Primary Care Provider Referral Research Articles

Racial and ethnic differences in the receipt of metabolic syndrome risk factor screening and treatment among individuals with prostate cancer treated with androgen deprivation therapy.

29 Background: Racial and ethnic health disparities in prostate cancer screening, and treatment constitute the largest of all cancer disparities. Androgen deprivation therapy (ADT) is widely used in the treatment of localized or metastatic prostate cancer. However, ADT is associated with toxic cardiovascular and metabolic adverse events that may occur as early as 6 months of therapy initiation. This study aimed to assess racial/ethnic differences and longitudinal changes in metabolic syndrome risk factor (MSRF) screening/treatment among patients with prostate cancer treated with ADT at a university-affiliated comprehensive cancer center in the southwestern U.S. between 2010-2021. We also aimed to identify patient and healthcare provider factors that influence MSRF screening among study sample. Methods: A retrospective observational cohort study of 803 patients treated with ADT for at least six months at the cancer center was conducted. Patients were followed three months pre- to 12 months post-ADT initiation to evaluate MSRF screening/treatment. Determination of MSRF screening was based on primary care provider referral for MSRF screening/treatment or receipt of blood glucose, lipid profile, and blood pressure screening within six months post-treatment with ADT. Patients were considered treated for MSRF if they were started or continued therapy (within six months of ADT initiation) with science advisory guideline recommended treatments. Results: Guideline-concordant MSRF screening rate approached 23.5%; MSRF treatment rate was 76.9%. A higher treatment rate in MSRF treatment was found for NHW compared to Hispanic men ( p=0.02). We found a significant difference in the proportion of patients receiving MSRF screening across all racial/ethnic groups ( p=0.03). MSRF screening rates from 13.9% to 35.6% were observed over the 10-year data collection period. Patients with dyslipidemia at baseline had higher odds of having MSRF screening than patients without dyslipidemia ( p<0.0001). Oncologists with >20 years of experience had higher odds of providing MSRF screening compared with <10 years of experience ( p=0.006). Conclusions: Minority populations had significantly lower odds of having MSRF screening than NHW patients after adjusting for clinical and socio-economic variables. Closer clinical attention and education, as well as the development and implementation of innovative practice tools and interventions to optimize MSRF screening and treatment are warranted to mitigate the harmful adverse effects of ADT in patients with prostate cancer.

Access to orthopedic specialist service in Ontario via eConsult.

Background:Increasing strain on public health resources in Canada, in particular with respect to accessing specialist care, necessitates the exploration of alternative models of care. The aim of this study was to assess the efficacy of electronic consultation (eConsult) in providing orthopedic surgery specialist service to patients in the Champlain Local Health Integration Network (LHIN) of Ontario.Methods:This was a cross-sectional review of all 564 Champlain LHIN orthopedic surgery referral requests received via the Champlain Building Access to Specialist service through the eConsult (BASE) system in 2017. Primary outcome measures were impact on primary care provider (PCP) referral pattern and time to receive orthopedic consultation.Results:eConsult prevented unnecessary in-person consultation 64% of the time, while PCP referral decisions were modified 51% of the time. Of all eConsults, 94% were rated as valuable to PCPs in their practice and 97% of eConsults resulted in actionable advice. eConsults took an average of 14.5 minutes of specialist time to complete, and the mean time from referral to response was 3.7 days.Conclusion:The eConsult system spares unnecessary consultation to orthopedic surgery; catches important referrals that would have otherwise been missed; saves time for patients, PCPs and orthopedic surgeons; and improves efficiency in a socialized health care system.

Provider and patient insights into the cancer care journey

To assess provider and patient preferences for an oncologist selection tool, value-based care, involvement in cancer care, and end-of-life planning. We conducted a cross-sectional survey of primary care providers (PCPs) and insured patients with cancer. We asked PCPs about their method of oncologist referral; utilization of an oncologist selection tool that directs patients to high-quality, high-value oncologists; involvement in cancer care and value-based care; and when an advance directive should be established. We asked patients to reflect upon their personal experience when selecting their oncologist, utilization of an oncologist selection tool, and establishing an advance directive. PCPs tend to refer patients to oncologists who are part of their health system (67.9%). Most PCPs (79.2%) were not currently utilizing an oncologist selection tool; most (77.3%) expressed a willingness to use such a tool. Most PCPs (69.8%) believe the best time to talk about an advance directive is at the time of cancer diagnosis. Patients ranked a PCP referral (52.7%) as "very important" when selecting an oncologist. One-third of patients used a web-based oncologist selection tool; 65.2% responded that an oncologist selection tool would be "somewhat" or "very" important. Most (54.5%) patients had an advance directive. These results present a compelling rationale for developing a data-driven oncologist selection tool, optimizing patient and provider involvement in care, and expanding the portion of patients who have an advance directive at the start of their cancer care to optimize their cancer journey.

