Primary Care Provider Follow-up Research Articles

Primary Care Provider Visits Among Cancer Survivors 5-7 Years Postdiagnosis.

Cancer survivors experience better outcomes when primary care providers (PCPs) are engaged in their care. Nearly all survivors have a PCP engaged in their care in the initial 5 years postdiagnosis, but little is known about sustained PCP engagement. We assessed PCP engagement in survivors' care 5-7 years postdiagnosis and characterized survivors most vulnerable to loss to PCP follow-up. We linked electronic health record ambulatory care and cancer registry data from an National Cancer Institute-Designated Comprehensive Cancer Center to identify eligible survivors (≥18 years; diagnosed with breast, colorectal, or uterine cancer; had an in-network PCP). We used multiple logistic regression to assess associations between survivor demographics, clinical factors, and health care utilization and odds of sustained PCP engagement. In 5-7 years postdiagnosis, PCPs were engaged in care for 43% of survivors. Survivors with sustained PCP-engagement were on average 4.6 years older than those without (P < .0001); survivors had 1.36 greater odds of having regular PCP visits for each decade increase in age on cancer diagnosis (P = .0030). Survivors were less likely to be lost to PCP follow-up if diagnosed at an earlier stage with odds at 0.57 and 0.10 for stage I and stage IV, respectively (P = .0005), and had 2.70 greater odds of engagement in care with at least one oncology visit annually 5-7 years postdiagnosis (P < .0001). Sustained PCP engagement is endorsed as critical by survivors, PCPs, and oncologists. We found most survivors were lost to PCP follow-up 5-7 years postdiagnosis. Our study is among the first to contribute empirical evidence of survivors being lost in transition. Findings from this study demonstrate the need to bridge gaps in long-term care for cancer survivors.

Exploring Telehealth to Improve Discharge Outcomes in Children.

The inpatient to outpatient transition is critical for patient safety but suffers from lack of standardization and communication. Expanding telehealth use allows unique opportunities to leverage secure video conferencing to streamline communication between families and hospital-based providers (HBPs) after hospital discharge. We conducted a qualitative study to evaluate HBP and caregiver beliefs regarding a proposed telehealth follow-up visit after hospital discharge (THDF). Interviews were conducted with pediatric hospitalists, senior pediatric residents, and caregivers of patients recently hospitalized on the study hospital's pediatric hospitalist service. Authors developed consensus regarding major themes to inform THDF design. These were organized into a conceptual model. We conducted 23 interviews with 6 hospitalists, 6 senior residents, and 11 caregivers. Three primary themes were identified: (1) Caregivers and HBPs agree THDF would be beneficial for patients and families; however, evidence is not robust enough to solidify provider buy-in. (2) Telehealth should supplement and enhance current discharge practices; it should not serve as a bandage for a broken system. Although a key aspect of THDF is to have the hospitalist provide follow-up care, this should be provided in addition to primary care provider follow-up. (3) HBPs expressed concerns about challenging workflows, competing demands, and inadequate resources, which are potential barriers to widespread adoption. THDF leverages expanding telehealth use to provide hospital-based follow-up. While HBPs shared workflow challenges in conducting telehealth, HBPs and caregivers believed potential benefits of THDF outweighed the challenges. This qualitative study will guide implementation of THDF in future studies.

Loss to primary care provider follow-up among survivors five to seven years post-diagnosis.

