Primary Care Internal Medicine Research Articles

Guideline Adherence for Echocardiographic Follow-Up in Outpatients with at Least Moderate Valvular Disease

Attention to resource utilization has led to increased scrutiny of the appropriateness of initial diagnostic imaging studies on the basis of current guidelines. Far less attention has been paid to examining the lack of appropriate follow-up studies. A retrospective cross-sectional analysis was performed of 3,781 consecutive outpatients referred for transthoracic echocardiography (TTE) from July to December 2008. Data from the electronic medical records were extracted to see if patients with at least moderate left-sided valvular stenosis or regurgitation underwent subsequent echocardiographic studies within 60 days of the period recommended by the 2006 American College of Cardiology and American Heart Association valve guidelines document. Of 342 outpatients with at least moderate valve dysfunction, 38 (11%) were excluded for reasons that precluded the need for a follow-up study (e.g. death, surgery). Of the remaining 304 patients, only 179 (59%) underwent follow-up echocardiography within the recommended period. Rates of timely follow-up TTE were higher when ordering physicians were cardiologists or cardiovascular surgeons (65%) compared with primary care physicians or internal medicine specialists (45%) (P < .01). Follow-up rates were significantly different for aortic stenosis (77%), mitral stenosis (67%), aortic regurgitation (49%), and mitral regurgitation (49%) (P < .01). Patients receiving timely follow-up TTE were younger (66 ± 15 vs 71 ± 15 years, P = .002) and more likely to be male (odds ratio, 1.79; 95% CI, 1.12-2.85; P = .01). To the authors' knowledge, this is the first study demonstrating low rates of compliance with guideline-recommended monitoring TTE in patients with at least moderate valve dysfunction. Cardiac practitioners have significantly better compliance. Strategies are needed to improve timely follow-up care in this population.

Initial evaluation of thyroid nodules by primary care physicians and internal medicine residents

ObjectiveThe article studied the knowledge and practice patterns of primary care providers and internal medicine residents in their initial evaluation of thyroid nodules and determined whether their practice is in accordance with published guidelines by the American Thyroid Association and American Association of Clinical Endocrinologists.MethodA survey was distributed to primary care physicians (PCPs) and internal medicine residents at a community hospital in Baltimore and a chart review was conducted at the Diabetes and Endocrine Center in the same hospital.ResultsA total of 47 physicians (70%) responded to the survey, 16 PCPs and 33 residents. Most responders (96%) will always obtain a TSH, and of these, 21% of PCP and 25% of residents will obtain a TSH without any other laboratory work-up. Fifty percent of the physicians (PCP, 75%; resident, 39%) will always obtain a thyroid ultrasound (p=0.043). Most physicians (97%) will refer for a fine-needle aspiration (FNA) biopsy of a nodule >1 cm. Sixty-two percent of the physicians will not put a euthyroid patient on levothyroxine suppression therapy. Many physicians (48%) are not aware of the AACE and ATA thyroid nodule guidelines. Most physicians (65%) have not read the guidelines. Of the 113 charts reviewed, TSH was obtained alone in 40% and with other laboratory tests in 74%. Thyroid ultrasound was done in 67%. Only one patient was on levothyroxine for levothyroxine suppression therapy.DiscussionAlthough many physicians were not aware of the guidelines, and a small number of physicians have read them, many PCP and residents responded in concordance with the guidelines in obtaining TSH, an ultrasound, performing FNA biopsy, and not providing levothyroxine suppressive therapy in euthyroid patients. No differences were found between the responses of PCP and residents except for obtaining an ultrasound. Chart review data also showed that majority of tests ordered for non-toxic thyroid nodule evaluation were in agreement with the guidelines. Limitations include low survey response rate among PCPs and that results are from one community hospital.ConclusionOur findings from the survey and chart review conclude that majority of primary care physicians were initiating the appropriate work up of thyroid nodules prior to referral to a specialist.

