Primary Care Sites Research Articles

80-LB: Hypoglycemia in People with Type 2 Diabetes Using Premixed (Biphasic) Insulin

Hypoglycemia is under-reported by many patients; but the time in hypoglycemia among patients with type 2 diabetes (T2D) using pre-mixed (biphasic) insulin is not clear. This pilot study aimed to determine the amount of time in hypoglycemia in this patient cohort. The study included people with T2D, aged 18 or over, treated with pre-mixed (biphasic) insulin for at least 6 months with their most recent HbA1c <7.5% (58 mmol/mol) recorded in medical notes in the last 12 months. Pregnant patients were excluded, as were patients on dialysis. A total of 43 participants (65.1% male) from 12 primary and secondary care sites in the UK enrolled in the 2-week single arm study using the FreeStyle Libre Pro Flash Glucose Monitoring SystemTM. Mean HbA1c was 6.9±0.8% (52.1±8.3 mmol/mol), age was 68.8±8.3 years, BMI was 35.0±9.2 kg/m2, average duration of pre-mixed insulin was 6.8±4.8 years with a mean daily dose of 53.4±40.7 units (mean±SD). The number of blood glucose tests performed per day (self-reported) was 1.9±1.1. Time in hypoglycemia <70 mg/dL (3.9 mmol/L) was 1.35±1.56 hours per day, biological hypoglycemia was experienced by 34 patients. Approximately half of the time in hypoglycemia (<70 mg/dL [3.9 mmol/L]; 0.82±1.06 hours) was during night time hours (23:00 to 06:00). Time in hyperglycemia >180 mg/dL (10.0 mmol/L) was 3.55±3.07 hours per day, which mostly occurred was during daytime hours (06:00 to 23:00) (3.15±2.83 hours per day) (mean±SD). Five anticipated sensor insertion site symptoms were experienced by four participants: erythema (n=2 [1 slight pink, 1 well-defined redness]), pain (n=1), bruising (n=1) and bleeding (n=1), all were mild in severity. This population, with HbA1c in target range, have a greater amount of hypoglycemia than the International Consensus and ADA targets of <1 hour per day, excursions occurred both during the day and at night. Further improvements on this level of glycemic control is challenging for this type of insulin therapy due to further escalation of the risk of nocturnal hypoglycemia. Disclosure I.R. Idris: None. N. Annamalai: None. T. Aung: None. I. Binnian: None. F.W. Gibb: None. M.I. Malik: None.

824-P: Quality of Behavior Change Action Plans Created in Primary Care Settings as a Tool for Patient Involvement in Type 2 Diabetes Care

Objectives: Action plans based on patient reported outcomes (PROs) made in consultation by adults with type 2 diabetes (T2D) and their health care team have been proposed as a tool to improve clinical outcomes. The aim is to evaluate the quality of action plans. Methods: A two-arm cluster-randomized trial comparing Connection to Health (CTH) and Enhanced Engagement CTH (EE-CTH) in 12 primary care sites in the San Francisco Bay Area. Adults with T2D filled out a health survey prior to consultation to collect PROs. Action plans made in consultation focused on unhealthy behavior detected by the survey. Providers in EE-CTH were additionally trained in motivational interviewing and relationship building skills. Action plan quality was rated using an adapted version of the GET-D coding system (dual coding of 20%, IRR >80%), and examined for associations with intervention, patient demographics and PROs. Results: Overall quality of action plans was moderate-high with a mean score of 14.22 (SD=4.07) on a 0-20 quality scale (n=700). Significantly higher quality plans were created in CTH (M=14.87, SD=3.92) compared to EE-CTH (M=13.50, SD=4.12) (t(698)=4.50, p<.001). Correlations with PROs and patient demographics were calculated with Pearson’s (r) or Spearman’s (rs) correlation. Higher patient health literacy and confidence in carrying out the plan were positively related to quality of action plans (rs =.089, p=.018) (rs =.138, p<.001), whereas gender, age, language, race, level of education, depression, and social determinants of health (SDH) were unrelated to action plan quality (p=n.s.). Discussion: Both CTH and EE-CTH resulted in moderate-high quality action plans, but considerable quality variability was seen across patients. Action plan quality was significantly higher in CTH compared to EE-CTH. Results suggest no link to most patient demographics and PROs. However, health literacy and confidence level are positively related to action plan quality. Disclosure P.H. Kjaer: None. M. Dedhia: None. J. Parra: Employee; Self; Behavioral Diabetes Institute. L. Fisher: None. M.B. Potter: None. N. Ejskjaer: None. S.E. Skovlund: None. D.M. Hessler: Consultant; Self; Eli Lilly and Company. Funding National Institutes of Health (DK108039)