331 Background: Cancer survivors experience better outcomes when primary care providers (PCPs) are engaged in their care. Several studies indicate that nearly all survivors have ≥1 PCP visits per year in the initial five years post-diagnosis; however, little is known about sustained PCP engagement in survivors’ care. Our objective was to assess PCP engagement in survivors’ care 5-7 years post-diagnosis, and to characterize survivors who are most vulnerable to loss to PCP follow-up. Methods: We linked electronic health record ambulatory care visit data to Atrium Health Wake Forest Baptist Comprehensive Cancer Center (AHWFBCCC) registry data to identify survivors who were (1) ages ≥18 years, (2) diagnosed with a breast, colorectal, or uterine cancer between January 1, 2014 and December 31, 2015, (3) treated at AHWFBCCC as of September 1, 2019, and (4) had a PCP in the WF Health Network. We used multiple logistic regression to assess associations between survivor demographics, clinical factors, and healthcare utilization and odds of sustained PCP engagement in care, defined as having at least one ambulatory visit per year with a family or internal medicine provider. Results: There were 638 survivors who met our inclusion criteria. Of these, 122 died within the six-year post-diagnosis period and were excluded from analysis. Our analytic sample included 516 survivors who were primarily female (88.4%), white (75.0%), non-Hispanic (95.7%) stage 1 (50.6%) breast cancer survivors (69.2%) with a mean age of 60.7 years. Most (84.7%) survivors lived in an urban area at the time of diagnosis. In years 5-7 post-diagnosis, PCPs were engaged in care for 43% of survivors. Survivors with sustained PCP-engagement were on average 4.6 years older than those without (p&lt;0.0001); survivors had 1.36 greater odds of having regular PCP visits for each decade increase in their age upon cancer diagnosis (p=0.0030). Survivors were less likely to be lost to PCP follow-up in if they were diagnosed at an earlier stage (p=0.0005) and had at least one visit annually with an oncologist 5-7 years post-diagnosis (p&lt;0.0001). Conclusions: Sustained PCP engagement has been endorsed as critical by survivors, PCPs, and oncologists. In this study, we found that in the 5-7 years post-diagnosis, most (57%) survivors were lost to PCP follow-up. Older survivors, those currently engaged in oncology care, and survivors with earlier stage cancer were less likely to be lost to PCP follow-up, perhaps attributable to higher overall healthcare utilization. Our study may overestimate loss to PCP follow-up since we were unable to assess PCP visits outside of the AHWFB network; however, our findings offer evidence in support of calls for interventions to promote sustained PCP engagement among survivors, including the information, care coordination, and self-management support that survivors and PCPs have consistently reported needing for improved survivorship care and outcomes.

Barriers experienced by families new to Alberta, Canada when accessing routine-childhood vaccinations

BackgroundAs Canada and other high-income countries continue to welcome newcomers, we aimed to 1) understand newcomer parents’ attitudes towards routine-childhood vaccinations (RCVs), and 2) identify barriers newcomer parents face when accessing RCVs in Alberta, Canada.MethodsBetween July 6th—August 31st, 2022, we recruited participants from Alberta, Canada to participate in moderated focus group discussions. Inclusion criteria included parents who had lived in Canada for < 5 years with children < 18 years old. Focus groups were transcribed verbatim and analyzed using content and deductive thematic analysis. The capability opportunity motivation behaviour model was used as our conceptual framework.ResultsFour virtual and three in-person focus groups were conducted with 47 participants. Overall, parents were motivated and willing to vaccinate their children but experienced several barriers related to their capability and opportunity to access RCVs. Five main themes emerged: 1) lack of reputable information about RCVs, 2) language barriers when looking for information and asking questions about RCVs, 3) lack of access to a primary care provider (PCP), 4) lack of affordable and convenient transportation options, and 5) due to the COVID-19 pandemic, lack of available vaccine appointments. Several minor themes were also identified and included barriers such as lack of 1) childcare, vaccine record sharing, PCP follow-up.ConclusionsOur findings highlight that several barriers faced by newcomer families ultimately stem from issues related to accessing information about RCVs and the challenges families face once at vaccination clinics, highlighting opportunities for health systems to better support newcomers in accessing RCVs.

Implementation of a compulsory clinical pharmacist-led medication deprescribing intervention in high-risk seniors in the emergency department.

The objective of this study was to assess the impact of an emergency department (ED) deprescribing intervention for geriatric adults. We hypothesized that pharmacist-led medication reconciliation for at-risk aging patients would increase the 60-day case rate of primary care provider (PCP) deprescribing of potentially inappropriate medications (PIMs). This was a retrospective, before-and-after intervention pilot study conducted at an urban Veterans Affairs ED. In November 2020, a protocol utilizing pharmacists to perform medication reconciliations for patients 75 years or older who screened positive using an Identification of Seniors at Risk tool at triage was implemented. Reconciliations focused on identifying PIMs and providing deprescribing recommendations to patients' PCPs. A preintervention group was collected between October 2019 and October 2020, and a postintervention group was collected between February 2021 to February 2022. The primary outcome compared case rates of PIM deprescribing in the preintervention group to the postintervention group. Secondary outcomes include per-medication PIM deprescribing rate, 30-day PCP follow-up visits, 7- and 30-day ED visits, 7- and 30-day hospitalizations, and 60-day mortality. A total of 149 patients were analyzed in each group. Both groups were similar in age and sex, with an average age of 82 years and 98% male. The case rate of PIM deprescribing at 60 days was 11.1% preintervention compared to 57.1% postintervention (p< 0.001). Preintervention, 91% of PIMs remained unchanged at 60 days compared to 49% (p< 0.05) postintervention. Regardless of PIM identification, the 30-day primary care follow-up rate increased postintervention: 31.5% and 55.7% (p< 0.0001), respectively. There was no improvement in 7- or 30-day subsequent ED visits, hospitalization, or mortality. Pharmacist-led medication reconciliation in high-risk geriatric patients was associated with an increase both in the rate of PIM deprescribing and in post-ED primary care engagement.

