania. We used descriptive statistics to characterize attitudes towards medication abortion provision, including the belief that it is within their scope of practice and interest in future provision, and to explore perceived barriers to provision. We used logistic regression models to assess factors associated with each of these attitudes. ResultsOf 397 eligible attendings and trainees, 121 (30%) completed the survey. Among those surveyed, 44% believed medication abortion is within the scope of practice of IM PCPs with trainees and female-identifying providers being significantly more likely to believe medication abortion is within their scope of practice compared to attending physicians and male physicians (60% vs 30%, p < 0.01 and 53% vs 31%, p = 0.01, respectively). Similarly, 43% endorsed interest in future provision, with trainees (67% vs 23%, p < 0.001) and female providers (54% vs 27%, p = 0.002) being more likely to express interest. The most cited barriers to provision included limited training in residency (70%) and low familiarity with abortion medications (57%). ConclusionsMany IM providers— particularly trainees— believe medication abortion is within their scope of practice and would like to provide this care. Interventions are needed to provide education and assistance complying with state and federal regulations to enable safe and efficient medication abortion provision by IM providers. ImplicationsIM departments and residency programs should seek to ensure training is offered to clinicians interested in providing medication abortion as a part of their primary care practice.

High-Dose vs Standard-Dose Amoxicillin Plus Clavulanate for Adults With Acute Sinusitis

Acute bacterial sinusitis is common, but currently recommended antibiotic treatment provides minimal benefit. To confirm the previous finding that high-dose amoxicillin plus clavulanate (with double the amount of amoxicillin) may be superior to standard-dose amoxicillin plus clavulanate in adults. This double-blind, comparative-effectiveness randomized clinical trial was conducted from February 26, 2018, through May 10, 2020, at the academic primary care internal medicine and pediatrics practice of Albany Medical Center, located in Cohoes, New York. Participants included adults aged 18 years or older who were prescribed amoxicillin plus clavulanate for acute bacterial sinusitis diagnosed in accordance with the Infectious Diseases Society of America guidelines. Amoxicillin 875 mg with clavulanate 125 mg plus either placebo (standard dose) or amoxicillin 875 mg (high dose) twice a day for 7 days. The primary efficacy outcome was a global rating of "a lot better" or "no symptoms" at the end of 3 days of treatment using a Global Rating of Improvement scale, with outcomes ranging from 1 (a lot worse) to 6 (no symptoms). The primary adverse effect outcome was severe diarrhea at 3 or 10 days after the start of treatment. At an unplanned interim analysis prompted by COVID-19 restrictions, 157 of a projected 240 participants had been enrolled (mean age, 48.5 [range, 18.7-84.0] years; 117 women [74.5%]), with 79 randomized to the standard dose and 78 to the high dose; 9 and 12, respectively, withdrew or were lost to follow-up before the assessment of the primary outcome. At day 3, 31 of 70 participants (44.3%) in the standard-dose group reported a global rating of "a lot better" or "no symptoms," as did 24 of 66 (36.4%) in the high-dose group, for a difference of -7.9% (95% CI, -24.4% to 8.5%; P = .35). The study was, therefore, stopped for futility. Diarrhea was common in both groups by day 3, with any diarrhea reported in 29 of 71 participants (40.8%) receiving the standard dose and 28 of 65 (43.1%) receiving the high dose and severe diarrhea reported in 5 of 71 (7.0%) and 5 of 65 (7.7%), respectively. The results of this randomized clinical trial suggest that adults treated for clinically diagnosed acute sinusitis did not appear to benefit from taking high-dose compared with standard-dose amoxicillin plus clavulanate. ClinicalTrials.gov Identifier: NCT03431337.

Update on technologies, medicines and treatments.

An abstract presented at the 2020 European Association for the Study of Diabetes (EASD) suggests that, in future, we might be able to monitor longer term exposure to glucose through our tears. The study measured glycated albumin (GA) in lacrimal fluid and found this to be strongly correlated to glycated albumin in blood, an indicator of glycaemia over a 2 week period.