Capacity for Development of Primary Care Residency Programs in Non-Teaching Hospitals in New York State (NYS)

Purpose: The demand for physicians in the U.S., especially those practicing adult primary care, is accelerating and will inevitably require the expansion of residencies, despite current constraints on funding for graduate medical education (GME). A previous study showed little interest in or capacity for expansion of primary care residencies in current teaching hospitals in NYS. This study examines the interest in and capacity for establishing new programs among current non-teaching hospitals in that state. Design and Methods: Chief Executive Officers of eligible non-teaching hospitals in NYS were surveyed and asked if they had interest in establishing a residency program, what medical specialties they would choose assuming availability of additional funds, and what barriers there were to residency development. Results: Fourteen of 46 (30%) NYS sites completed the survey. All but one was interested in establishing residencies; 85 percent would establish new programs in Emergency Medicine; 76 percent in Family Medicine; and 54 percent in Internal Medicine and/or Primary Care Internal Medicine. Virtually all cited significant concerns related to funding, faculty supply, and need for medical school affiliations. Conclusions: A minimum of 28 percent of non-teaching hospitals in NYS have a significant interest in establishing a GME program. If implemented this could increase training in Family Medicine by 40 percent and Internal Medicine by 11 percent. However, there are formidable financial and structural barriers to doing so. Enhanced support programs that go beyond lifting of the current GME cap will be necessary to increase the training of primary care physicians.

Collaboratively Improving Diabetes Care in Sweden Using a National Quality Register: Successes and Challenges-A Case Study.

Since 1996, the Swedish National Diabetes Register (NDR) enabled health care providers to monitor their clinical performance over time and compare it with the national average. All health systems of Swedish county councils report data. By 2014, the NDR included data from 360 000 patients. Comparisons among county councils show significant variations in clinical outcomes and in adherence to evidence-based national guidelines. The purpose of this study was to evaluate whether and how a quality improvement collaborative could influence clinical practice and outcomes. Twenty-three diabetes teams from all over Sweden, both primary care units and internal medicine departments, joined a quality improvement collaborative. The project was inspired by the Breakthrough Collaborative Model and lasted for 20 months. Evaluation data were collected from the teams' final reports and the NDR throughout the study period. The teams reported improved patient outcomes significantly compared with the national average for systolic blood pressure and low-density lipoprotein levels. In contrast, glycated hemoglobin A1c levels deteriorated in the whole NDR population. Five themes of changes in practice were tested and implemented. Success factors included improved teamwork, with active use of register data, and testing new ideas and learning from others.

Patient-reported geriatric symptoms as risk factors for hospitalization and emergency department visits.

There is an urgent need to identify predictors of adverse outcomes and increased health care utilization in the elderly. The Mayo Ambulatory Geriatric Evaluation (MAGE) is a symptom questionnaire that was completed by patients aged 65 years and older during office visits to Primary Care Internal Medicine at Mayo Clinic in Rochester, MN. It was introduced to improve screening for geriatric conditions. We conducted this study to explore the relationship between self-reported geriatric symptoms and hospitalization and emergency department (ED) visits within 1 year of completing the survey. This was a retrospective cohort study of patients who completed the MAGE from April 2008 to December 2010. The primary outcome was an ED visit or hospitalization within 1 year. Predictors included responses to individual questions in the MAGE. Data were obtained from the electronic medical record and administrative records. Logistic regression analyses were performed from significant univariate factors to determine predictors in a multivariable setting. A weighted scoring system was created based upon the odds ratios derived from a bootstrap process. The sensitivity, specificity, and AUC were calculated using this scoring system. The MAGE survey was completed by 7738 patients. The average age was 76.2 ± 7.68 years and 57% were women. Advanced age, a self-report of worse health, history of 2 or more falls, weight loss, and depressed mood were significantly associated with hospitalization or ED visits within 1 year. A score equal to or greater than 2 had a sensitivity of 0.74 and specificity of 0.45. The calculated AUC was 0.60. The MAGE questionnaire, which was completed by patients at an outpatient visit to screen for common geriatric issues, could also be used to assess risk for ED visits and hospitalization within 1 year.