What factors are important to new patients when selecting an orthopedic oncologist?

BACKGROUNDUnderstanding how patients choose a provider may improve the overall experience by identifying ways to tailor a clinical practice.AIMTo identify factors that patients consider important when choosing an orthopedic oncologist. METHODSNew patients presenting to an orthopedic oncology clinic within a tertiary academic medical center from January 2019 to August 2020 were invited to complete an anonymous survey. The questionnaire consisted of 27 items including a Likert-type assessment of the importance of selection factors.RESULTSA total of 101 new patients with a median age of 66 years (range, 14 years to 91 years) responded. Most were referred by another doctor (n = 63, 62.4%), and of the referring providers, the most frequent specialty was orthopedic surgery (n = 32, 51%). Using a Likert-type scale with 1 representing ‘least important’ and 5 representing ‘most important’, the most important factor was the hospital reputation (mean, 4.65; SD, 0.85). Additional factors of importance were the number of years in practice (3.87 ± 1.3) and a primary care provider referral (3.71 ± 1.6). Patients younger than 40 years old found social media (P = 0.016) and internet presence (P = 0.035) of their surgeon to be more important than older patients. In contrast, older patients considered care within an academic center to be of greater importance than younger patients (P = 0.014).CONCLUSIONThis investigation suggests a primary care referral, as well as hospital and physician reputation, are among the most important factors when selecting an orthopedic oncologist. Furthermore, social media utilization appears to be more important for younger patients.

Factors influencing primary care provider referral for bariatric surgery: Systematic review.

To identify barriers to and facilitators of primary care provider (PCP) referral for bariatric surgery in patients with obesity. MEDLINE, EMBASE, and PsycINFO databases were searched and reference lists of included articles were screened to identify additional relevant articles. Two reviewers independently reviewed citations and full-text articles, and appraised the quality of the included articles using the Critical Appraisal Skills Programme Tool Qualitative Checklist and the Appraisal Tool for Cross-Sectional Studies. They extracted data on the study characteristics and the barriers to and facilitators of PCP referral for bariatric surgery. Appraisal discrepancies were resolved through consensus among authors. Overall, 882 citations were identified and 18 articles were then selected for this review. Barriers included fear of surgery complications and side effects, cost, lack of availability, perception that surgery is a quick fix or a last resort, and prior negative experiences. Facilitators included direct requests from patients, patient motivation, previously failed weight-loss interventions, and obesity-related comorbidities. Those PCPs who were knowledgeable about the risks and benefits of bariatric surgery were more likely to refer their patients. Education and continuing professional development programs regarding bariatric surgery are needed to improve PCP knowledge and capacity to manage patients with obesity. Also, educating the general public on obesity, weight management, and available treatment options can empower patients and families to manage their weight and pursue evidence-informed treatments.

Use of an Integrated Care Management Program to Uncover and Address Social Determinants of Health for Individuals With Lupus.

ObjectiveWe studied patients with systemic lupus erythematosus (SLE) enrolled in a nurse‐led, multihospital, primary care–based integrated care management program (iCMP) for complex patients with chronic conditions to understand whether social determinants of health (SDoH), including food insecurity, housing instability, and financial constraints, were prevalent in this population.MethodsThe academic hospital‐based iCMP enrolls the top 2% of medically and psychosocially complex patients identified on the basis of clinical complexity health care use, and primary care provider referral. A nurse conducts needs assessments and coordinates care. We reviewed the electronic medical records of enrolled patients with SLE to identify SDoH needs and corresponding actions taken 1 year prior to iCMP enrollment using physicians’ and social workers’ notes, and during enrollment using iCMP team members’ notes.ResultsAmong 69 patients with SLE in the iCMP, in the year prior to enrollment, 57% had documentation of one or more SDoH challenges, compared with 94% during enrollment. iCMP nurses discussed and addressed one or more SDoH issues for 81% of the patients; transportation challenges, medication access, mental health care access, and financial insecurity were the most prevalent. Nurses connected 75% of these patients with related resources and support.ConclusionAlthough SDoH‐related issues were not used to identify patients for the iCMP, the vast majority of enrolled medically and psychosocially complex patients with SLE had these needs. The iCMP team uncovered and addressed SDoH‐related concerns not documented prior to iCMP participation. Expansion of care management programs like the iCMP would help identify, document, and address these barriers that contribute to disparities in chronic disease care and outcomes.