Provider Perspectives of Transitions of Care at a Tertiary Care Children's Hospital With a Hospitalist-Run Discharge Clinic.

Children's hospitals are discharging patients to home with increasingly complex outpatient needs, making safe transitions of care (ToCs) of vital importance. Our study involved a survey of both outpatient providers and pediatric hospitalists associated with our medical center to better describe providers' views on the ToC process. The survey included questions assessing views on patient care responsibilities, resource availability, our hospitalist-run postdischarge clinic (PDC), and comfort with telemedicine. Our hospitalists generally believed that primary care providers (PCPs) did not have adequate access to important ToC elements, whereas PCPs felt their access was adequate. Both provider types felt it was the inpatient team's responsibility to manage patient events between discharge and PCP follow-up and that a hospitalist-run PDC may reduce interim emergency room visits. This study challenges perceptions about the ToC process in children and describes a generalizable approach to assessing provider perceptions surrounding the ToC within individual health systems.

Lessons from the implementation of a trauma center-based program to support primary care providers in managing opioids and pain after trauma hospitalization

BackgroundDecreasing exposure to prescription opioids is critical to lowering risk of opioid misuse, overdose and opioid use disorder. This study reports a secondary analysis of a randomized controlled trial implementing...

A Standardized Radiology Template Improves Incidental Adrenal Mass Follow-Up: A Prospective Effectiveness and Implementation Study.

Incidental adrenal masses (IAMs) are common but rarely evaluated. To improve this, we developed a standardized radiology report recommendation template and investigated its implementation and effectiveness. We prospectively studied implementation of a standardized IAM reporting template as part of an ongoing quality improvement initiative, which also included primary care provider (PCP) notifications and a straightforward clinical algorithm. Data were obtained via medical record review and a survey of radiologists. Outcomes included template adoption rates and acceptability (implementation measures), as well as the proportion of patients evaluated and time to follow-up (effectiveness outcomes). Of 4,995 imaging studies, 200 (4.0%) detected a new IAM. The standardized template was used in 54 reports (27.0%). All radiologists surveyed were aware of the template, and 91% affirmed that standardized recommendations are useful. Patients whose reports included the template were more likely to have PCP follow-up after IAM discovery compared with those with no template (53.7% versus 36.3%, P= .03). After adjusting for sex, current or prior malignancy, and provider ordering the initial imaging (PCP, other outpatient provider, or emergency department or inpatient provider), odds of PCP follow-up remained 2.0 times higher (95% confidence interval 1.02-3.9). Patients whose reports included the template had a shorter time to PCP follow-up (log-rank P= .018). PCPs ultimately placed orders for biochemical testing (35.2% versus 18.5%, P= .01), follow-up imaging (40.7% versus 23.3%, P=.02), and specialist referral (22.2% versus 4.8%, P < .01) for a higher proportion of patients who received the template compared with those who did not. Use of a standardized template to communicate IAM recommendations was associated with improved IAM evaluation. Our template demonstrated high acceptability, but additional strategies are necessary to optimize adoption.