52-Year-Old Woman With Hypotension, Hypothyroidism, and Hyponatremia

Resident in Internal Medicine (C.H.B.) and Fellow in Cardiovascular Diseases (A.M.K.), Mayo School of Graduate Medical Education, Mayo Clinic, Rochester, MN; Advisor to resident and fellow and Consultant in Primary Care Internal Medicine, Mayo Clinic, Rochester, MN (A.C.G.). A 52-year-old woman with hypothyroidism presented to the emergency department with nausea, malaise, and hyponatremia. Her illness had begun 3 months previously with increasing generalized weakness, fatigue, insomnia, bilateral carpal tunnel syndrome requiring surgical release, and decreased appetite with a corresponding weight loss of 8 kg. At that time, her thyroid-stimulating hormone (TSH) level was 8.0 mIU/L (reference range, 0.3-5.0 mIU/L), so her physician increased her levothyroxine dosage from 75 mg/d to alternating daily doses of 75 mg and 88 mg. Her symptoms had accelerated during the past 2 weeks and now included constipation, worsening exercise tolerance, and vomiting. She noted that most women in her family have hypothyroidism and that her daughter had just been diagnosed as having granulomatosis with polyangiitis. The patient did not smoke tobacco, drink alcohol, or use illicit drugs, had never been incarcerated, had no sick contacts, and had not traveled outside her home state in the Midwest. Because her symptoms had not improved despite treatment during the past 3 months and now had worsened, she sought evaluation in the emergency department. On admission, her temperature was 37 C, and she had orthostatic vital signs. Her supine, sitting, and standing blood pressure and heart rate were 108/68 mm Hg and 79 beats/min, 88/71 mm Hg and 105 beats/min, and 64/39 mm Hg and 64 beats/min, respectively. She was alert and oriented and had a slender body habitus. Her mucous membranes were moist, but she appeared slightly volume depleted because jugular venous pulsations were not visible on examination despite manual pressure applied to her abdomen. Cardiothoracic, neurologic, thyroid, and abdominal examinations yielded normal findings. Her skin appeared slightly hyperpigmented, but there was no buccal or palmar crease hyperpigmentation.

Telemedicine: an enhanced emergency care program for older adults

Telemedicine: an enhanced emergency care program for older adults Paul Y Takahashi,1 Anupam Chandra,1 Frederick North,1 Jennifer L Pecina,2 Benjavan Upatising,3 Gregory J Hanson11Mayo Clinic Division of Primary Care Internal Medicine, 2Mayo Clinic Department of Family Medicine, Rochester, MN, USA; 3Regenstrief Center for Healthcare Engineering, Purdue University, West Lafayette, IN, USAAbstract: Recent changes and consolidations in health care systems have resulted in an increase in new health care delivery models. Telemedicine holds great promise as one of these models. There is a great potential for new patient evaluation and treatment models in emergency care (EC), especially when patients are miles away from a medical team. Evaluations can be performed in a patient&#39;s home, a nursing care facility, and in hospitals that focus on advanced subspecialty care. Due to rapid developments in this area, current care models are constantly being evaluated and modified. This review article outlines current telemedicine models for EC and summarizes their potential benefits to patients and the health care system. The review examines the role that the telephone, a fundamental tool of telemedicine, plays in these new models. The review also examines evidence of improved health care outcomes by highlighting the role of telemedicine in reducing hospitalizations. The patient is the primary focus; as a result, this review also examined patient experiences and satisfaction levels regarding telemedicine health care teams. The authors support these technological advances and their potential for information transfer. Health care providers need to continue developing these models by making use of increasing amounts of information. One of the main implementation barriers of these new models in the US and other countries is the issue of payment and reimbursement. Despite this, advancements in EC telemedicine continue.Keywords: telemedicine, emergency care, geriatric, patient evaluation models

Attitudes regarding perioperative care of patients with OSA: a survey study of four specialties in the United States.

