Primary Care Physician Follow-up Research Articles

Automated Communication Tools and Computer-Based Medication Reconciliation to Decrease Hospital Discharge Medication Errors.

This study sought to determine the effects of automated primary care physician (PCP) communication and patient safety tools, including computerized discharge medication reconciliation, on discharge medication errors and posthospitalization patient outcomes, using a pre-post quasi-experimental study design, in hospitalized medical patients with ≥2 comorbidities and ≥5 chronic medications, at a single center. The primary outcome was discharge medication errors, compared before and after rollout of these tools. Secondary outcomes were 30-day rehospitalization, emergency department visit, and PCP follow-up visit rates. This study found that discharge medication errors were lower post intervention (odds ratio = 0.57; 95% confidence interval = 0.44-0.74; P < .001). Clinically important errors, with the potential for serious or life-threatening harm, and 30-day patient outcomes were not significantly different between study periods. Thus, automated health system-based communication and patient safety tools, including computerized discharge medication reconciliation, decreased hospital discharge medication errors in medically complex patients.

A mixed-methods approach to understanding barriers to postpartum retention in care among low-income, HIV-infected women.

Optimal retention in HIV care postpartum is necessary to benefit the health and wellbeing of mothers and their infants. However, postpartum retention in HIV care among low-income women is suboptimal, particularly in the Southern United States. A mixed-methods study was conducted to identify factors associated with postpartum retention in care among HIV-infected women. Participants (n=35) were recruited during pregnancy at two county clinics and completed self-report demographic and psychosocial surveys. Twenty-two women who returned for a postpartum appointment completed a semi-structured interview about lifestyle factors and retention in care. Of the participants enrolled at baseline, 71.4% completed a follow-up with an obstetrician (OB), while 57.1% completed a follow-up with a primary care physician (PCP). High CD4 count at delivery, low viral load at baseline, low levels of depression, high interpersonal social support, and fewer other children were significantly associated with completion of postpartum follow-up. Barriers and facilitators to retention identified during qualitative interviews included competing responsibilities for time, lack of social support outside of immediate family members, limited transportation access, experiences of institutionalized stigma, knowledge about the benefits of adherence, and strong relationships with healthcare providers. OB and PCP follow-up postpartum was suboptimal in this sample. Findings underscore the importance of addressing depressive symptoms, social support, viral suppression, competing responsibilities for time, institutionalized stigma, and transportation issues in order to reduce the barriers that inhibit women from seeking postpartum HIV care.

You've Got Mail … and Need Follow‐up: The Effect and Patient Perception of E‐mail Follow‐up Reminders After Emergency Department Discharge

The hypothesis was that a reminder about recommended primary care physician (PCP) follow-up, sent via e-mail to patients discharged from the emergency department (ED), would increase the proportion of patients who followed up with their PCPs within the recommended time frame. Patient receptiveness to e-mail follow-up reminders was also assessed. This was a mixed methods clinical intervention study with subjects randomized either to receive the usual care discharge instructions only or to also receive a reminder e-mail message the day after the ED visit. The reminder e-mail contained the subject's PCP's name and address and the recommended PCP follow-up time interval. A blinded review of outpatient PCP medical records was conducted to determine whether and when follow-up occurred. Researchers attempted to contact patients with a telephone survey 2 weeks after their ED visits. The primary outcomes between groups were compared using chi-square tests and relative risks (RRs) with 95% confidence intervals (CIs). Thirty-three percent of the intervention group and 32% of the control group followed-up as recommended (RR = 1.04, 95% CI = 0.81 to 1.33); 52% of the intervention group and 48% of the control group followed-up within 10 days of the recommended time (RR = 1.08, 95% CI = 0.91 to 1.29). The 334 patients (57%) successfully contacted via telephone demonstrated a high interest in receiving future e-mail reminders (75%), with the group that received e-mail reminders more likely to want one in the future than those who did not receive e-mail reminders (82.5% vs. 69.76%; p = 0.04). E-mail reminders sent after ED visits did not improve patients' adherence to the recommended timing of primary care follow-up contained in discharge instructions. Subjects in both the control and the intervention groups favorably viewed the concept of e-mail reminders, suggesting that the value of e-mail reminders after ED discharge may be in areas such as patient satisfaction that were not specifically targeted for measurement in this study.