Abstract B115: Bridging the gap: Characterizing transportation barriers in rural southern Illinois

Abstract Introduction: Despite the widespread availability of preventative tests and procedures, colorectal cancer (CRC) remains one of the leading causes of cancer deaths in the United States. While national CRC screening rates have increased, they have languished in rural areas. Routine screening is most effective in reducing CRC mortality when accompanied by timely diagnostic follow-up, but transportation barriers are a hindrance to continuity of care. Distances between homes and providers exacerbate the problem in rural areas. We examined reported transportation barriers in seven counties at both patient and clinic levels as part of a collaborative endeavor with a rural health system in Southern Illinois to characterize current conditions and design multilevel interventions to increase screening and follow-up in rural populations. Methods: Semistructured interviews and focus groups were conducted with six patients and forty providers across eleven primary care sites and two colonoscopy providers. Interview domains included screening barriers and facilitators. Interview transcripts and field notes underwent text analysis with inductive codes. Themes such as financial resources, transport reliability, and time constraints were used to create subcategories and refine analysis. Transportation was discussed at multiple levels of influence in screening decisions, planning, and completion. Here we present a detailed analysis of how distance and transportation were discussed. Results: Limited regional provider availability dictates that medical visits require long travel times for many patients. Patients described travel distance and discomfort during transit to colonoscopies as obstacles. Those who had an easier time arranging transportation relied on social support, but encountered issues coordinating time off work. Staff had varying knowledge of available transportation and clinics had different levels of resources to support patients. Travel assistance included referral to transport services, public transport vouchers, and reimbursement. Some clinics did not offer travel assistance, or only provided help in cases of urgent medical need. Outsourced transport service reliability was variable and often required advance notice, which affected colonoscopy scheduling. Some sites that offered transport assistance cited poor communication among clinic staff and role specialization as reasons that patient needs were not met. Discussion: Patient need communication and provider and staff education regarding community transportation present opportunities to reduce transportation barriers. Evidence-based interventions such as dedicated non-emergency medical transport services are needed to address reliability, infrastructure needs, and the hardships of taking time off work for appointments. In designing multilevel interventions, researchers must consider differences in financial and human resources across sites and limited staff and patient time. Citation Format: Chanelle Y. Chua, Julia Maki, Marci Moore-Connelley, Jean Hunleth, Kevin Oestmann, Sonya Izadi, Liz Rolf, Graham Colditz, Aimee James. Bridging the gap: Characterizing transportation barriers in rural southern Illinois [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr B115.

Lung Cancer Staging at Diagnosis in the Veterans Health Administration: Is Rurality an Influencing Factor? A Cross-Sectional Study.

PurposeTo evaluate the association between rurality and lung cancer stage at diagnosis.Methods:We conducted a cross-sectional study using Veterans Health Administration (VHA) data to identify veterans newly diagnosed with lung cancer between October 1, 2011 and September 30, 2015. We defined rurality, based on place of residence, using Rural-Urban Commuting Area (RUCA) codes with the subcategories of urban, large rural, small rural, and isolated. We used multivariable logistic regression models to determine associations between rurality and stage at diagnosis, adjusting for sociodemographic and clinical characteristics. We also analyzed data using the RUCA code for patients’ assigned primary care sites and driving distances to primary care clinics and medical centers.Findings:We identified 4,220 veterans with small cell lung cancer (SCLC) and 25,978 with non-small cell lung cancer (NSCLC). Large rural residence (compared to urban) was associated with early-stage diagnosis of NSCLC (OR = 1.12; 95% CI: 1.00–1.24) and SCLC (OR = 1.73; 95% CI: 1.18–1.55). However, the finding was significant only in the southern and western regions of the country. White race, female sex, chronic lung disease, higher comorbidity, receiving primary care, being a former tobacco user, and more recent year of diagnosis were also associated with diagnosing early-stage NSCLC. Driving distance to medical centers was inversely associated with late-stage NSCLC diagnoses, particularly for large rural areas.Conclusions:We did not find clear associations between rurality and lung cancer stage at diagnosis. These findings highlight the complex relationship between rurality and lung cancer within VHA, suggesting access to care cannot be fully captured by current rurality codes.