Obstructive sleep apnea (OSA) is a risk factor for significant perioperative complications. This national survey study sought to determine the attitudes of physicians involved in the perioperative care of OSA patients. We modified the perioperative survey used by Turner et al. among Canadian anesthesiologists. We mailed the survey to 3,000 US physicians practicing in the following specialties (750 of each specialty): anesthesiology (A), primary care (family practice or internal medicine) (PC), sleep (SM), and general surgery (S). The survey asked questions about attitudes and practice patterns regarding OSA in the perioperative setting. Of 2,730 eligible subjects, 783 questionnaires (28.7%) were returned. Overall, 94% felt OSA was a risk factor for perioperative complications (no difference by specialty) and 90% felt it was a moderate to major risk factor (A = 91%, PC = 81%, SM = 94%, S = 72%; p < 0.001). Fifty-two percent reported experience with a patient having an adverse outcome related to OSA in the perioperative setting. Despite this, only 71% reported regularly screening for OSA preoperatively, mostly by history and physical examination (A = 89%, PC = 52%, SM = 88%, S = 49%; p < 0.001). If they suspected a patient of having OSA, 32% would delay surgery pending a sleep study (A = 4%, PC = 41%, SM = 54%, S = 27%; p < 0.001), while 20% would proceed with surgery without any special precautions (A = 22%, PC = 21%, SM = 5%, S = 31%; p < 0.001). Only 27% of respondents reported that their hospital had a written policy for perioperative care of OSA patients. The majority of physicians in this survey felt OSA was a significant risk factor for perioperative complications and most reported experience with OSA patients having an adverse outcome. Perioperative management guidelines for OSA are not available at most institutions. Further work is needed to help physicians identify and intervene on patients with OSA in the perioperative setting before adverse events develop.

Value and Process of Curbside Consultations in Clinical Practice: A Grounded Theory Study

ObjectivesTo clarify the value and process of the curbside consultation and identify ways to optimize this activity. Participants and MethodsWe conducted 13 focus groups at an academic medical center and outlying community sites (September 2011 to January 2013), involving a purposive sample of 54 primary care and subspecialist internal medicine and family medicine physicians. Focus group discussions were transcribed and then analyzed using a constant comparative approach to identify benefits, liabilities, mechanisms, and potential improvements related to curbside consultations. ResultsWe developed a model describing the role and process of the curbside consultation. Focus group participants perceived that curbside consultations add particular value in offering immediate, individualized answers with bidirectional information exchange, and this in turn expedites patient care and elevates patient confidence. Despite the uncompensated interruption and potential risks, experts provide curbside consultations because they appreciate the honor of being asked and the opportunity to help colleagues, expedite patient care, and teach. Key decisions for the initiator (each reflecting a potential barrier) include whom to contact, how to contact that expert, and how to determine availability. Experts decide to accept a request on the basis of personal expertise, physical location, and capacity to commit time and attention. Participants suggested systems-level improvements to facilitate expert selection, clarify expert availability, enhance access to clinical information, and acknowledge the expert’s effort. ConclusionsCurbside consultations play an important role in enhancing communication and care coordination in clinical medicine, but the process can be further improved. Information technology solutions may play a key role.

Physician clinical management strategies and reasoning: a cross-sectional survey using clinical vignettes of eight common medical admissions.

BackgroundPhysicians often select clinical management strategies not strongly supported by evidence or guidelines. Our objective was to examine the likelihood of selecting, and rationale for pursuing, clinical management strategies with more or less guideline support among physicians using clinical vignettes of eight common medical admissions.MethodsWe conducted a cross-sectional survey using clinical vignettes of attending physicians and housestaff at one internal medicine program in New York City. Each clinical vignette included a brief clinical scenario and a varying number of clinical management strategies: diagnostic tests, consultations, and treatments, some of which had strong evidence or guideline support (Level 1 strategies) while others had limited evidence or guideline support (Level 3 strategies). Likelihood of selecting a given management strategy was assessed using Likert scales and multiple response options were used to indicate rationale(s) for selections.ResultsOur sample included 79 physicians; 68 (86%) were younger than 40 years of age, 34 (43%) were female. There were 31 attending physicians (39%) and 48 housestaff (61%) and 39 (49%) had or planned to have primarily primary care internal medicine clinical responsibilities. Overall, physicians were more likely to select Level 1 strategies “always” or “most of the time” when compared with Level 3 strategies (82% vs. 43%; p < 0.001), with wide variation across the eight medical admissions. There were no differences between attending and housestaff physician likelihood of selecting Level 3 strategies (47% vs. 45%, p = 0.36). Supportive evidence and local practice patterns were the two most common rationales behind selections; supportive evidence was cited as the most common rationale for selecting Level 1 when compared with Level 3 strategies (63% versus 30%; p < 0.001), whereas ruling out other severe conditions was cited most often for Level 3 strategies.ConclusionsFor eight common medical admissions, physicians selected more than 80% of management strategies with strong evidence or guideline support, but also selected more than 40% of strategies for which there was limited evidence or guideline support. The promotion of evidence-based care, including the avoidance of care that is not strongly supported by evidence or guidelines, may require better evidence dissemination and educational outreach to physicians.