Role of a care transition pharmacist in a primary care resource center.

The role of a care transition pharmacist (CTP) in a primary care resource center is described. A CTP role was implemented as part of a primary care resource center team to provide medication therapy management services for patients at high risk for readmission, including patients with chronic obstructive pulmonary disease, with heart failure, or with complex medication regimens and taking more than nine medications. Patients were initially identified upon admission and were seen by the CTP who conducted a medication therapy review, provided patient education, and ensured that any medication-related issues were addressed before discharge. In addition, the CTP followed up with patients by telephone within 72 hours of discharge. CTP interventions included reinforcement of the plan of care (67%), medication-related interventions in which specific issues were addressed (9%), contacting of the physician for treatment plan clarification or care gap (9%), reinforced scheduling of the primary care physician follow-up appointment (8%), and referral of the patient to another caregiver (6%). Patients who received postdischarge follow-up from the CTP were significantly less likely to have an acute care visit within 30 days of discharge compared with patients not contacted by the CTP and had improved Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores. Patients discharged from a community hospital who received a follow-up telephone call from a CTP were less likely to be admitted to the hospital or have an emergency department visit within 30 days of an acute care admission. HCAHPS patient satisfaction scores also improved in medication-related and discharge preparation question domains after CTP services were implemented.

Evidence into practice: emergency physician management of common pediatric fractures.

Randomized trials have shown that removable immobilization devices are at least as good as circumferential casts for the management of common specific types of pediatric wrist and ankle fractures. Our main objective was to determine the proportion of emergency physicians who prescribe removable devices for distal radius buckle fractures and/or nondisplaced distal fibular Salter-Harris I fractures. We also examined follow-up referral patterns for these injuries. This was an online survey of members of 2 national emergency physician associations in Canada: Pediatric Emergency Research Canada and the Canadian Association of Emergency Physicians. Of the 849 eligible participants, 447 responded to the survey, yielding an aggregate response rate of 52.7%. Organization-specific response rates were 169 (70.4%) of 240 for the Pediatric Emergency Research Canada and 278 (45.6%) of 609 for the Canadian Association of Emergency Physicians. Overall, 263 of 416 (63.2%; 95% confidence interval [CI], 58.6-67.8) of emergency physicians treat buckle fractures of the distal radius with a removable splint and refer 212 of 398 (53.3%; 95% CI, 48.4-58.2) of these injuries to the primary care physician for follow-up. For Salter-Harris I fractures of the distal fibula, emergency physicians treat 201 of 416 (48.3%; 95% CI, 43.5-53.1) with a removable ankle support and refer 94 of 398 (23.6%; 95% CI, 19.4-27.8) to the primary care physician for follow-up. At least 50% of the surveyed Canadian emergency physicians treat distal radius buckle fractures and/or Salter-Harris I fibular fractures with a removable immobilization device, and the primary care physician follow-up of these injuries occur with some regularity for both these injuries.

The role of primary care physician and cardiologist follow-up for low-risk patients with chest pain after emergency department assessment

Chest pain is one of the most common reasons for presentation to the emergency department (ED); however, there is a paucity of data evaluating the impact of physician follow-up and subsequent management. To evaluate the impact of physician follow-up for low-risk chest pain patients after ED assessment. We performed a retrospective observational study of low-risk chest pain patients who were assessed and discharged home from an Ontario ED. Low risk was defined as ≥50 years of age and no diabetes or preexisting cardiovascular disease. Follow-up within 30 days was stratified as (a) no physician, (b) primary care physician (PCP) alone, (c) PCP with cardiologist, and (d) cardiologist alone. The primary outcome was death or myocardial infarction (MI) at 1 year. Among 216,527 patients, 29% had no-physician, 60% had PCP-alone, 8% had PCP with cardiologist, and 4% had cardiologist-alone follow-up after ED discharge. The mean age of the study cohort was 64.2 years, and 42% of the patients were male. After adjusting for important differences in baseline characteristics between physician follow-up groups, the adjusted hazard ratios for death or MI were 1.07 (95% CI 1.00-1.14) for the PCP group, 0.81 (95% CI 0.72-0.91) for the PCP with cardiologist group, and 0.87 (95% CI 0.74-1.02) for the cardiologist alone group, as compared with patients who had no follow-up. In this cohort of low-risk patients who presented to an ED with chest pain, follow-up with a PCP and cardiologist was associated with significantly reduced risk of death or MI at 1 year.