\u201cShe knows me best\u201d: a qualitative study of patient and caregiver views on the role of the primary care physician follow-up post-hospital discharge in individuals admitted with chronic obstructive pulmonary disease or congestive heart failure

BackgroundPatients with chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF) are at high-risk of readmission after hospital discharge. There is conflicting evidence however on whether timely follow-up with a primary care provider reduces that risk. The objective of this study is to understand the perspectives of patients with COPD and CHF, and their caregivers, on the role of primary care provider follow-up after hospital discharge.MethodsA qualitative study design with semi-structured interviews was conducted among patients or their family caregivers admitted with COPD or CHF who were enrolled in a randomized controlled study at three acute care hospitals in Ontario, Canada. Participants were interviewed between December 2017 to January 2019, the majority discharged from hospital at least 30 days prior to their interview. Interviews were analyzed independently by three authors using a deductive directed content analysis, with the fourth author cross-comparing themes.ResultsInterviews with 16 participants (eight patients and eight caregivers) revealed four main themes. First, participants valued visiting their primary care provider after discharge to build upon their longitudinal relationship. Second, primary care providers played a key role in coordinating care. Third, there were mixed views on the ideal time for follow-up, with many participants expressing a desire to delay follow-up to stabilize following their acute hospitalization. Fourth, the link between the post-discharge visit and preventing hospital readmissions was unclear to participants, who often self-triaged based on their symptoms when deciding on the need for emergency care.ConclusionsPatients and caregivers valued in-person follow-up with their primary care provider following discharge from hospital because of the trust established through pre-existing longitudinal relationships. Our results suggest policy makers should focus on improving rates of primary care provider attachment and systems supporting informational continuity.

The association between hospital care transition planning and timely primary care follow-up.

To determine whether Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Care Transitions (CTM-3) Scores were associated with timely (14-day) primary care provider (PCP) follow-up visits, and to look for disparities across various types of urban and rural hospitals. Data were obtained for 3,299 hospitals: 2,000 urban, 544 micropolitan prospective payment system (PPS), 109 micropolitan critical access hospital (CAH), 252 noncore rural PPS, and 394 noncore rural CAH. HCAPPS data were drawn from CMS Hospital Compare (2015). The dependent variable, 14-day PCP follow-up rate for each hospital, was drawn from the 2015 Dartmouth Atlas. In analysis adjusting only for hospital characteristics, higher CTM-3 scores were positively associated with PCP follow-up; however, the relationship was no longer significant after controlling for area-level (contextual) measures, such as percent minority population, percent unemployed, and percent uninsured. In the fully adjusted model, rates of PCP follow-up were significantly higher for micropolitan PPS, noncore PPS, and noncore CAH hospitals than for urban hospitals. In fully adjusted analysis, the lack of significance between CTM-3 scores and PCP follow-up suggests that community characteristics facilitate or impede timely PCP follow-up to an extent that may overshadow in-hospital efforts. Disparities between CAHs and rural PPS hospitals may be due to differing enrollments in quality incentive plans; future research is needed to address this issue. Compounding this issue, the strong negative relationship between percent Medicaid reimbursement (payor mix) and PCP follow-up suggests possible disparities for safety net hospitals.

Patient preferences for cancer survivorship care: Results of an online survey.

12064 Background: Nearly 17 million cancer survivors live in the United States. Workforce shortages are projected to diminish the number of available medical oncologists (MOs) to care for newly diagnosed patients with cancer and for the growing number of cancer survivors. Models of survivorship care include oncologist-led, primary care-led, and shared care approaches. Recent proposals recommend a risk-stratified approach to care, guided by individual and cancer-specific factors, but there is little evidence regarding patient preferences for non-oncologist survivorship care. Methods: We developed a survey in partnership with patient advocates. The primary endpoints were patient-reported comfort with survivorship care by a primary care provider (PCP) or in a dedicated survivorship clinic. We distributed the survey to online, cancer-specific patient communities from June to August 2020. Logistic regression analyses were adjusted for patient age, race and ethnicity, insurance, and cancer type and stage. Results: Of 1166 responses, 975 surveys were complete and available for analysis. Respondents were primarily women (91%), white (92%), and US residents (73%); 78% had a college or graduate degree. Two-thirds had private insurance. Thirty-six different cancer types were reported; 61% of respondents had breast cancer, and 25% were treated for more than one type of cancer. Most respondents (83%) had nonmetastatic disease, 74% reported experiencing late effects of cancer therapy, and almost all (93%) had a PCP. Only 21% of respondents were comfortable seeing a PCP (versus MO) for survivorship care, including cancer follow-up, side effect management, and monitoring for recurrence or progression. About half (55%) were comfortable with follow-up in a survivorship clinic instead of with their MO. Multivariable analyses showed no significant associations between age, race or ethnicity, insurance, cancer type, or stage at diagnosis and comfort with follow-up care from a PCP or in a survivorship clinic. In analyses restricted to the 439 respondents with a history of early-stage breast cancer, the 239 (54%) who were within 1 to 5 years of diagnosis were less comfortable with PCP versus MO follow-up, compared with the 52 (12%) who were &gt; 15 years from diagnosis (OR 0.40; 95% CI 0.20–0.75; p= 0.004). In this sub-analysis, time from diagnosis was not associated with comfort being seen in a survivorship clinic. Conclusions: In our study, most patients with a history of cancer were not comfortable receiving follow-up care from their PCP. It is often recommended that survivors of early-stage breast cancer transition to primary care for follow-up and surveillance, but our study revealed comfort with this approach only many years after diagnosis. While both PCP survivorship training and patient confidence in PCP follow up is needed, preferences of cancer survivors should be considered in designing new models of survivorship care.