0929 Caregiver-Reported Versus Clinician-Documented Child Sleep Problems and Sleep-Related Health Behaviors in Primary Care

Abstract Introduction Sleep problems are highly prevalent in early childhood but often under-identified in pediatric primary care. This study identified the prevalence of caregiver-reported versus primary care provider (PCP)-documented sleep problems and sleep-related health behaviors in young children presenting to well child visits (WCVs). Methods Caregivers (85.4% mothers) of 198 young children (2-5 years, M = 3.3, 53.7% female, 62.9% Black) presenting to urban (74.1%) and suburban (25.9%) primary care sites for well child visits (WCVs) completed research surveys on child behavioral sleep problems, snoring, and sleep-related health behaviors (e.g., caffeine consumption) on the day of their child’s WCV. Electronic medical record review was used to identify the rate of PCP-documented sleep problems and related recommendations in the WCV progress note. Results Fifteen percent of caregivers reported a child sleep problem according to questionnaire data, which did not significantly differ from the 12.0% of children with a PCP-documented sleep problem in the WCV progress note (p = .31). However, significantly more caregivers (28.3%) reported bedtime difficulties (resistance; tantrums) on questionnaires (p <.001), which were not captured in the 12.0% of WCVs noting sleep problems. A total of 8% of WCVs included child sleep recommendations. Child snoring was reported by 17.0% of caregivers, but was less frequently documented in WCVs (4.5%, p <.001). Although many caregivers reported poor child sleep-related health behaviors, including daily child caffeine consumption (21.1%) and bedroom electronics (62.9%), significantly fewer PCPs documented these issues (caffeine: 2.0%; electronics: 6.6%) or related recommendations (decrease caffeine: 1.0%; eliminate electronics: 3.5%) in the progress note (all p-values <.001). Conclusion Although caregiver-endorsed child sleep problems on surveys did not differ from PCP-documented concerns, there are gaps in documenting other problematic sleep-related health behaviors, such as caffeine consumption and electronics use. More resources to address sleep-related health behaviors, as well as sleep problems, in pediatric primary care are needed. Support Sleep Research Society Foundation and K23HD094905 (AAW)

Effect of Antihypertensive Medication Reduction vs Usual Care on Short-term Blood Pressure Control in Patients With Hypertension Aged 80 Years and Older

Deprescribing of antihypertensive medications is recommended for some older patients with polypharmacy and multimorbidity when the benefits of continued treatment may not outweigh the harms. This study aimed to establish whether antihypertensive medication reduction is possible without significant changes in systolic blood pressure control or adverse events during 12-week follow-up. The Optimising Treatment for Mild Systolic Hypertension in the Elderly (OPTIMISE) study was a randomized, unblinded, noninferiority trial conducted in 69 primary care sites in England. Participants, whose primary care physician considered them appropriate for medication reduction, were aged 80 years and older, had systolic blood pressure lower than 150 mm Hg, and were receiving at least 2 antihypertensive medications were included. Participants enrolled between April 2017 and September 2018 and underwent follow-up until January 2019. Participants were randomized (1:1 ratio) to a strategy of antihypertensive medication reduction (removal of 1 drug [intervention], n = 282) or usual care (control, n = 287), in which no medication changes were mandated. The primary outcome was systolic blood pressure lower than 150 mm Hg at 12-week follow-up. The prespecified noninferiority margin was a relative risk (RR) of 0.90. Secondary outcomes included the proportion of participants maintaining medication reduction and differences in blood pressure, frailty, quality of life, adverse effects, and serious adverse events. Among 569 patients randomized (mean age, 84.8 years; 276 [48.5%] women; median of 2 antihypertensive medications prescribed at baseline), 534 (93.8%) completed the trial. Overall, 229 (86.4%) patients in the intervention group and 236 (87.7%) patients in the control group had a systolic blood pressure lower than 150 mm Hg at 12 weeks (adjusted RR, 0.98 [97.5% 1-sided CI, 0.92 to ∞]). Of 7 prespecified secondary end points, 5 showed no significant difference. Medication reduction was sustained in 187 (66.3%) participants at 12 weeks. Mean change in systolic blood pressure was 3.4 mm Hg (95% CI, 1.1 to 5.8 mm Hg) higher in the intervention group compared with the control group. Twelve (4.3%) participants in the intervention group and 7 (2.4%) in the control group reported at least 1 serious adverse event (adjusted RR, 1.72 [95% CI, 0.7 to 4.3]). Among older patients treated with multiple antihypertensive medications, a strategy of medication reduction, compared with usual care, was noninferior with regard to systolic blood pressure control at 12 weeks. The findings suggest antihypertensive medication reduction in some older patients with hypertension is not associated with substantial change in blood pressure control, although further research is needed to understand long-term clinical outcomes. EudraCT Identifier: 2016-004236-38; ISRCTN identifier: 97503221.