Greater Mortality Risk Among Patients With Delayed Follow-up After Implantable Cardioverter Defibrillator Procedures

BackgroundSubstantial numbers of deaths occur among implantable cardioverter defibrillator (ICD) recipients. Timely follow-up after ICD implantation might improve patient outcomes. Our objective was to examine follow-up care and outcomes among patients undergoing ICD implantation. MethodsWe compared patient characteristics and outcomes of those with late (> 12 weeks) vs early defibrillator clinic follow-up after ICD implantation in the Ontario ICD Database from 2007 to 2011. We examined the effect of ICD clinic follow-up visits after implant compared with primary care physician tracer on mortality outcomes using time-varying covariate analyses. ResultsAmong 8096 ICD recipients (age 64.6 ± 12.6 years), 1145 (14%) received delayed follow-up. Patients with early ICD clinic follow-up experienced reduced risk of all-cause mortality, with a hazard ratio [HR] of 0.69 (95% confidence interval [CI], 0.50-0.95; P = 0.023) adjusted for clinical factors, primary care visits after discharge, and distance to follow-up centre. Early ICD clinic follow-up was associated with a reduction in out-of-hospital death with adjusted HR of 0.52 (95% CI, 0.36-0.76; P = 0.001) but not with a significant change in cardiovascular hospitalizations. In a tracer analysis, early primary care physician follow-up was associated with a nonsignificant trend toward increased mortality with an adjusted HR of 1.48 (95% CI, 0.97-2.25; P = 0.072). Reduced estimated glomerular filtration rate, secondary prevention or replacement devices, myocardial ischemia, smoking, and greater geographic distance to the implanting centre increased the odds of delayed follow-up. ConclusionsAfter device implantation, early defibrillator clinic follow-up was associated with reduced risk of all-cause and out-of-hospital death compared with those experiencing delayed follow-up.

Changing chronic medications in hospitalized patients—Bridging the inpatient–outpatient divide

There is consensus that the hospital is an appropriate place to start chronic medications for conditions that caused the hospitalization (e.g. aspirin for a patient admitted with acute myocardial infarction). However, little is known about physician attitudes towards starting chronic medications for conditions unrelated to the reason for hospitalization (e.g. aspirin in a patient with a history of myocardial infarction admitted for cellulitis). While hospitalists can identify and remedy potential gaps in the management of chronic conditions, changes in such medications during the hospital stay can create a number of problems. Contextual factors such as prior medication trials, patient preferences, and longstanding patterns of disease management may be unknown to the inpatient clinician, and medication confusion, non-adherence, and adverse effects can result from multiple medication changes.1,2 The lack of consensus about changing chronic medications for conditions unrelated to the reason for admission reflects a lack of clarity regarding the risk-benefit equation in this area. The study by Breu and colleagues3 in this issue provides one of the first studies of hospitalist and primary care physician (PCP) attitudes about changing chronic medications during hospitalization for conditions unrelated to the reason for admission. The authors had hospitalists and PCPs consider six cases, half involving a medication change related to the reason for admission and half involving a medication change unrelated to the reason for admission. They found that PCPs were more likely than hospitalists to feel inpatient interventions were appropriate when unrelated to reason for admission. However, the majority of both hospitalists and PCPs did not feel interventions in these cases were appropriate. While this study provides useful insight into the attitudes of physicians towards these issues, it is likely that even more physicians would be skeptical of initiating chronic medications in the hospital if the scenarios reflected the messy reality that often faces clinicians when patients are hospitalized. The study asked physician respondents to assume full outpatient electronic medical record (EMR) access and communication at discharge. However, in practice, inpatient physicians often do not have full outpatient EMR access. If they do have full access to records, they typically do not have the time to thoroughly review the chart, leading to over half of internal medicine patients having at least one medication discrepancy at admission.4 In addition, communication between hospitalists and PCPs occurs infrequently, and discharge summaries often are often not available by the time of the first post-discharge and lack important information, such as diagnostic test results and discharge medications.2 We believe that in most clinical settings, the serious problems that accompany changing medications in hospitalized patients argue for a judicious approach to modifying medications for chronic conditions not related to the reason for hospitalization. However, the more important question is how the prescribing process in hospitalized patients can be re-envisioned in a manner that allows individualization of these decisions to serve both the short- and long-term needs of patients. Because the success and appropriateness of long-term treatment decisions often depends on contextual factors, PCP follow-up, and patient medication compliance, in most cases decisions about initiating long-term therapy for conditions not central to the hospital admission should involve each of these parties. Shared decision making models involve clinicians and patients sharing information, expressing treatment preferences, deliberating the options, and coming to agreement on a treatment plan,5 and these models have been associated with improved adherence and disease-specific outcomes.6 Shared decision making in many cases could be done quickly and efficiently through a quick check-in with the PCP and a brief discussion with the patient. When consensus cannot be reached with these methods, then raising the issue with the PCP and patient but deferring the final decision until after discharge would be appropriate. In hospitalized patients, less is often more, and minimizing the number of non-essential medication changes may ultimately yield better outcomes. While inpatient clinicians can identify important gaps in care, the best solutions come from discussions that can bridge the inpatient-outpatient divide and ultimately serve the long-term needs of patients.