Improving Care for Patients With Stage III or IV NSCLC: Learnings for Multidisciplinary Teams From the ACCC National Quality Survey.

Insufficient characterization of the optimal multidisciplinary team and lack of understanding of barriers to quality care are unmet needs in the management of stage III or IV non-small-cell lung cancer (NSCLC). A national survey was conducted to inform the design and execution of process improvement plans and address identified barriers. A steering committee of multidisciplinary specialists and representation from patient advocacy collaborated for a comprehensive, double-blind, web-based survey (January-April 2019) to obtain insights on care delivery for patients with advanced NSCLC in a diverse set of US community cancer programs. Overall, 639 responses (160 unique cancer programs across 44 US states) were included; 41% (n = 261) of respondents indicated an absence of a thoracic multidisciplinary clinic in their cancer program. Engagement in shared decision making was significantly associated with the presence of navigation and radiation oncology disciplines (P ≤ .04); 19.2% and 33.3% of respondents belonged to cancer programs with no lung cancer screening and no protocol for biomarker testing, respectively. The frequency of tumor board meetings negatively correlated with time to complete disease staging (P = .03); the average time to first therapeutic intervention in newly diagnosed patients was 4 weeks. The most challenging barriers to quality care included insufficient quantity of biopsy material for biomarker testing, lack of primary care provider referrals, and diagnostic costs. Improving the quality of advanced NSCLC care, including optimization of a multidisciplinary team framework, may surmount barriers to care coordination, diagnosis and staging, and treatment planning, consequently improving adherence to evolving standards of care.

Selection of patients for large mailed fecal immunochemical test colorectal cancer screening outreach programs: A systematic review.

Digital health care offers an opportunity to scale and personalize cancer screening programs, such as mailed outreach for colorectal cancer (CRC) screening. However, studies that describe the patient selection strategy and process for CRC screening are limited. Our objective was to evaluate implementation strategies for selecting patients for CRC screening programs in large health care systems. We conducted a systematic review of 30 studies along with key informant surveys and interviews to describe programmatic implementation strategies for selecting patients for CRC screening. PubMed and Embase were searched since inception through December 2018, and hand searches were performed of the retrieved reference lists but none were incorporated (n = 0). No language exclusions were applied. Common criteria for outreach exclusion included: being up-to-date with routine CRC screening (n = 22), comorbidities (n = 20), and personal history (n = 22) or family history of cancer (n = 9). Key informant surveys and interviews were performed (n = 28) to understand data sources and practices for patient outreach selection, and found that 13 studies leveraged electronic medical care records, 10 studies leveraged a population registry (national, municipal, community, health), 4 studies required patient opt-in, and 1 study required primary care provider referral. Broad ranges in fecal immunochemical test completion were observed in community clinic (n = 8, 31.0-59.6%), integrated health system (n = 5, 21.2-82.7%), and national regional CRC screening programs (n = 17, 23.0-64.7%). Six studies used technical codes, and four studies required patient self-reporting from a questionnaire to participate. This systematic review provides health systems with the diverse outreach practices and technical tools to support efforts to automate patient selection for CRC screening outreach.

Predictors of Nonurgent Emergency Visits at a Midsize Community-Based Hospital System: Secondary Analysis of Administrative Health Care Data

IntroductionNonurgent visits to the emergency department compromise efficiency in treating patients with urgent conditions and inversely influence the satisfaction of patients and staff. There is inconclusive evidence of the factors associated with nonurgent ED visits. Therefore, the purpose of this study was to explore the independent factors associated with nonurgent ED visits in a midsize community-based Canadian hospital system. MethodsThis was a retrospective, secondary analysis of data from 2 community hospitals in southwestern Ontario, Canada. We included ED patients in the analysis if they were local residents from the city or the surrounding county. ResultsNonurgent visits constituted approximately 27% of all ED visits and were more likely to be associated with patients with a primary care provider referral (odds ratio = 2.87; 95% confidence interval, 2.75-2.99) and with patients who had no primary care provider (odds ratio = 1.10; 95% confidence interval, 1.04-1.16). Other predictors included younger age, season, time of day, ED arrival mode, geographical proximity of residence to the emergency department, and case presentation. DiscussionThe findings of this study may assist health care providers and stakeholders in developing strategies to minimize nonurgent ED visits.