Follow-Up Care of Distal Radius Buckle Fractures

Source: Colaco K, Willan A, Stimec J, et al. Home management versus primary care physician follow-up of patients with distal radius buckle fractures: a randomized controlled trial. Ann Emerg Med. 2021;77(2):163-173; doi:10.1016/j.annemergmed.2020.07.039Investigators from the University of Toronto conducted a randomized controlled trial to assess outcomes associated with home management versus physician follow-up in children with distal buckle fractures. Children were eligible if they were 5-17 years old and were diagnosed in the study ED within the previous 3 days with a distal radius buckle fracture during the 2018-2019 study period. The standard management for all patients diagnosed with a distal buckle fracture at the study ED is a removable splint. All participants completed a demographic survey at enrollment as well as a baseline modified Activities Scale for Kids-38 (ASKp38) scale that assessed wrist function the week before injury (with the average score for patients with no disabilities being 95%).Participants were randomized to either removal of the splint at home with physician follow-up as needed or to see their primary care physician 1-2 weeks after the ED visit. All participants were advised to wear the splint continuously (except for bathing) for the first week and then as needed to manage pain or swelling symptoms. All participants were advised to restrict activities that could lead to reinjury for 6 weeks.The primary outcome was ASKp38 scores at 3 weeks post-ED visit, assessed via telephone. A secondary outcome was health care resource use and parental expenses related to the child’s injury, assessed by parent report at 3 and 6 weeks post-ED visit and medical records. Total patient health care costs were estimated by multiplying health care resources data by corresponding unit prices. The investigators assessed outcomes by allocation arm using an intention-to-treat analysis.There were 149 participants enrolled, 73 in the home management group and 76 in the primary care physician follow-up group. Follow-up was completed for 90.4% of participants in the home management group and 88.2% of the physician follow-up group at 3 weeks, and 89% and 86.8%, respectively, at 6 weeks. There were no significant differences in baseline demographics or baseline ASKp38 scores. Mean ASKp38 scores at 3 weeks were similar between both groups (95.4% and 95.9% in the home management and physician follow-up groups, respectively). Total mean healthcare and parent costs in the physician follow-up group were greater than in the home management group ($149.10 vs $26.80, respectively).The investigators conclude that home removal of splints for distal buckle fractures is noninferior to physician follow-up and less costly.Dr Bechtel has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.Buckle (torus) fractures of the distal radius are the most common fractures in children.1 There are many ways these fractures can be managed, as they are very stable and have an excellent prognosis. Primary care physicians are becoming the standard of care for follow-up of buckle fractures instead of orthopedic or fracture clinic follow-up. Primary care physician follow-up for distal forearm buckle fractures has demonstrated excellent recovery and management mainly based on patient symptoms rather than frequent radiographic follow-up common to orthopedists or fracture clinics.2 The current investigators sought to determine whether symptomatic home management versus primary care provider follow-up of torus fractures had equivalent functional outcomes in children managed with a removable splint.Indeed, the authors did find that home management was just as efficacious as primary care provider follow-up in terms of functional use scores at 3 weeks. Notably, children who were managed at home had even lower costs and fewer follow-up radiographs obtained than children who had follow-up with their primary care provider. There are, however, 2 significant limitations of the current study that should be noted. The first is that most of the population had post-secondary school education and telephone and electronic access and had a primary care provider. Thus, extrapolating the results to a different population (eg, lower parental education, lack of telephone access or a primary care provider) is not possible at this time. The second limitation is that the population was also primarily English-speaking, so it is likely not practical to expect similar results in a non-English speaking population of caregivers based on the current study.In English-speaking families with telephone and electronic access and a primary care physician, at-home management of children with torus fractures with a removable splint is less costly and just as efficacious as follow-up with a primary care physician.The benefits that accrue with home splint removal are potentially more than financial. Parental time away from employment or other priorities, as well as school absence by affected children, are obviated by home management of distal radius fractures.