The Role of Primary Care Physician and Cardiologist Follow-Up for Patients With Chest Pain After Discharge From the Emergency Department

The Role of Primary Care Physician and Cardiologist Follow-Up for Patients With Chest Pain After Discharge From the Emergency Department

Caregiver Asthma Knowledge, Aptitude, and Practice in High Healthcare Utilizing Children: Effect of an Educational Intervention

Factors underlying high healthcare utilization among Hispanic and African American (AA) children with asthma are not well known. We hypothesized that low parental knowledge and suboptimal practices are associated with high healthcare utlization and sought to elucidate these factors and identify ethnicity-specific differences. We also hypothesized that a targeted educational intervention will decrease emergency department (ED) visits and hospitalizations. A 57-item questionnaire investigating asthma knowledge, aptitude, and practice was administered during a hospitalization to 268 caregivers (158 Hispanic and 110 AA) of high healthcare utilizer children. Responses were compared between ethnicities. Participants were randomized into an education group and a control group to investigate the impact of an in-hospital educational intervention on future ED visits and hospitalizations. More than 80% of caregivers knew that asthma is associated with muscle constriction and mucus production. Overall, 66.7%-86.9% of caregivers found preventive steps including allergen avoidance, regular primary care physician (PCP) follow-up, and medication adherence helpful, but only 45.2% reported adherence to controller medications. Similarly, caregivers found management steps, including albuterol use, avoidance of ineffective medications, and need to contact PCP helpful but 33% Hispanic caregivers contacted their child's PCP at the time of the exacerbation leading the current hospitalization, compared with 17% AA caregivers (P=0.006). Moreover, 40% and 30% Hispanic and 27% and 18% AA caregivers felt stressed and helpless, respectively, about their child's asthma. Despite high baseline levels of knowledge, there were fewer ED visits in the education group (1.56±1.94) compared with the control group (2.05±2.32) (P=0.02) 2 years after the intervention. Although Hispanic and AA caregivers of children with high healthcare utilization were knowledgeable of asthma pathophysiology, and preventive and management steps, they reported being stressed and helpless and were unable to implement the steps at the time of an exacerbation, seeking care at the ED rather than contacting their PCP. The high health utilizers who underwent a targeted educational intervention had fewer ED visits 2 years following the intervention.

Incidental Findings in Trauma Patients: Dedicated Communication with the Primary Care Physician Ensures Adequate Follow‐Up

Frequent use of computed tomography (CT) in trauma patients results in frequent detection of non-trauma-related incidental findings (IFs). Inpatient documentation and disclosure at discharge are infrequent, even when they are potentially serious. We aimed to not only identify the incidence of IFs but also to evaluate the effectiveness of an intervention to trigger follow-up. In this before-after study, all trauma patients evaluated by the trauma surgery service who underwent CT were admitted for >24 h, had at least one IF requiring follow-up, and had a primary care physician (PCP) employed in our health care system were identified. The historical control period was from January 2006 to December 2008. The intervention period was from December 2011 to September 2012. Intervention consisted of notifying the PCP via email or postal letter. The outcome of interest-the rate of follow-up-was compared between both groups. During the historical period, 364 (20.5 %) of 1,774 eligible trauma patients had 434 IFs requiring follow-up. During the study period, 197 (26 %) of 692 trauma patients had 212 IFs requiring follow-up. Overall, 91 % of study patients with postdischarge PCP follow-up had documented follow-up of the IF. There was a significant improvement in the rate of follow-up in the study group compared to that of the control group (51 vs. 11 %; p < 0.0001). Detection of IFs is common in trauma patients. A dedicated effort of communicating the presence of an IF to the patient's PCP triggered a follow-up for 91 % of patients who saw their PCP after hospital discharge.