MON-LB105 Resident Obesity Management: Comfort Correlates With Action

The projected prevalence of obesity in the US is 50% by 2030.1 Little data exists on resident physician obesity management in their primary care clinics.2 We aimed to explore internal medicine (IM) resident comfort, knowledge, and treatment practice of obesity in primary care.IM residents at one academic medical center (N=125), at 5 primary care sites were anonymously surveyed about knowledge, comfort, and practice behaviors around obesity management. In this exploratory analysis, respondents self-reported comfort with lifestyle counselling and weight management medication (WMM) prescription on 4-point Likert scales; scores were combined into an overall Comfort Score (CS). Correlation analysis (Pearson’s correlation) compared CS with the following Clinical Actions: referral to lifestyle specialists, lifestyle counseling, WMM prescription, and bariatric surgery referral.The response rate was 70/125 (56%). Most residents (91%) reported discomfort with prescribing WMMs and most (84%) had never prescribed one. While most residents (81%) were “comfortable” or “somewhat comfortable” with lifestyle counseling, only 33% reported consistently providing it. Of the 31% of residents that correctly identified indications for bariatric surgery, only 9% reported referring patients they considered appropriate for surgery. Notably, a higher CS was significantly correlated with more frequent bariatric surgery referrals (r = 0.29; p = 0.015), lifestyle counselling (r = 0.33; p = 0.004), WMM prescription (r = 0.32; p=0.006), and lifestyle specialist referral (r = 0.25; p = 0.035). Reported barriers to lifestyle counseling were lack of time (93%), poor familiarity with resources (50%), and lack of training in motivational interviewing (36%). Barriers to WMM prescription were unfamiliarity with the medications (84%) and side effect concerns (61%). Finally, 90% desired more training in pharmacotherapy, and 77% wanted more information on referral processes for surgical and medical interventions.Most residents surveyed do not feel adequately prepared to provide evidence-based management of obesity via lifestyle changes counseling, WMM prescription, or specialty care referral. Comfort and knowledge of system processes/resources and WMMs are critical to resident management of obesity. These are potential targets for educational intervention in residency curricula that may improve care for patients with obesity.Citations: 1. Ward ZJ, Bleich SN, Cradock AL, et al. Projected U.S. State-Level Prevalence of Adult Obesity and Severe Obesity. N Engl J Med. 2019;381(25):2440-2450. doi:10.1056/NEJMsa19093012. Huang J, Yu H, Marin E, Brock S, Carden D, Davis T. Physicians’ Weight Loss Counseling in Two Public Hospital Primary Care Clinics. Acad Med. 2004. doi:10.1097/00001888-200402000-00012

Introduction of sacubitril/valsartan in primary care follow-up of heart failure: a prospective observational study (THESEUS).

AimsSwitch from angiotensin converting enzyme inhibitor treatment to sacubitril/valsartan (sac/val) is associated with benefit in heart failure with reduced ejection fraction (HFrEF). Reports on management of this switch are largely based on randomized controlled trials, retrospective analyses, and hospital‐based care, while patients with chronic heart failure (CHF) are frequently followed‐up in primary care. The THESEUS study aimed to characterize the transition to sac/val and early maintenance period of HFrEF in primary care.Method and resultsTHESEUS was a prospective, observational, non‐interventional study, performed at primary care sites throughout Switzerland. Patient characteristics, sac/val transition, and maintenance were reported at study enrolment and approximately 3 and 6 months after sac/val initiation. The primary endpoint was achievement of 200 mg BID sac/val with maintenance for ≥12 weeks. Secondary outcomes included dosing regimens, healthcare utilization in the 6 months prior to sac/val initiation and during the study, patient well‐being, safety, and tolerability. Fifty‐eight patients with CHF were enrolled from 45 primary care centres. Six patients were excluded, and 19 achieved the primary endpoint (36.5%, Achievers). Non‐Achievers underwent fewer titration steps than Achievers (1.9 ± 0.9 vs. 3.1 ± 1.4). In both groups, patient well‐being improved and the percentage of New York Heart Association III patients decreased. Healthcare utilization decreased (19% vs. 30.8% in the 6 months pre‐enrolment period). The most frequent reasons for target dose non‐achievement were asymptomatic and symptomatic hypotension (15.3% and 12.1%, respectively).ConclusionsResults from THESEUS suggest that transition to sac/val is manageable in primary care, with a safety profile corresponding to reports from specialized heart failure care.

Primary Care Physician Factors Associated with Inbox Message Volume

The objective of this study was to better understand the relationship between panel size, full-time status, and estimated socioeconomic status of a patient panel with types and number of primary care clinician inbox messages. The study used data from the Epic Signal database to examine inbox volume and types of messages for 86 primary care clinicians at 19 primary care sites. We measured correlations and performed multiple regression analysis to understand the relationship between inbox volume and types of messages and 3 factors: panel size, full-time status, and estimated socioeconomic status of patient panels. The study found positive correlation between the number of messages and panel size, full-time status, and estimated socioeconomic status of patient panels. The number of patient portal messages generated from patient panels with higher socioeconomic status accounted for the positive correlation in total inbox messages and that factor. These findings contribute to our understanding of primary care workload, specifically as it relates to panel size, full-time status, and patient panel socioeconomic status. Increase in clinical time or panel size needs to come with trained team members or additional time to address inbox messages.