Abstract P379: Features to Increase Primary Care Provider Referrals to Intensive Behavioral Counseling for Cardiovascular Disease Prevention

Background: The US Preventive Services Task Force recommends adults with certain cardiovascular disease (CVD) risk factors be offered or referred to intensive behavioral counseling to promote a healthful diet and physical activity for CVD prevention. However, only 1 in 12 primary care providers (PCPs) currently follow this recommendation. This study assessed system and programmatic features PCPs reported would increase their likelihood of referring patients at risk for CVD to intensive behavioral counseling and whether this varied by the percentage of at-risk patients with whom they discuss physical activity. Methods: DocStyles 2018, a web-based panel survey of PCPs, assessed the percentage of at-risk patients with whom PCPs discuss physical activity and the degree to which select features would increase their likelihood of referring to intensive behavioral counseling. Results: Overall, 60.8% of PCPs discussed physical activity with most of their at-risk patients; 21.8% did so with many and 17.4% with few or some. The proportion of PCPs identifying features as increasing their likelihood of referring to intensive behavioral counseling by a great extent ranged from 24.1% for an automated referral in electronic health records, 35.3% for patient progress reports, 41.5% for the program being accredited or evidence-based, to 67.2% for the program having no cost to the patient (Table). These proportions increased for each feature as the percentage of at-risk patients with whom they discuss physical activity increased. Conclusion: PCPs identified programmatic features (i.e. being accredited and of no cost) as having the greatest influence on their likelihood of referring patients at risk for CVD to intensive behavioral counseling, although this varied by the percentage of at-risk patients with whom they discuss physical activity. Findings suggest that the effectiveness of strategies to improve behavioral counseling referrals by PCPs may depend on their current physical activity counseling practices.

Pharmacist Interventions in Improving Clinical Outcomes in Patients with Type 2 Diabetes Mellitus Among the Underrepresented Population: A Collaborative Ambulatory Care Pharmacy Practice (CAPP) Approach.

Objective:The objective of this study was to evaluate the impact of pharmacist's interventions through a collaborative ambulatory care pharmacy practice (CAPP) model in patients with type 2 diabetes mellitus (T2DM) among the underrepresented population.Methods:Eligible patients were 18 years and older with a diagnosis of T2DM with or without comorbid cardiovascular disease risk factors. Patients were enrolled through routine primary care provider referrals. During a one-on-one, face-to-face scheduled clinic visit, the pharmacist provided a comprehensive medication management by reviewing vital signs and laboratory values, provided medication reconciliation and management, followed by medication counseling through a CAPP approach in a primary care setting. The pharmacist worked in close collaboration with the primary care provider to intervene on medication therapy through recommendations to initiate, adjust, modify, or discontinue drug therapy and order laboratory tests and drug concentration levels as appropriate. Each visit was documented as a “PharmD Progress Note” in the patient's electronic medical record. Follow-up visits were scheduled until patients' targeted treatment goals were achieved. Primary and secondary outcome data were collected and then analyzed.Findings:A pharmacist saw 47 patients over 12 months. Sixty-four percent of the participating patients were able to achieve targeted treatment goals. A statistically significant decrease in the mean change in hemoglobin A1c, diastolic blood pressure, fasting blood glucose, and triglyceride levels was observed from the baseline which was −2.3%, −7.75 mmHg, −76.1 mg/dL, and −55.5 mg/dL, respectively. No significant changes in other clinical outcomes were observed.Conclusion:The CAPP model demonstrated a significant reduction in clinical endpoints in patients with T2DM among the high-risk underrepresented population.