Osteoporosis Is Undertreated After Low-energy Vertebral Compression Fractures.

Despite guidelines recommending postfracture bone health workup, multiple studies have shown that evaluation and treatment of osteoporosis has not been consistently implemented after fragility fractures. The primary aim of this study was to evaluate rates of osteoporosis evaluation and treatment in adult patients after low-energy thoracolumbar vertebral compression fractures (VCFs). We retrospectively reviewed all patients ≥60 years old presenting to a single academic trauma center with acute thoracolumbar VCFs after a ground-level fall from 2016 to 2020 . Rates of osteoporosis screening with dual-energy x-ray absorptiometry and initiation of pharmaceutical treatment were recorded at four time points: before the date of injury, during index hospitalization, at first primary care provider follow-up, and at final primary care provider follow-up. Rates of subsequent falls and secondary fragility fractures were recorded. One-year mortality and overall mortality were also calculated. Fifty-two patients with a mean age of 83 years presenting with thoracic and/or lumbar fractures after a ground-level fall were included. At a mean final follow-up of 502 days, only 10 patients (19.2%) received pharmacologic therapy for osteoporosis and only 6 (11.5%) underwent postinjury dual-energy x-ray absorptiometry evaluation. Twenty-five patients (48%) had at least one subsequent fall at a mean of 164 days from the initial date of injury. Eleven patients with subsequent falls sustained an additional fragility fracture because of the fall, including six operative injuries. One-year mortality among the 52 patients was 26.9%, and the overall mortality rate was 44.2% at the final follow-up. Osteoporosis remains a major public health issue that markedly affects quality of life and healthcare costs. Our study demonstrates the additional need for improved osteoporosis workup and intervention among patients who have sustained VCFs. We hope that our study helps raise awareness for improved osteoporosis evaluation and treatment among spine surgeons and all medical professionals treating patients with fragility fractures. Retrospective Case Series, Level IV Evidence.

Opportunities to Improve Sexual and Reproductive Care Among Hospitalized Adolescents.

Improved access to sexual and reproductive care (SRC) improves adverse outcomes among adolescents, yet barriers continue to exist. Although the continued declining rate of adolescent pregnancy over the past decades is encouraging, adolescents in the United States still experience disproportionately high rates of unplanned pregnancy and sexually transmitted infections (STIs) compared with adolescents in other industrialized countries.1–3 Nearly 90% of adolescent pregnancies are unplanned, leading to increased risk for preventable outcomes, including preterm delivery, low birth weight, and neonatal mortality.4,5 In addition, unintended teen-aged pregnancy is associated with reduced education attainment and career earning potential.6 Rates of STIs among adolescents remain high, with nearly 1 in 4 girls testing positive for an STI annually.7 In addition, only half of adolescents are fully vaccinated against the human papillomavirus (HPV), leaving those who are unvaccinated at risk for developing HPV-associated cancers.8 Despite multiple national organizations advocating for provision of comprehensive care for adolescents at every clinical encounter, adolescent reproductive and sexual health needs often go unmet.9,10 In light of recent events, including the COVID-19 pandemic as well as the current administration’s health care reform policies, access to evidence-based SRC is even further decreased, particularly among vulnerable populations, including adolescents; thus, efforts to address these needs are now more critical than ever.11,12 Many adolescents, particularly those at highest risk for unintended pregnancy and STIs, have limited access to SRC because of numerous barriers, including poor access and confidentiality concerns.13–15 Open parent-teenager communication regarding sexual and reproductive health promotes reduced risk behaviors, but most teenagers do not receive these discussions with their parents, guardians, or health care providers.16 Among …

Increasing Primary Care Follow-up after Preparticipation Physical Evaluations.