Abstract 326: De-escalation of Aspirin for Primary Prevention of Atherosclerotic Cardiovascular Disease in the Primary Care Setting

Background: For several decades, aspirin (ASA) has been used as primary prevention against ASCVD in adults. In 2018, three major trials (ASPREE, ARRIVE, and ASCEND) redefined our understanding of ASA and showed a net harm rather than benefit when ASA is used for primary prevention of ASCVD. These trials greatly impacted the current 2019 ACC/AHA Primary Prevention Guidelines, which now recommend the following: (a) Low-dose ASA might be considered for primary prevention of ASCVD in select higher ASCVD adults aged 40-70 years who are not at increased bleeding risk and (b) Low-dose ASA should not be administered for primary prevention of ASCVD among adults over the age of 70. The objective of the project was to re-evaluate the use and indications of ASA in our patient population and appropriately remove ASA when no longer indicated. With proper resident education and intervention, we hypothesized that we could reduce the number of inappropriate ASA prescriptions by 10%. Methods/Results: During a 6-month observational period, 254 patients at Ryan Health/Adair (a federally qualified health center which also serves as a primary care site for an internal medicine residency clinic) were found to be taking ASA, and of those 140 patients were found to be on ASA for primary ASCVD prevention. The interventions included implementation of an algorithm that reflected the most up to date guidelines. The intervention lasted 3 months. Any patient that was found to be on ASA inappropriately was discontinued. During this period ASA was successfully removed from 25 patients’ medication list, with an overall reduction by 17.9%. Of the 25 patients, 20% were over the age of 70, 80% were between the ages of 40-70, and 48% were male. In the remaining 115 patients in which ASA was continued, 27.8% were over the age of 70, 69.6% were between the ages of 40-70, 2.6% were under the age of 40, and 49.6% were male. The successful ASA removal group comprised of 44% Hispanic/Latino, 44% African American, 4% White, and 8% Unidentified. The ASA non-removal group comprised of 34.8% Hispanic/Latino, 44.3% African American, 5.2% White, and 15.7% Unidentified. Additionally, 80% of the patient taken off ASA spoke English, while only 69.6% of patient in the ASA non-removal group spoke English. Conclusions: Several differences were found between the two groups. Some key limitations between the two groups included (a) unclear past medical history leading to physicians being uncomfortable with removing ASA, (b) inability to speak in patient’s native language to facilitate proper discussion about ASA removal, and (c) patient refusal to stop ASA. Next steps include further cardiac testing (CT coronaries, stress test) to better characterize the risk of patients with unclear history. However, overall, there is likely a net benefit in prioritizing ASA removal in the primary care setting now that it is no longer recommended in key populations.

Agreement between Self-Reported "Ideal" and Currently Used Contraceptive Methods among Women Veterans Using the Veterans Affairs Healthcare System.

Women veterans who use the Veterans Affairs Healthcare System theoretically have access to the full range of contraceptive methods. This study explores match between currently used and self-reported "ideal" methods as a potential marker of contraceptive access and preference matching. This mixed methods study uses data from a nationally representative survey of reproductive-aged women veterans who use the Veterans Affairs Healthcare System for primary care, including 979 participants at risk of unintended pregnancy. Women reported all contraceptive methods used in the past month and were asked, "If you could choose any method of contraception or birth control to prevent pregnancy, what would be your ideal choice?" and selected a single "ideal" method. If applicable, participants were additionally asked, "Why aren't you currently using this method of contraception?" We used adjusted logistic regression to identify patient-, provider-, and system-level factors associated with ideal-current method match. We qualitatively analyzed open-ended responses about reasons for ideal method nonuse. Overall, 58% were currently using their ideal method; match was greatest among women selecting an IUD as ideal (73%). Non-White race/ethnicity (adjusted odds ratio, 0.68; 95% confidence interval, 0.52-0.89) and mental illness (adjusted odds ratio, 0.69; 95% confidence interval, 0.52-0.92) were negatively associated with ideal-current match in adjusted analyses; the presence of a gynecologist at the primary care site was associated with an increased odds of match (adjusted odds ratio, 1.35; 95% confidence interval, 1.03-1.75). Modifiable barriers to ideal method use were cited by 23% of women, including access issues, cost concerns, and provider-level barriers; 79% of responses included nonmodifiable reasons for mismatch including relationship factors and pregnancy plans incongruent with ideal method use, suggesting limitations of our measure based on differential interpretation of the word "ideal." Many women veterans are not currently using the contraceptive method they consider ideal. Results emphasize the complexity of contraceptive method selection and of measuring contraceptive preference matching.