Primary Care Providers’ Prediabetes Screening, Testing, and Referral Behaviors

Introduction:Intensive behavioral counseling is effective in preventing type 2 diabetes, and insurance coverage for such interventions is increasing. Although primary care provider referrals are not required for entry to the Centers for Disease Control and Prevention (CDC)–recognized National Diabetes Prevention Program lifestyle change program, referral rates remain suboptimal. This study aims to assess the association between primary care provider behaviors regarding prediabetes screening, testing, and referral and awareness of the CDC-recognized lifestyle change program and the Prevent Diabetes STAT: Screen, Test, and Act Today™ toolkit. Awareness of the lifestyle change program and the STAT toolkit, use of electronic health records, and the ratio of lifestyle change program classes to primary care physicians were hypothesized to be positively associated with primary care provider prediabetes screening, testing, and referral behaviors.Methods:Responses from primary care providers (n= 1,256) who completed the 2016 DocStyles cross-sectional web-based survey were analyzed in 2017 to measure self-reported prediabetes screening, testing, and referral behaviors. Multivariate logistic regression was used to estimate the effects of primary care provider awareness and practice characteristics on these behaviors, controlling for provider characteristics.Results:Overall, 38% of primary care providers were aware of the CDC-recognized lifestyle change program, and 19% were aware of the STAT toolkit; 27% screened patients for prediabetes using a risk test; 97% ordered recommended blood tests; and 23% made referrals. Awareness of the lifestyle change program and the STAT toolkit was positively associated with screening and referring patients. Primary care providers who used electronic health records were more likely to screen, test, and refer. Referring was more likely in areas with more lifestyle change program classes.Conclusions:This study highlights the importance of increasing primary care provider awareness of and referrals to the CDC-recognized lifestyle change program.

The impact of insurance coverage on access to orthopedic spine care.

Poor socioeconomic status is a significant barrier to health care in the United States. Policy changes have attempted to expand insurance coverage in hopes of improving access to care. These policies have prioritized primary care and preventative medicine. Access to specialty care, particularly orthopaedic care, has not received the same attention. This study examines access to orthopaedic spine surgery practices based on type of insurance coverage. Five offices with board certified orthopaedic spine surgeons were randomly contacted from each state. A fictitious patient provided a scripted surgical indication for their appointment. They provided their insurance coverage as either Medicare, Medicaid or a private plan. Timing of the provided appointment was recorded. Any appointment was subsequently canceled so as not to interfere with the practice's scheduling. Two hundred and thirty-four orthopaedic spine surgery practices were contacted between January and June of 2016. Eighty-six percent of practices accepted a private plan without primary care provider (PCP) referral. Greater than 99% of practices accepted privately insured patients if a PCP referral were included. Those with Medicare were able to obtain an appointment from 81% of practices. No practices contacted in this study offered an appointment to the caller with Medicaid. Policy changes have expanded insurance coverage in order to improve access to care for patients of low socioeconomic status. There was a significant barrier to accessing spine care for patients with Medicaid insurance. Access was greatest for those with private insurance followed by those with Medicare. This study demonstrates that there is a significant disparity in ability to access spine specialists despite having insurance coverage.

Maximizing Colonoscopy Completion Rates and Quality: Effect of Direct Primary Care Provider versus Gastroenterology Referral in Colorectal Cancer Screening and Surveillance

Introduction: Colorectal cancer (CRC) is the 2nd leading cause of cancer death in the US and the 4th worldwide. In the US, incidence has declined as a result of screening strategies, since early diagnosis is the most important prognostic factor. CRC screening with colonoscopy provides visualization of precancerous polyps and the opportunity for immediate removal. The effect in CRC mortality is stronger when colonoscopies are of good quality. A good bowel preparation increases diagnostic accuracy and therapeutic safety. Methods: A retrospective review of CRC screening rates in our inner-city community health clinic identified our screening rate was 37%, significantly below the citywide average of 70%. To improve our screening rate, direct colonoscopy referral by Primary Care Provider (PCP) was added to our EMR's order set. We aimed to determine if referral origin, PCP vs Gastroenterologist (GI), impacts completion rates and quality of bowel preparation. We reviewed all referral orders for screening or surveillance colonoscopy at our facility from June 2015 to September 2016. Patients >50 years old were included and those on which colonoscopies were performed for diagnostic purposes were excluded. Results: We identified 313 patients referred for CRC screening or surveillance colonoscopy. Of these, 50.5% were referred by GI and 49.5% by PCP. Baseline characteristics were compared among groups (Table 1). Older patients and those with diabetes or liver disease were more likely to be referred by GI (Table 2). 60% of our patients (N=188) completed their colonoscopy. Patients referred by GI were more likely to complete their colonoscopy compared to those with direct PCP referral, 72.8% vs 47.1% respectively (p < 0.0001). Also, the GI referral group was more likely to have better bowel preparation compared to the direct PCP referral group (p=0.0017).Table: Table. Patient baseline characteristics and characteristics per referral typeTable: Table. Odds of GI referral for colonoscopy evaluation per patients' factorsConclusion: This study is part of the quality improvement endeavors undertaken at our clinic to improve our 37% CRC screening rate. Despite providing direct PCP referrals for colonoscopy, patients referred by GI were more likely to complete their colonoscopy and to have better bowel preparation. We theorize that multiple factors contributed to our findings, including PCP's knowledge of procedure's details and confidence answering questions. Hence, the approach of our PCPs towards CRC screening and surveillance should be explored. Further studies are needed to evaluate interventions as ours and their impact in improving CRC screening rates.