Background:Preparticipation physical evaluations (PPEs) strive to prevent injuries and sudden death in athletes. Ideally, the medical home is the best setting for completion. However, many school systems request large PPE screenings for their student-athletes. This quality-improvement project aimed to increase primary care provider (PCP) follow-up for athletes “cleared with recommendation” (CR) or “disqualified” (DQ) during our mass PPEs.Methods:Our team evaluated prior PPE data for athlete clearance and PCP follow-up for CR or DQ athletes. The prominent gaps in our PPEs were resident education, PCP or medical home identification, and communication. Our team implemented interventions during the 2018 PPEs to increase both CR and DQ athlete follow-up at the medical home.Results:Retrospective baseline data revealed that physicians categorized 11% (67/582) of athletes at our PPEs as CR or DQ. Of these athletes, the PCP and specialist follow-up rate was 13% (9/67). Our process changed to enhance athlete follow-up, but the rate only increased slightly to 15% (18/120). Medical home identification improved. Successful interventions included resident education, medical home identification, and increased communication.Conclusions:Despite our interventions, this quality-improvement initiative was unsuccessful in reaching the aim. This project found small achievements in educational opportunities, improved documentation, medial home identification for student-athletes, and lead to local changes in our standard operating procedures. Although our aim was ambitious, 100% athlete follow-up with the PCP or medical home ensures athletic safety and decreases liability for all.

Improving Mental Health Communication From the Pediatric Emergency Department to Primary Care.

Suicide is a leading cause of adolescent death, and emergency department (ED) visits are recognized as an opportunity to identify at-risk youth. For patients screening positive for mental health concerns, we implemented a quality improvement initiative to enhance documentation of results and interventions in the ED, increase communication between the ED and primary care providers (PCPs), and increase PCP follow-up. Interventions included education, feedback, and an alert in our electronic health record. Completion of a Behavioral Health Screen (BHS-ED) initiates an alert that reminds ED providers how to document and communicate results and needed follow-up to the PCP. We reviewed a random monthly sample of ED charts for adolescents 14 to 19 years old presenting with nonpsychiatric complaints who screened positive for severe depression or suicidality. Outcome measures included documentation of BHS-ED results in the ED note, communication of positive results to the PCP, PCP follow-up of results, and ED return visits. Documentation of BHS-ED results increased from 73% at baseline to 88% of patients after the intervention. For patients discharged from the ED with nonpsychiatric chief complaints, communication to PCPs increased from 1% at baseline to 40% during the final 3 months of the study. When PCP communication occurred, 67% of in-network PCPs followed up with patients versus 5% when no communication took place from the ED. A multifaceted intervention including education and an electronic health record alert improved ED documentation, communication, and PCP follow-up of issues identified during ED-based mental health screens.

Primary care provider preferences for glucocorticoid management of acute asthma exacerbations in children

Objective Primary care providers (PCP) frequently care for children with acute asthma exacerbations in the outpatient setting. The objective of this study is to evaluate PCP preferences and perceptions regarding oral glucocorticoids prescribed from both outpatient primary care and ED settings for the treatment of children with acute asthma exacerbations. Methods PCPs belonging to the Colorado Chapter of the American Academy of Pediatrics were surveyed between February and May 2019. Survey items were generated by a multidisciplinary team and underwent content and criteria validation and pilot testing. Survey items evaluated PCP preferred oral glucocorticoid and dosing regimen for children with acute asthma exacerbations, provider- and patient-level factors contributing to glucocorticoid preferences, and perception of glucocorticoid regimens in terms of treatment failure, resolution of symptoms and adherence. Results A total of 109 of 600 (18.2%) PCPs responded. Equal proportions of PCPs reported preferring oral prednisone/prednisolone (50.5%) and oral dexamethasone (49.5%) for children with acute asthma exacerbations. Forty-four percent of PCPs reported no preference in type of glucocorticoid utilized by surrounding emergency departments (EDs). However, for children receiving dexamethasone in the ED but with persistent symptoms on PCP follow-up, 50.5% of PCPs would switch patients to prednisone/prednisolone. PCPs did not perceive more treatment failure or rapid resolution of symptoms with dexamethasone but reported better adherence with dexamethasone. Conclusion There is variability in PCP glucocorticoid management of pediatric acute asthma exacerbations. There is a need for further investigations to evaluate for differences in clinical outcomes based on PCP glucocorticoid treatment choices.