Prodromal symptoms and health care consumption prior to out-of-hospital cardiac arrest in patients without previously known ischaemic heart disease

AimsTo describe prodromal symptoms and health care consumption prior to an out-of-hospital cardiac arrest (OHCA) in patients without previously known ischaemic heart disease (IHD). BackgroundThe most common lethal event of cardiovascular disease is sudden cardiac death, and the majority occur outside hospital. Little is known about prodromal symptoms and health care consumption associated with OHCAs. DesignCase-crossover study. MethodsMedical records of 403 OHCA cases without previously known IHD, age 25–74 years in the MONICA myocardial registry in Norrbotten County 2000–2008, were reviewed. Presenting symptoms and emergency visits at public primary care facilities and internal medicine clinics in Norrbotten County were analyzed from the week prior to the OHCA and from the same week one year previously, which served as a control week. Unlike most studies we included unwitnessed arrests and those where no cardiopulmonary resuscitation (CPR) was attempted. ResultsEmergency visits were more common during the week prior to the OHCA than during the control week, both for visits to primary care (29 vs. 6, p<0.001) and to internal medicine clinics (16 vs. 0, p<0.001). Symptoms were more prevalent during the week prior to the OHCA (36.7 vs. 6.7%, p<0.001). The most prevalent symptoms were chest pain (14.6 vs. 0%, p<0.001), gastrointestinal symptoms (7.7 vs. 1.2%, p<0.001) and dyspnoea/peripheral oedema (6.9 vs. 0.2%, p<0.001). ConclusionsPatients who suffer an OHCA seek health care and present prodromal symptoms significantly more often the week prior to the event than the same week one year earlier.

Patient Perceptions of Osteoporosis Treatment Thresholds

Many older patients express concerns about medication risks, and have higher risk thresholds than physicians for cardiovascular preventive medications. We hypothesized that patients have relatively high risk thresholds for fracture preventive medications. Women ≥ 60 years old were recruited from 3 primary care internal medicine clinics in Wisconsin. Participants were provided information regarding fracture risks and treatment risks and benefits, followed by a series of vignettes depicting a 70-year-old woman at baseline fracture risks between 5-50%. Fracture risks were shown graphically and treatment side effects were provided for each vignette, and participants were asked to respond regarding whether they would accept treatment. The association of vignette treatment acceptance with participant beliefs regarding medication risks was examined in analyses adjusted for perceived risk of medications, patient numeracy, and prior respondent experience with osteoporosis. The mean age of women in the cohort was 69.4 years (SD 7.29). Ninety-one percent were non-Hispanic whites, 34% reported a history of fracture, and 20.3% a history of osteoporosis. Subjects varied substantially in their responses to vignettes, but only 51% reported they would accept prescription osteoporosis treatment at the threshold currently recommended by national physician treatment guidelines, and fewer would accept treatment at lower risks. Belief that medications are generally not worth their risks was associated with lower acceptance of treatment at all levels of fracture risk. There is substantial variability in preferences for postmenopausal osteoporosis treatment. Presentation of individualized fracture risks as recommended by current guidelines has potential to allow better targeting to higher-risk patients, but further work is needed regarding how to present this information and counsel patients.

EPA-0910 - Medication possession ratio among depressed patients enrolled in collaborative care.

Non-adherence to antidepressant medications is a major barrier to achieving treatment response and remission in clinical practice. Medication possession ratio (MPR) has been used to reflect treatment adherence of patients with chronic conditions including depression. An MRP =/> 80% correlates with high compliance. Systematic reviews of interventions to improve antidepressant medication adherence found that education interventions failed to demonstrate clear benefit on adherence; however, proactive care and collaborative care management (CCM) were associated with significant degree of adherence and improved clinical outcomes (1, 2). We looked into MPR measured from our institution's administrative pharmacy data among patients with depression seen at Primary Care Internal Medicine and enrolled in CCM from March 2008 until July 2012; we also determined predictors of non-adherence. Data was analyzed on 515 patients who gave research consent. Yearly mean MPR was calculated at 6 month intervals beginning December 2010 until July 2012. Rate of yearly MPR =/> 80% ranged from 27% to 42% but remained consistent beyond the timeframe of CCM enrollment. Race, presence of co-morbid hypertension and hyperlipidemia were associated with significantly decreased medication adherence (MPR In conclusion, approximately one third of patients with depression enrolled in CCM exhibited high medication adherence reflected by mean MRP =/>80%. While CCM has resulted in 46% remission rate at 12 months in this patient group, medication adherence appeared to be lower which implied that features intrinsic to CCM may account mostly for depression treatment effectiveness.