Promoting the Shared-Care Model for Adolescent and Young Adults With Cancer: Optimizing Referrals and Care Coordination With Primary Care Providers.

The "shared-care model" for patients with cancer involves care coordination between primary care providers (PCPs) and oncologists, with the goal of optimizing survivorship care. However, a high proportion of adolescent and young adult (AYA) cancer survivors do not have a PCP. Study objectives were to increase the percentage of AYAs with a PCP documented in the electronic medical record (EMR) via the use of a best practice advisory (BPA) or "stopgap" intervention; to increase communication between providers by the number of routed clinic notes; and to assess oncology providers' attitudes/beliefs about the model and intervention. Data were collected for the 6 months before implementation of the BPA to determine the percentage of AYAs with a PCP and the number of notes routed to providers (time point 1 [T1]). The same data were collected at time point 2 (T2) after the BPA had been implemented for 6 months. Oncology providers participated in an education video module and an online survey at T1 and a survey at T2. At T1, 47.1% of 756 AYAs had a documented PCP in the EMR. At T2, the percentage increased to 55.1% (P<.002). The number of routed notes did not change significantly from T1 to T2. Providers that completed the intervention survey agreed/strongly agreed that the shared-care model is a desirable model of care (T1 = 86%; T2 = 93%) and that a BPA is useful for facilitating PCP referrals (T1 = 76%; T2 = 39%). This BPA is feasible for increasing the percentage of AYAs with a PCP documented in the EMR and could potentially lead to increased PCP referral and communication among providers for the benefit of long-term survivorship care. Providers generally agree with the shared-care model; however, the BPA implementation requires modification.

Establishing an Effective Primary Care Provider Referral Network for the National Diabetes Prevention Program

Establishing an Effective Primary Care Provider Referral Network for the National Diabetes Prevention Program

After-Hours Call Center Triage of Pediatric Head Injury: Outcomes After a Concussion Initiative.

The aim of the study was to characterize referral patterns and medical outcomes of children with head injury triaged by an after-hours call center of a large urban pediatric network, both before and after an institutional concussion initiative. The initiative included a revised call center triage algorithm referring patients with a suspected concussion to see a primary care provider (PCP) within 24 hours, concussion-specific continuing education for medical providers, and a new concussion information Web site. Patients aged 5 to 18 years with head injury using the after-hours call center were identified by retrospective review of electronic medical records before (2011) and after (2012) the initiative. A random 50% sample was taken from each year for further analysis. A total of 127 and 159 eligible patient encounters were randomly selected from 2011 to 2012, respectively. From 2011 to 2012, PCP referrals significantly increased from 7% (95% confidence interval [CI], 4%-13%) to 38% (95% CI, 31%-45%), P < 0.001. Concussion diagnoses also significantly increased from 35% (95% CI, 27%-44%) to 58% (95% CI, 50%-66%), P < 0.001. Emergency department referrals and head computed tomography scans decreased but the differences were not statistically significant. No patients had intracranial injury on computed tomography. Most injuries were not sports related. After an institutional concussion initiative including implementation of a revised head trauma telephone triage algorithm, more head injuries were evaluated by PCPs and more concussions were ultimately diagnosed without an increase in emergency department referrals. Clinicians can benefit from continuing education and infrastructure to aid in initial concussion diagnosis and management.