Impact of a "Chart Closure" Hard Stop Alert on Prescribing for Elevated Blood Pressures Among Patients With Diabetes: Quasi-Experimental Study.

BackgroundUniversity of California at Los Angeles Health implemented a Best Practice Advisory (BPA) alert for the initiation of an angiotensin-converting enzyme inhibitor (ACEI) or angiotensin-receptor blocker (ARB) for individuals with diabetes. The BPA alert was configured with a “chart closure” hard stop, which demanded a response before closing the chart.ObjectiveThe aim of the study was to evaluate whether the implementation of the BPA was associated with changes in ACEI and ARB prescribing during primary care encounters for patients with diabetes.MethodsWe defined ACEI and ARB prescribing opportunities as primary care encounters in which the patient had a diabetes diagnosis, elevated blood pressure in recent encounters, no active ACEI or ARB prescription, and no contraindications. We used a multivariate logistic regression model to compare the change in the probability of an ACEI or ARB prescription during opportunity encounters before and after BPA implementation in primary care sites that did (n=30) and did not (n=31) implement the BPA. In an additional subgroup analysis, we compared ACEI and ARB prescribing in BPA implementation sites that had also implemented a pharmacist-led medication management program.ResultsWe identified a total of 2438 opportunity encounters across 61 primary care sites. The predicted probability of an ACEI or ARB prescription increased significantly from 11.46% to 22.17% during opportunity encounters in BPA implementation sites after BPA implementation. However, in the subgroup analysis, we only observed a significant improvement in ACEI and ARB prescribing in BPA implementation sites that had also implemented the pharmacist-led program. Overall, the change in the predicted probability of an ACEI or ARB prescription from before to after BPA implementation was significantly greater in BPA implementation sites compared with nonimplementation sites (difference-in-differences of 11.82; P<.001).ConclusionsA BPA with a “chart closure” hard stop is a promising tool for the treatment of patients with comorbid diabetes and hypertension with an ACEI or ARB, especially when implemented within the context of team-based care, wherein clinical pharmacists support the work of primary care providers.

A system uptake analysis and GUIDES checklist evaluation of the Electronic Asthma Management System: A point-of-care computerized clinical decision support system.

ObjectiveComputerized clinical decision support systems (CCDSSs) promise improvements in care quality; however, uptake is often suboptimal. We sought to characterize system use, its predictors, and user feedback for the Electronic Asthma Management System (eAMS)—an electronic medical record system–integrated, point-of-care CCDSS for asthma—and applied the GUIDES checklist as a framework to identify areas for improvement.Materials and MethodsThe eAMS was tested in a 1-year prospective cohort study across 3 Ontario primary care sites. We recorded system usage by clinicians and patient characteristics through system logs and chart reviews. We created multivariable models to identify predictors of (1) CCDSS opening and (2) creation of a self-management asthma action plan (AAP) (final CCDSS step). Electronic questionnaires captured user feedback.ResultsOver 1 year, 490 asthma patients saw 121 clinicians. The CCDSS was opened in 205 of 1033 (19.8%) visits and an AAP created in 121 of 1033 (11.7%) visits. Multivariable predictors of opening the CCDSS and producing an AAP included clinic site, having physician-diagnosed asthma, and presenting with an asthma- or respiratory-related complaint. The system usability scale score was 66.3 ± 16.5 (maximum 100). Reported usage barriers included time and system accessibility.DiscussionThe eAMS was used in a minority of asthma patient visits. Varying workflows and cultures across clinics, physician beliefs regarding asthma diagnosis, and relevance of the clinical complaint influenced uptake.ConclusionsConsidering our findings in the context of the GUIDES checklist helped to identify improvements to drive uptake and provides lessons relevant to CCDSS design across diseases.

Evaluating the prevalence of child psychosocial concerns in rural primary care.

Child psychosocial concerns in rural areas are assumed to be greater than national averages due to mental health provider shortages, however, there is minimal empirical support for this claim. The present study aimed to replicate findings showing a higher prevalence of child psychosocial concerns in rural areas. In addition, this study evaluated six distinct definitions of "rural" to determine whether the operational definition of rurality was associated with prevalence of psychosocial concerns.Caregivers presenting with their child at 8 pediatric primary care sites (N = 2,672) completed a demographic questionnaire and the Pediatric Symptom Checklist (PSC). Logistic regression models tested associations between operational definitions of rurality and prevalence of clinically significant child psychosocial concerns. Multiple logistic regression models were used to test additional independent effects of maternal education level while controlling for child age.The effects of rurality on prevalence of clinically significant psychosocial concerns were inconsistent across the six measures of rurality; when significant, however, effects were small and in the opposite direction than hypothesized.These findings highlight discrepancies in results based on disparate operational definitions and measures of rurality. When rurality was associated with child psychosocial concerns, children in more highly populated areas reported more psychosocial concerns than children in smaller rural areas.