Perceived Versus Objective Breast Cancer Risk in Diverse Women

Prior research suggests that women do not accurately estimate their risk for breast cancer. Estimating and informing women of their risk is essential for tailoring appropriate screening and risk reduction strategies. Data were collected for BreastCARE, a randomized controlled trial designed to evaluate a PC-tablet based intervention providing multiethnic women and their primary care physicians with tailored information about breast cancer risk. We included women ages 40-74 visiting general internal medicine primary care clinics at one academic practice and one safety net practice who spoke English, Spanish, or Cantonese, and had no personal history of breast cancer. We collected baseline information regarding risk perception and concern. Women were categorized as high risk (vs. average risk) if their family history met criteria for referral to genetic counseling or if they were in the top 5% of risk for their age based on the Gail or Breast Cancer Surveillance Consortium Model (BCSC) breast cancer risk model. Of 1,261 participants, 25% (N=314) were classified as high risk. More average risk than high risk women had correct risk perception (72% vs. 18%); 25% of both average and high risk women reported being very concerned about breast cancer. Average risk women with correct risk perception were less likely to be concerned about breast cancer (odds ratio [OR]=0.3; 95% confidence interval [CI]=0.2-0.4) while high risk women with correct risk perception were more likely to be concerned about breast cancer (OR=5.1; 95%CI=2.7-9.6). Many women did not accurately perceive their risk for breast cancer. Women with accurate risk perception had an appropriate level of concern about breast cancer. Improved methods of assessing and informing women of their breast cancer risk could motivate high risk women to apply appropriate prevention strategies and allay unnecessary concern among average risk women.

In the Life: A Case of Autonomy, Exploitation, and Undue Influence in Geriatric Home Care

How Come?You ain't my brother nowI don't trust wayYou stamp your feet on meI don't shine upTo this devil-goosin' stuffYou been layin' on in my behalfOh you ain't my lovin' buddy nowSometime I think mannerYou come in my houseAnd dirty-arm me aroundIs something I don't particularly cherishKenneth PatchenHurrah for Anything ( 1957)UP IN THE OLD HOTELMr. G was an 88-year-old man who lived in a single-room occu- pancy (SRO) residential hotel in New York City (NYC). This hotel was once a traditional SRO for short- or long-term stayers but is now run by a privately funded social service agency as a low-cost residence for independently living adults older than 55 years. Many are formerly homeless and were referred by NYC Department of Homeless Services, whereas others were marginally housed and referred by community agencies. Mr. G was a self-referral and had lived quietly in same room for 24 years.There are about 275 residents in building, in a colorful cross- section of NYC life, ranging from self-described Bowery bums blue-collar workers and secretaries professional dancers, musicians, and artists. Each room has its own bathroom but no kitchen. The hotel provides weekly housekeeping, two low-cost meals a day in its cafeteria, and social work services by a staff of six. Monthly contact with a case manager is required, as is a home visit every 6 months, but finances are not routinely monitored. The hotel also sponsors activi- ties such as exercise and crafts classes, entertainment and outings for residents, and features a library and computer room, TV room, and drop-in center for homeless older adults.The Department of Community Medicine, founded in 1969 at former St. Vincent's Hospital and now under Lutheran Family Health Centers, has run a small part-time clinic at this hotel for more than 30 years, caring for street homeless and hotel's residents alike on a walk-in or ongoing basis. The team has known many residents for years, beginning in shelter clinics and hospital-based SRO clinic, and once patients are housed, continuing care at hotel. Some become homebound, requiring home visits, a visiting nurse, and even hospice enable them remain in their precious and hard-won rooms. Some attend weekly for medication management and checkups. Our team is made up of a nurse, a social worker, an outreach worker, and a physician, who all work at other program sites as well, and we see about 25 patients a week. The physician is a graduate of Mt. Sinai's medical school and St. Vincent's internal medicine primary care residency; clinic currently hosts Mt. Sinai medical students.The PatientMr. G was first seen in 2002 for a flu shot and a pneumonia shot- denied depression, declined medical care, and did not respond recall slips and outreach visits. He next came in 2003 for a flu shot given by another physician. In early 2007, was brought in by social work supervisor and saw nurse. He had been scheduled for cataract repair at New York Eye and Ear Infirmary, but did not go, feeling nervous. He did not return follow up with doctor. In spring of 2007, his case manager came ask if we could bathe a resident-we suggested an aide and bring resident in-later this turned out be Mr. G.A new case manager joined staff, made a home visit, and brought Mr. G clinic in May 2007. He said that had fallen recently and gone Cabrini Hospital emergency room (ER). Records showed that was at scene when EMS came hotel for someone else-he was taken in as well because was leaning against a wall and he didn't look good per notes. He left ER against medical advice to follow up with primary care doctor after being told that his chest x-ray showed a lung mass. Now wanted us find results of the x-ray of spot on lungs. …