Role of PCP referral and weight loss in the Hopkins POWER trial

PurposePrimary care providers (PCPs) play an important role in identifying and counseling obese patients to lose weight, but it is unknown whether PCP referral of patients into a weight loss intervention is associated with greater weight loss. The objectives are to determine if PCP referral is associated with greater 1) weight loss, 2) end of study patient–provider relationship quality, and 3) satisfaction and participation rates in the intervention.Methods415 obese patients enrolled in the Hopkins POWER trial from six primary care practices in the Baltimore area. We conducted a secondary analysis of results from the trial using longitudinal mixed-effects model and generalized linear model, adjusting for clinic, sex, age, and race. The primary outcome was absolute weight change from baseline to 24 months. Secondary outcomes were patient–provider relationship quality and satisfaction and participation rates in the intervention.ResultsParticipants in both PCP and non-PCP referral groups lost a similar amount of weight from baseline to 24 months. PCP referral was not significantly associated with percentage of completed coach contacts, web logins, and satisfaction with trial, but was associated with higher end of study patient–provider relationship quality (p = 0.007).ConclusionsOur study represents the first of its kind to examine the role of PCP referral of patients into a weight loss trial. While we did not find evidence that PCP referral is associated with increased weight loss, further research is needed to determine how PCPs can use their relationship with patients to promote weight loss and enhance intervention effects.

An expanded delivery model for outpatient burn rehabilitation.

Despite the numerous multidisciplinary services burn centers provide, a number of challenges to obtaining optimal outcomes exist. The goal of this study was to overcome the barriers to effective burn rehabilitation by utilizing an expanded care coordinator (ECC) to supplement the existing outpatient services. In this between-group, single-blind, randomized, controlled trial, the control group (n = 41) received standard outpatient care and the experimental group (n = 40) received additional services provided by the ECC, including telephone calls at set intervals (24 hours postdischarge, 2, 4, 8, 12 weeks postdischarge and 5, 7, 9 months postdischarge). The ECC was trained in motivational interviewing, crisis intervention, and solution-focused counseling. He assisted patients before and after each clinic visit, coordinated outpatient services in their geographic area (physical and occupational therapy, counseling, primary care provider referrals, etc.), and helped develop problem-solving approaches to accomplish individualized goals. Outcome measures included patient identified goals utilizing the goal attainment scale, the urn-specific health scale-brief, the Short Form 12, a patient satisfaction survey, and a return to work survey. The average subject age was 43 years (SD = 16.9) with a mean TBSA of 19% (SD = 18.8). The average length of hospitalization was 36 days (SD = 42.9). The patient and injury characteristics were similar between the study groups. For the experimental group, 33% completed seven calls, with 23% completing all the eight calls. All were assessed using general linear models and were adjusted for sex, age, length of hospitalization, urban vs rural area of residence, %TBSA burn, and ethnicity. There was no difference between the control and experimental groups for any of the outcome measures at either 6 or 12 months postburn. No differences in outcomes between the groups were found. All participants appreciated the individualized goal setting process that was used as an outcome measure and this may have accounted for the similar outcomes in both the groups. (The measure may have been more of an intervention, thus contributing to the strength of the control group.) Although most patients with burn injuries may not need an intervention that is this intensive, a subset of patients at higher risk or with more severe injuries may benefit from more intensive and personalized services. Future research should examine the benefits of individual goal setting processes for all the patients and also attempt to identify those patients most at risk for poorer outcomes and therefore, likely to benefit of more intensive personalized services.

Influence of colonoscopy quality measures on patients' colonoscopist selection.

The Affordable Care Act emphasizes the use of quality metrics and greater patient understanding of health-care options and access to physician performance data. The objectives of this study were to determine patients' familiarity with colonoscopy quality measures (CQMs) and their influence on patient selection of a colonoscopist. A prospective survey of patients before screening or surveillance colonoscopy at university hospital, community hospital, and ambulatory procedure center endoscopy units was performed from 2011 to 2012. Among the 417 participants, 20% (85/417) researched their physician's rating. The rates of familiarity with CQM were 88 % (353/402) for adequate bowel preparation, 30% (118/398) for adenoma detection rate (ADR), 26% (102/397) for cecal intubation rate, and 21% (82/394) for greater-than-6-min withdrawal time. Ninety-six percent (366/386) believed that colonoscopists' reporting of ADR to other physicians was important or very important. In selecting a colonoscopist, primary care provider referral was ranked as the first or second-most important of four factors in 87% (339/391). Even among patients who responded "it is very important" to report CQM to other doctors and patients, none ranked CQM as the most important factor in selecting a colonoscopist. Patient awareness of CQM, other than adequate bowel preparation, was low. Quality measure reporting is important to patients, but primary care provider referral was the most important factor in colonoscopist selection. This suggests that primary care providers, as well as patients, are important to include in educational strategies regarding quality metrics.