A Mobile App to Prevent Depression Among Low-Income Primary Care Patients in the Dominican Republic: Sociocultural Adaptations.

Introduction: Mental health mobile apps (MHapps) can provide depression treatment to people worldwide who do not have access to care, but few apps are culturally targeted to the population. In this series of studies, we described sociocultural considerations of MHapp development, and we explored participants' perceptions of acceptability, usability, and cultural relevance of the MHapp. Method: Individual interviews were conducted in three separate primary care sites in the Dominican Republic among convenience samples of staff and patients (n = 23, 18, and 21, respectively), using mixed methods of data collection. Results: Modifications were made during the iterative design process to reflect user preferences, which included a female gendered voice, the addition of animations, and changes to the psychoeducational content. Discussion: Primary care patients reported strong interest in MHapps due to its convenience, privacy, and affordability. Our findings support the necessity of detailed examination of user preferences to develop culturally congruent MHapp psychoeducation.

Evaluation of Point-of-Care Decision Support for Adult Acne Treatment by Primary Care Clinicians

Acne is a common reason for referral to dermatologists from primary care clinicians. We previously modeled the impact of algorithm-based acne care in reducing dermatology referrals, missed appointments, and treatment delays. To prospectively evaluate the downstream outcomes following a real-time, algorithm-based electronic decision-support tool on the treatment of patients referred for acne. This prospective cohort study included 260 treatment-naive patients referred to a dermatologist for the chief concern of acne, as well as the referring primary care clinicians, at 33 primary care sites affiliated with Brigham and Women's Hospital from March 2017 to March 2018. We developed and implemented a decision-support tool into the electronic medical record system at an academic medical center. The algorithm identified patients referred to a dermatologist who had not previously been treated for acne and offered guideline-based recommendations for treatment via a real-time notification. Treatment modification by referring clinicians. Of 260 patients referred for acne, 209 (80.4%) were women, 146 (56.1%) were non-Hispanic white, and 236 (90.8%) listed English as the preferred language. Patients had a median (quartile 1-quartile 3) age of 28.8 years (24.4-35.1 years) and 185 of 260 had private insurance (71.1%). In total, the algorithm was associated with cancellation of the initial referral in 35 of 260 (13.5%) instances and treatment initiation by the referring clinician in 51 of 260 (19.6%) instances. This decision-support algorithm was associated with a modest reduction in rates of acne-related referrals to dermatologists, and an increased likelihood of treatment initiation by the referring clinician.

Evaluating the impact of onsite diabetes education teams in primary care on clinical outcomes

BackgroundTo evaluate the impact of integrating diabetes education teams in primary care on glycemic control, lipid, and blood-pressure management in type 2 diabetes patients.MethodsA historical cohort design was used to assess the integration of teams comprising nurse and dietitian educators in 11 Ontario primary-care sites, which delivered individualized self-management education. Of the 771 adult patients with A1C ≥ 7% recruited, 487 patients attended appointments with the diabetes teams, while the remaining 284 patients did not. The intervention’s primary goal was to increase the proportion of patients with A1C ≤7%. Secondary goals were to reduce mean A1C, low-density lipoprotein, total cholesterol-high density lipoprotein, and diastolic and systolic blood pressure, as recommended by clinical-practice guidelines.ResultsAfter 12 months, a higher proportion of intervention-group patients reached the target for A1C, compared with the control group. Mean A1C levels fell significantly among all patients, but the mean reduction was larger for the intervention group than the control group. Although more intervention-group patients reached targets for all clinical outcomes, the between-group differences were not statistically significant, except for A1C.ConclusionsNurse and dietitian diabetes-education teams can have a clinically meaningful impact on patients’ ability to meet recommended A1C targets. Given the study’s historical cohort design, results are generalizable and applicable to day-to-day primary-care practice. Longer follow-up studies are needed to investigate whether the positive outcomes of the intervention are sustainable.

VA-Community Dual Care: Veteran and Clinician Perspectives.