The Race for Readmission Reduction

Background: In 2012, the Centers for Medicare and Medicaid Services began to reduce payments to qualifying hospitals for 30-day readmission rates that were higher than predicted for specific diagnoses. The process was broadened to include skilled nursing facilities in 2018. It is reasonable to expect future expansion will include acute inpatient rehabilitation facilities. A pre-intervention quality improvement project from 2017 identified that patients admitted to an acute inpatient rehabilitation facility (IRF) for the primary diagnosis of debility were readmitted within 30 days of discharge at a rate of 38%, which was nearly three times higher than the next most readmitted diagnosis. A literature review identified rapid primary care provider (PCP) outpatient follow up as a worthy intervention to reduce readmissions. Objectives: Over a six-month intervention period, we attempted to achieve a reduction in 30-day readmission rates in the debility population of an IRF by scheduling PCP follow-ups within seven business days after discharge. Results: Of those that received the intervention, 7% were readmitted (P=0.018). Of those who did not receive the intervention, 56% were readmitted. Conclusion: The adoption of PCP follow-up within seven business days of discharge may lower the 30-day readmission rate for patients admitted to IRF with a primary diagnosis of debility.

Factors Influencing Primary Care Follow-Up After Pediatric Mild Traumatic Brain Injury.

To identify socioeconomic, demographic, and caregiver factors associated with children attending primary care provider (PCP) follow-up after emergency department (ED) evaluation for mild traumatic brain injury (mTBI). Pediatric trauma center ED. Children 8 to 18 years of age sustaining mTBI less than 48 hours prior to an ED visit. Mean age of the 183 participants was 12 years with no significant differences between those who attended follow-up and those who did not in race, ethnicity, insurance provider, or PCP office setting. Thirty-day longitudinal cohort study. Insurance type, PCP practice setting, and a caregiver attitudes survey regarding mTBI recovery and management (5 questions each scored on a 5-point Likert scale). The primary outcome was attending a PCP follow-up visit within 1 month of injury. Females were more likely than males to attend PCP follow-up (adjusted odds ratio: 2.27 [95% confidence interval: 1.00-5.18]). Increasing scores on the caregiver attitudes survey indicating greater concerns about recovery were significantly associated with attending PCP follow-up (adjusted odds ratio: 1.12 per unit increase in composite score [95% confidence interval: 1.02-1.23]). No other socioeconomic, demographic, or injury characteristics were associated with attending PCP follow-up. The ED counseling regarding PCP follow-up of mTBI should stress the importance of follow-up care to monitor recovery and identify presence of lingering symptoms.

Caring for Women After Hypertensive Pregnancies and Beyond: Implementation and Integration of a Postpartum Transition Clinic.

Purpose We developed a postpartum transition clinic to better support women after hypertensive pregnancy. Description Our program goals were (1) early postpartum hypertension medical management, (2) patient and provider education around CVD risk, (3) transition to primary care provider (PCP) and (4) a sustainable clinical model reimbursed by private and public insurances. We focused on women immediately postpartum in this analysis. Assessment Over the course of 5years, a racially and socioeconomically diverse population of 412 immediately postpartum women received care for one, two or more appointments. Referral diagnoses included antepartum preeclampsia (PET) 51% (210/412), postpartum preeclampsia/hypertension (PP-PET) 22.3% (92/412), preeclampsia superimposed on chronic hypertension (siPET) 10.2% (42/412), chronic hypertension (cHTN) 8.8% (37/412), and gestational hypertension (gHTN) 7.8% (31/412). Almost half of women had 2-3 visits 47.3% (195/412) with no difference by diagnosis (p = 0.18). No show rates were consistently around 25%. Acquisition of home blood pressure monitors increased from 56.8% (44/94) to 93.8% (61/65) over the 5years (p < 0.0001). Nearly half of patients seen had antihypertensive medication adjustments 48.3% (199/412). Of those patients scheduled, 86.8% (79/91) attended a nutrition consultation. For patients with PCPs within our system, 79.5% (105/132) kept their scheduled follow upPCP appointments. Conclusion We report a postpartum transition clinic after hypertensive pregnancy. In this diverse population, patients attended 2-3 visits, incorporated home blood pressure monitoring, adjusted antihypertensive medications and initiated prevention measures such as nutrition referrals and PCP follow-up. An internist salary was sustained through billings and collections from private and public insurance.