Association Between Physician Follow-Up and Outcomes of Care After Chest Pain Assessment in High-Risk Patients

Assessment of chest pain is one of the most common reasons for emergency department visits in developed countries. Although guidelines recommend primary care physician (PCP) follow-up for patients who are subsequently discharged, little is known about the relationship between physician follow-up and clinical outcomes. An observational study was conducted on patients with higher baseline risk, defined as having diabetes mellitus or established cardiovascular disease, who were evaluated for chest pain, discharged, and without adverse clinical outcomes for 30 days in Ontario from 2004 to 2010. Multivariable proportional hazard models were constructed to adjust for potential confounding between physician groups (cardiologist, PCP, or none). Among 56767 included patients, 17% were evaluated by cardiologists, 58% were evaluated by PCPs alone, and 25% had no physician follow-up. The mean age was 66±15 years, and 53% were male. The highest rates of diagnostic testing, medical therapy, and coronary revascularization were seen among patients treated by cardiologists. At 1 year, the rate of death or MI was 5.5% (95% confidence interval, 5.0-5.9) in the cardiology group, 7.7% (95% confidence interval, 7.4-7.9) in the PCP group, and 8.6% (95% confidence interval, 8.2-9.1) in the no-physician group. After adjustment, cardiologist follow-up was associated with significantly lower adjusted hazard ratio of death or MI compared with PCP (hazard ratio, 0.85; 95% confidence interval, 0.78-0.92) and no physician (hazard ratio, 0.79; 95% confidence interval, 0.71-0.88) follow-up. Among patients with higher baseline cardiovascular risk who were discharged from the emergency department after evaluation for chest pain in Ontario, follow-up with a cardiologist was associated with a decreased risk of all-cause mortality or hospitalization for MI at 1 year compared with follow-up with a PCP or no physician follow-up.

Follow-Up of Breast Cancer Survivors

important study of the follow-up preferences of breast cancer survivors. However, I was struck by the marked disconnect between the study’s findings and the authors’ conclusions. In this survey of the self-perceived impact of follow-up by different types of providers, the 218 breast cancer survivors who completed the questionnaire overwhelmingly preferred follow-up with a medical oncologist to follow-up with a primary care physician (PCP) or nurse practitioner (NP). The odds ratios for the belief that medical oncologist follow-up relative to PCP follow-up would decrease breast cancer worry, and increase the chance of surviving cancer, were 36 (95% CI, 21 to 62) and 42 (95% CI, 24 to 74), respectively. Confidence in follow-up by an NP was nonsignificantly lower than that for a PCP. Nevertheless, the authors concluded that “Breast cancer survivors are comfortable with both PCPs and NPs providing follow-up care . . . the NP-led survivorship clinic model, with increased guidance for PCPs, offers a promising route for improving quality of and satisfaction with survivor care.” 1(p158) Breast cancer worry and fear of recurrence are high among breast cancer survivors, and often correlate poorly with objective prognosis. For example, in one study of 136 patients treated with curative intent, more than 50% had moderate to high levels of fear of recurrence. 2 It is inconceivable that a follow-up model that would exacerbate such fears would improve patient satisfaction. Shifting follow-up care from the oncologist to a PCP or NP could have more subtle detrimental effects on patient care, particularly for future medical oncology graduates, who would see far fewer follow-up patients during their training, and would never acquire the experience of monitoring large numbers of patients treated with adjuvant systemic therapy over several years. How will they be able to have balanced discussions with patients for whom the indication for chemotherapy is borderline if they have never seen the 40-year-old ICU nurse who can no longer work because of “chemo brain,” or the mother of six children who develops a cardiomyopathyrelated stroke? Nor will their perspective be balanced if they are asked to see only the patients with complications in the NP-led follow-up clinic next door. Even if patient care could somehow be unaffected, medical oncologists would have much to lose in terms of job satisfaction if we handed most, if not all, of our patients over to other health care professionals for follow-up. Undoubtedly most of us would prefer to see another patient responding to neoadjuvant chemotherapy than a whining but otherwise well survivor. But, more important, a clinic with several women in their thirties dying of metastatic disease is only bearable if, in the same clinic, there is also a patient, expected to have died 15 years ago of locally advanced disease, proudly showing pictures of her son’s wedding or daughter’s graduation. Referring patients with breast cancer who have completed active treatment to their PCP or a NP for follow-up is appropriate and optimal in many cases. Most patients, who greatly prefer medical oncologist follow-up initially, will gladly “graduate” back to their PCP after several years. However, the decision and timing should be made jointly by the patient and medical oncologist, taking into account factors such as patient preference and tumor prognosis. A health care system that allows both traditional and alternative follow-up models will maximize patient satisfaction, maintain the quality of oncology care, and avoid oncologist burn-out.