Features of effective medical knowledge resources to support point of care learning: a focus group study.

ObjectiveHealth care professionals access various information sources to quickly answer questions that arise in clinical practice. The features that favorably influence the selection and use of knowledge resources remain unclear. We sought to better understand how clinicians select among the various knowledge resources available to them, and from this to derive a model for an effective knowledge resource.MethodsWe conducted 11 focus groups at an academic medical center and outlying community sites. We included a purposive sample of 50 primary care and subspecialist internal medicine and family medicine physicians. We transcribed focus group discussions and analyzed these using a constant comparative approach to inductively identify features that influence the selection of knowledge resources.ResultsWe identified nine features that influence users' selection of knowledge resources, namely efficiency (with sub-features of comprehensiveness, searchability, and brevity), integration with clinical workflow, credibility, user familiarity, capacity to identify a human expert, reflection of local care processes, optimization for the clinical question (e.g., diagnosis, treatment options, drug side effect), currency, and ability to support patient education. No single existing resource exemplifies all of these features.ConclusionThe influential features identified in this study will inform the development of knowledge resources, and could serve as a framework for future research in this field.

Barriers and Decisions When Answering Clinical Questions at the Point of Care

Answering clinical questions affects patient-care decisions and is important to continuous professional development. The process of point-of-care learning is incompletely understood. To understand what barriers and enabling factors influence physician point-of-care learning and what decisions physicians face during this process. Focus groups with grounded theory analysis. Focus group discussions were transcribed and then analyzed using a constant comparative approach to identify barriers, enabling factors, and key decisions related to physician information-seeking activities. Academic medical center and outlying community sites. Purposive sample of 50 primary care and subspecialist internal medicine and family medicine physicians, interviewed in 11 focus groups. Insufficient time was the main barrier to point-of-care learning. Other barriers included the patient comorbidities and contexts, the volume of available information, not knowing which resource to search, doubt that the search would yield an answer, difficulty remembering questions for later study, and inconvenient access to computers. Key decisions were whether to search (reasons to search included infrequently seen conditions, practice updates, complex questions, and patient education), when to search (before, during, or after the clinical encounter), where to search (with the patient present or in a separate room), what type of resource to use (colleague or computer), what specific resource to use (influenced first by efficiency and second by credibility), and when to stop. Participants noted that key features of efficiency (completeness, brevity, and searchability) are often in conflict. Physicians perceive that insufficient time is the greatest barrier to point-of-care learning, and efficiency is the most important determinant in selecting an information source. Designing knowledge resources and systems to target key decisions may improve learning and patient care.