Many veterans receive care in both community settings and the VA. Recent legislation has increased veteran access to community providers, raising concerns about safety and coordination. This project aimed to understand the benefits and challenges of dual care from the perceptions of both the Veterans their clinicians. We conducted surveys and focus groups of veterans who use both VA and community care in VT and NH. We also conducted a web-based survey and a focus group involving primary care clinicians from both settings. The main measures included (1) reasons that veterans seek care in both settings; (2) problems faced by veterans and clinicians; (3) association of health status and ease of managing care with sites of primary care; and (4) association of veteran rurality with dual care experiences. The primary reasons veterans reported for using both VA and community care were (1) for convenience, (2) to access needed services, and (3) to get a second opinion. Veterans reported that community and VA providers were informed about the others' care more than half the time. Veterans in isolated rural towns reported better overall health and ease of managing their care. VA and community primary care clinicians reported encountering systems problems with dual-care including communicating medication changes, sharing lab and imaging results, communicating with specialists, sharing discharge summaries and managing medication renewals. Both Veterans and their primary clinicians report substantial system issues in coordinating care between the VA and the community, raising the potential for significant patient safety and Veteran satisfaction concerns.

Comparison of timeline follow-back self-report and oral fluid testing to detect substance use in adult primary care patients

BackgroundTimeline Follow-back (TLFB) interviews using self-report are often used to assess substance use. Oral fluid testing (OFT) offers an objective measure of substance use. There are limited data on the agreement between TLFB and OFT. MethodsIn this secondary analysis from a multisite study in five primary care sites, self-reported TLFB and OFT data collected under confidential conditions were compared to assess concordance (N=1799). OFT samples were analyzed for marijuana, heroin, cocaine, and non-medical use of prescription opioids. Demographic differences in discordance relative to TLFB and OFT concordant results for marijuana, the only substance with an adequate sample size in this analysis, were examined using multinomial logistic regression. ResultsOverall concordance rates between TLFB and OFT were 94.9 % or higher for each substance, driven by large subgroups with no use. Among participants with discordant use, marijuana was the only substance with lower detection on OFT than self-report (27.6 % OFT-positive only vs 32.2 % TLFB-positive only), whereas cocaine (65.6 % vs 8.6 %), prescription opioids (90.4 % vs 6.0 %), and heroin (40.7 % vs 26.0 %) all had higher detection via OFT than TLFB. Participants who reported marijuana use but had a negative OFT were more likely to be younger, Hispanic, and White compared to those with TLFB and OFT concordant positive results. ConclusionsTLFB and OFT show disparate detection of different substances. Researchers should consider the implications of using either self-report or oral fluid testing in isolation, depending on the substance and collection setting. Triangulating multiple sources of information may improve detection of drug use.

Daily emollient during infancy for prevention of eczema: the BEEP randomised controlled trial

SummaryBackgroundSkin barrier dysfunction precedes eczema development. We tested whether daily use of emollient in the first year could prevent eczema in high-risk children.MethodsWe did a multicentre, pragmatic, parallel-group, randomised controlled trial in 12 hospitals and four primary care sites across the UK. Families were approached via antenatal or postnatal services for recruitment of term infants (at least 37 weeks' gestation) at high risk of developing eczema (ie, at least one first-degree relative with parent-reported eczema, allergic rhinitis, or asthma, diagnosed by a doctor). Term newborns with a family history of atopic disease were randomly assigned (1:1) to application of emollient daily (either Diprobase cream or DoubleBase gel) for the first year plus standard skin-care advice (emollient group) or standard skin-care advice only (control group). The randomisation schedule was created using computer-generated code (stratified by recruiting centre and number of first-degree relatives with atopic disease) and participants were assigned to groups using an internet-based randomisation system. The primary outcome was eczema at age 2 years (defined by UK working party criteria) with analysis as randomised regardless of adherence to allocation for participants with outcome data collected, and adjusting for stratification variables. This trial is registered with ISRCTN, ISRCTN21528841. Data collection for long-term follow-up is ongoing, but the trial is closed to recruitment.Findings1394 newborns were randomly assigned to study groups between Nov 19, 2014, and Nov 18, 2016; 693 were assigned to the emollient group and 701 to the control group. Adherence in the emollient group was 88% (466 of 532) at 3 months, 82% (427 of 519) at 6 months, and 74% (375 of 506) at 12 months in those with complete questionnaire data. At age 2 years, eczema was present in 139 (23%) of 598 infants with outcome data collected in the emollient group and 150 (25%) of 612 infants in the control group (adjusted relative risk 0·95 [95% CI 0·78 to 1·16], p=0·61; adjusted risk difference –1·2% [–5·9 to 3·6]). Other eczema definitions supported the results of the primary analysis. Mean number of skin infections per child in year 1 was 0·23 (SD 0·68) in the emollient group versus 0·15 (0·46) in the control group; adjusted incidence rate ratio 1·55 (95% CI 1·15 to 2·09).InterpretationWe found no evidence that daily emollient during the first year of life prevents eczema in high-risk children and some evidence to suggest an increased risk of skin infections. Our study shows that families with eczema, asthma, or allergic rhinitis should not use daily emollients to try and prevent eczema in their newborn.FundingNational Institute for Health Research Health Technology Assessment.