Decreased Length of Stay After TKA Is Not Associated With Increased Readmission Rates in a National Medicare Sample

There is a trend toward decreasing length of hospital stay (LOS) after TKA although it is unclear whether this trend is detrimental to the overall postoperative course. Such information is important for future decisions related to cost containment. We determined whether decreases in LOS after TKA are associated with increases in readmission rates. We retrospectively reviewed the rates and reasons for readmission and LOS for 4057 Medicare TKA patients from 2002 to 2007. We abstracted data from the Medicare Patient Safety Monitoring System. Hierarchical generalized linear modeling was used to assess the odds of changing readmission rates and LOS over time, controlling for changes in patient demographic and clinical variables. The overall readmission rate in the 30days after discharge was 228/4057 (5.6%). The 10 most common reasons for readmission were congestive heart failure (20.4%), chronic ischemic heart disease (13.9%), cardiac dysrhythmias (12.5%), pneumonia (10.8%), osteoarthrosis (9.4%), general symptoms (7.4%), acute myocardial infarction (7.0%), care involving other specified rehabilitation procedure (6.3%), diabetes mellitus (6.3%), and disorders of fluid, electrolyte, and acid-base balance (5.9%); the top 10 causes did not include venous thromboembolism syndromes. We found no difference in the readmission rate between the periods 2002-2004 (5.5%) and 2005-2007 (5.8%) but a reduction in LOS between the periods 2002-2004 (4.1±2.0days) and 2005-2007 (3.8±1.7days). The most common causes for readmission were cardiac-related. A reduction in LOS was not associated with an increase in the readmission rate in this sample. Optimization of cardiac status before discharge and routine primary care physician followup may lead to lower readmission rates.

C-A2-04: The Geisinger Transitions of Care Initiative: Overview of an Interdisciplinary Quality Improvement Process

John B Bulger, DO, Kenric A Maynor, MD and Seth Frazier, MBA John B Bulger, DO, Geisinger Health System; Kenric A Maynor, MD, Geisinger Health System; Seth Frazier, MBA, Geisinger Health System

Weight Loss Maintenance Following a Primary Care Intervention for Low‐income Minority Women

Although the primary care setting offers an innovative option for weight loss interventions, there is minimal research examining this type of intervention with low-income minority women. Further, there is a lack of research on the long-term effects of these programs. The purpose of this investigation was to examine the weight loss maintenance of low-income African-American women participating in a primary care weight management intervention. A randomized controlled trial was conducted with overweight and obese women (N = 144) enrolled at two primary care clinics. Women received a 6-month tailored weight loss intervention delivered by their primary care physician and completed follow-up assessments 9, 12, and 18 months following randomization. The weight loss maintenance of the tailored intervention was compared to a standard care comparison group. The weight loss of intervention participants (-1.52 +/- 3.72 kg) was significantly greater than that of standard care participants (0.61 +/- 3.37 kg) at month 9 (P = 0.01). However, there was no difference between the groups at the 12-month or 18-month follow-ups. Participants receiving a tailored weight loss intervention from their physician were able to maintain their modest weight loss up to 3-6 months following treatment. Women demonstrated weight regain at the 18-month follow-up assessment, suggesting that more intensive follow-up in the primary care setting may be needed to obtain successful long-term weight loss maintenance.