Diagnostic Accuracy of the Primary Care Screener for Affective Disorder (PC-SAD) in Primary Care

Background:Depression goes often unrecognised and untreated in non-psychiatric medical settings. Screening has recently gained acceptance as a first step towards improving depression recognition and management. The Primary Care Screener for Affective Disorders (PC-SAD) is a self-administered questionnaire to screen for Major Depressive Disorder (MDD) and Dysthymic Disorder (Dys) which has a sophisticated scoring algorithm that confers several advantages. This study tested its performance against a ‘gold standard’ diagnostic interview in primary care.Methods:A total of 416 adults attending 13 urban general internal medicine primary care practices completed the PC-SAD. Of 409 who returned a valid PC-SAD, all those scoring positive (N=151) and a random sample (N=106) of those scoring negative were selected for a 3-month telephone follow-up assessment including the administration of the Structured Clinical Interview for DSM-IV-TR Axis I Disorders (SCID-I) by a psychiatrist who was masked to PC-SAD results. Results:Most selected patients (N=212) took part in the follow-up assessment. After adjustment for partial verification bias the sensitivity, specificity, positive and negative predictive value for MDD were 90%, 83%, 51%, and 98%. For Dys, the corresponding figures were 78%, 79%, 8%, and 88%. Conclusions:While some study limitations suggest caution in interpreting our results, this study corroborated the diagnostic validity of the PC-SAD, although the low PPV may limit its usefulness with regard to Dys. Given its good psychometric properties and the short average administration time, the PC-SAD might be the screening instrument of choice in settings where the technology for computer automated scoring is available.

Validity of the Patient Health Questionnaire (PHQ)-9 and PHQ-2 in general internal medicine primary care at a Japanese rural hospital: a cross-sectional study

ObjectiveTwo depression screening tools, Patient Health Questionnaire (PHQ)-9 and PHQ-2, have not had their validity examined in general internal medicine settings in Japan. We examined the validity of these screening tools. MethodsA total of 598 outpatients of an internal medicine clinic in a rural general hospital were enrolled consecutively and stratified by PHQ-9 score. Seventy-five patients randomly selected and 29 patients whose results from the PHQ-9 were considered to be positive for depressive disorder were then interviewed with a semistructured interview, the Mini International Neuropsychiatric Interview. We calculated diagnostic accuracy of the PHQ-9 and PHQ-2 to detect major depression and that of the suicidality item of the PHQ-9 to detect suicidality using sampling weights with multiple imputations. ResultsSensitivity and specificity for depression were 0.86 and 0.85, respectively, for the PHQ-9 with cutoff points of 4/5, and 0.77 and 0.95, respectively, for the PHQ-2 with cutoff points of 2/3. Sensitivity and specificity of the suicidality item of the PHQ-9 were 0.70 and 0.97, respectively. ConclusionIn internal medicine clinics in Japanese rural hospitals, the PHQ-2 with an optimal cutoff point for each setting plus the suicidality item of the PHQ-9 can be recommended to detect depression without missing suicidality.

Abstract 309: Prioritizing Blood Pressure Measurements Results In Improved Hypertension Control

Background: Blood pressure (BP) measurement is a national core quality measure for hypertension care and hypertension control rates remain a major performance measure. It remains unclear whether improving measurement directly results in better control rates in hypertension management. Purpose: To utilize electronic medical records to explore the relationship between measurement of blood pressure and hypertension control rates among 4 eligible primary care providers groups - Primary Care Internal Medicine (PCIM), Family medicine (FM), General Internal Medicine (GIM), Preventive Medicine (PREV) - and 2 eligible specialist groups - Cardiology (CARD), Nephrology (NEPH) at an academic group medical practice. Methods: A two year cross sectional study involving adults seen by eligible primary or specialist providers at 2 or more office visits with a hypertension ICD-9 code in two years with at least one office visit in the measurement year. We measured the proportion of patients who had their BP measured at their last hypertension visit (LHV) in 2009 and 2010. We compared measurement rates with control rates as defined by the proportion of hypertension patients with BP &lt; 140/90 mmHg at their LHV. Results: In 2009, 84.2% of 17989 patients (95% CI 83.6 - 84.7%) had their BP measured at their LHV compared to 85.3% (95% CI 84.8 - 85.8%) of 17992 patients in 2010, an increase of 1.2% (p=0.0026). Measurement rates varied widely across the different provider groups. PCIM, a high performing group, had significant improvement in measurement rates from 2009 to 2010 and demonstrated improvement in control rates. Lower performing groups, Nephrology and GIM, had significant improvement in measurement but did not see a direct translation to improved control rates. There was an associated worsening of the control rates for Preventive medicine along with a decrease in the measurement rates from 2009 to 2010. Conclusion: High BP measurement rates are associated with high hypertension control rates. Prioritizing BP measurement may result in improved intermediate outcomes in hypertension management.