A randomized study of two different information-based interventions on the management of osteoporosis in minimal and moderate trauma fractures

Despite the high risk for subsequent fracture following an initial osteoporotic fracture, the majority of subjects with minimal trauma fractures receive no treatment for osteoporosis. The primary aim of this investigation was to determine whether an information-based intervention could change post-fracture management of osteoporosis. A secondary aim was to define participant- and doctor-related barriers to osteoporosis management. Consecutive fracture patients (n=254) from the outpatient fracture clinic at St Vincent's Hospital, Sydney were interviewed over a 15-month period (February 2002-July 2003). Fracture risk factors, prior investigation and treatment for osteoporosis were collected at baseline. Participants were initially contacted after 3 months to ascertain follow-up management. All those not investigated or treated by their primary care physician were then randomized to either a personalized letter or the same letter plus an offer of a free bone mineral density (BMD) test. Participants were contacted after 9 months to record further investigations or treatment for osteoporosis. Less than 20% of the participants had a primary care physician follow-up 3 months after the fracture, leaving 159 who were randomized to a personalized letter (n=79) and a personalized letter plus the offer of a free BMD test (n=80). There was a significant increase in the number of people investigated for osteoporosis in the group receiving the letter plus BMD offer [38% (letter + BMD) vs. 7% (letter only); p=0.001). A high proportion of those tested had low BMD (49% osteopenia and 17% osteoporosis). However, the rates of treatment in both groups were very low (6%). Furthermore, even among the few individuals (23%) who contacted their primary care physician, only 25% were recommended treatment. The belief that the fracture was osteoporotic was an independent predictor of having a BMD test, a primary care physician follow-up and treatment. Other independent predictors were age over 50 years for a primary care physician follow-up, female sex for having a BMD test and having had a BMD test for treatment. This study demonstrates that an information-based intervention led to a modest increase in the proportion of people investigated for osteoporosis; however. there was no significant effect on treatment rates. The offer of a free BMD assessment was associated with a significantly higher rate of investigation than a personalized letter alone (odds ratio: 8.5; 95% confidence interval: 3.1-24.5), but this investigation did not affect treatment rate. The low uptake of either a BMD or a visit to a primary care physician together with low rates of treatment recommendation even among people who contacted their primary care physician reflects significant participant and doctor-related barriers to osteoporosis management.

Expedited discharge in trauma patients requiring anticoagulation for deep venous thrombosis prophylaxis: the LEAP Program.

With rising health care costs, methods to decrease length of hospital stay without compromising care are necessary. One area that extends length of stay in trauma patients is inpatient anticoagulation to a therapeutic international normalized ratio. The 1998 American College of Chest Physicians guidelines recommend thromboprophylaxis with low-molecular-weight heparin (LMWH) and oral warfarin in this population. The LMWH Expedited Anticoagulation Program (LEAP) was created with the following goals: to decrease the number of inpatient warfarin days and to reduce overall number of hospital days. Inpatient anticoagulation was initiated with warfarin and LMWH. LEAP included early multidisciplinary collaboration to ensure third-party approval, outpatient primary care physician follow-up, and LMWH self-injection before discharge. Patients were discharged on LMWH (discontinued by primary care provider when a therapeutic international normalized ratio was attained) and warfarin (continued until resolution of orthopedic injuries). From August 2000 to August 2001, adult patients were included in the prospective study. Primary inclusion criteria were blunt acetabular fracture, bilateral lower extremity fracture, and contralateral upper and lower extremity fractures. Patients with similar injuries receiving warfarin for deep venous thrombosis prophylaxis between June 1999 and June 2000 were the control population. Anticoagulation care was similar for the study and control subjects. There were 182 patients evaluated for LEAP inclusion. After initial evaluation, 108 patients were enrolled in LEAP (Injury Severity Score of 13). There were 69 control subjects (Injury Severity Score of 13). The average number of inpatient warfarin days was decreased from 8.8 days to 5.0 days in the control and study populations, respectively (p < 0.0001). The average length of hospitalization was shortened from 17.3 days in the control group to 12.9 days in the study (LEAP) population (p < 0.002). LEAP has successfully decreased the number of inpatient days on warfarin and total hospital days for trauma patients requiring deep venous thrombosis prophylaxis. These results have substantially decreased health care costs and increased available hospital beds in this era of high hospital occupancy.