Prior Primary Care Research Articles

Same-Day Primary Care Referral Versus Usual Care for Patients With Elevated Blood Pressures Seen in a Preoperative Clinic.

Background While several studies have suggested that anesthesia and surgical care episodes provide an opportunity to improve the diagnosis and treatment of hypertension, few studies have implemented and tested pragmatic care coordination efforts for this population. The present study aimed to examine the effects of same-day primary care referral vs. usual care on outpatient hypertension treatment among patients with elevated preoperative clinic blood pressure (BP). Methodology With institutional review board approval of the project as a quality improvement (QI) initiative not requiring consent, we conducted a prospective QI project comparing same-day preoperative primary care referral vs. usual care within comparable cohorts of US Veterans presenting to a preoperative evaluation clinic with elevated BP for whom treatment assignment was based on prior primary care clinic affiliation. Outpatient BP, antihypertensive medications, and antihypertensive dosages at the initial visit and for one year after the initial preoperative clinic visit were followed in the electronic health record. Results Between June 1, 2018, and June 1, 2019, one of the two on-site primary care groups (Firm A) at our facility agreed to accommodate same-day BP referrals. Patients in the second primary care group received standard preoperative care (Firm B). Charts for the pseudo-randomized cohort of Firm A and B patients were compared after 12 months to assess for changes in BP and hypertension treatment. Firm A and B patients were similar in demographics. Overall, 68 (91%) Firm A patients were correctly referred for primary care appointments. Moreover, 28 of 68 (41.2%) patients adhered to the same-day referral recommendation, with the remainder declining to attend the primary care visit. BPs were similar between Firm A and Firm B groups at 3, 6, 9, and 12 months post-intervention. Firm A adherent patients (i.e., those attending the referral) received hypertension treatment intensification sooner than Firm A non-adherent and Firm B patients (median (interquartile range) days to intensification = 21 (0.5-103.5) vs. 154 (45.5-239) and 170 (48-220), respectively; p = 0.038 and p = 0.048, respectively). Conclusions Our protocol achieved a high degree of same-day primary care referral (91%) in hypertensive patients presenting at the preoperative clinic. Although this limited study did not demonstrate improved BP control in patients who received same-day primary care, this group did show increased rates of rapid treatment intensification which may infer improved long-term health outcomes. Further work examining logistical barriers to patients attending same-day referrals is warranted.

A prospective study to evaluate the contribution of the pediatric appendicitis score in the decision process.

The objective of this study was to assess the likelihood of acute appendicitis (AA) in children presenting with abdominal symptoms at the emergency department (ED), based on their prior primary care (PC) consultation history. Between February and June 2021, we prospectively enrolled all children presenting at the ED with acute abdominal pain indicative of possible acute appendicitis (AA). Subsequently, they were categorized into three groups: those assessed by a PC physician (PG), those brought in by their family without a prior consultation (FG), and those admitted after a PC consultation without being assessed as such. The primary objective was to assess the probability of AA diagnosis using the Pediatric Appendicitis Score (PAS). Secondary objectives included analyzing PAS and C-reactive protein (CRP) levels based on the duration of pain and final diagnoses. 124 children were enrolled in the study (PG, n = 56; FG, n = 55; NG, n = 13). Among them, 29 patients (23.4%) were diagnosed with AA, with 13 cases (23.2%) from the PG and 14 cases (25.4%) from the FG. The mean PAS scores for AA cases from the PG and FG were 6.69 ± 1.75 and 7.57 ± 1.6, respectively, (p = 0.3340). Both PAS scores and CRP levels showed a significant correlation with AA severity. No cases of AA were observed with PAS scores < 4. There was no significant difference in PAS scores between patients addressed by PG and FG, even though PAS scores tended to be higher for patients with AA. We propose a new decision-making algorithm for PC practice, which incorporates inflammatory markers and pain duration. Institutional Ethics Committee registration number: 447-2021-103 (10/01/2021). ClinicalTrials.gov Identifier: NCT04885335 (Registered on 13/05/2021).

Reducing Acute Hospitalizations at High-Performing CPC+ Primary Care Practice Sites: Strategies, Activities, and Facilitators.

Despite evidence suggesting that high-quality primary care can prevent unnecessary hospitalizations, many primary care practices face challenges in achieving this goal, and there is little guidance identifying effective strategies for reducing hospitalization rates. We aimed to understand how practices in the Comprehensive Primary Care Plus (CPC+) program substantially reduced their acute hospitalization rate (AHR) over 2 years. We used Bayesian analyses to identify the CPC+ practice sites having the highest probability of achieving a substantial reduction in the adjusted Medicare AHR between 2016 and 2018 (referred to here as AHR high performers). We then conducted telephone interviews with 64 respondents at 14 AHR high-performer sites and undertook within- and cross-case comparative analysis. The 14 AHR high performers experienced a 6% average decrease (range, 4% to 11%) in their Medicare AHR over the 2-year period. They credited various care delivery activities aligned with 3 strategies for reducing AHR: (1) improving and promoting prompt access to primary care, (2) identifying patients at high risk for hospitalization and addressing their needs with enhanced care management, and (3) expanding the breadth and depth of services offered at the practice site. They also identified facilitators of these strategies: enhanced payments through CPC+, prior primary care practice transformation experience, use of data to identify high-value activities for patient subgroups, teamwork, and organizational support for innovation. The AHR high performers observed that strengthening the local primary care infrastructure through practice-driven, targeted changes in access, care management, and comprehensiveness of care can meaningfully reduce acute hospitalizations. Other primary care practices taking on the challenging work of reducing hospitalizations can learn from CPC+ practices and may consider similar strategies, selecting activities that fit their context, personnel, patient population, and available resources.

Time intervals in the pathway to emergency cancer diagnosis

Aim: Evidence on time-based metrics for cancers diagnosed through emergency presentation is lacking. We examined the duration of intervals from first symptoms to cancer diagnosis in the emergency versus primary care (PC) presentation route. Methods: Retrospective study of outpatients diagnosed with 15 solid cancers over 5 years. The outcome was the length of prediagnostic intervals by diagnostic route. Results: Median intervals in emergency presenters (n=3167) were shorter than in PC presenters (n=2215). However, intervals in emergency presenters with three or more prior PC consultations were similar to PC but remarkably longer than in those with one or two and no consultations. Conclusion: As we provide new interval measures for the emergency diagnostic pathway, results highlight the contribution of prior consultations to interval lengths.

Care patterns and predictors of community residence among older patients after hospital discharge for traumatic brain injury.

An increasing number of older adults with traumatic brain injury (TBI) require hospitalization, but it is unknown whether they return to their community following discharge. We examined community residence following acute hospital discharge for TBI in Texas and identified factors associated with 90-day community residence and readmission. We conducted a retrospective cohort study using 100% Texas Medicare claims data of patients older than 65 years hospitalized for a TBI from January 1, 2014, through December 31, 2017, and followed for 20 weeks after discharge. Discharges to short-term and long-term acute hospital, inpatient rehabilitation facility (IRF), skilled nursing facility (SNF), long-term nursing home (NH), and hospice were identified. The primary outcome was 90-day community residence. Our secondary outcome was 90-day, all-cause readmission. In Texas, 26,985 Medicare fee-for-service patients were hospitalized for TBI (Racial and ethnic minorities: 21.1%; Females 57.3%). At 90 days and 20 weeks following discharge, 80% and 84% were living in the community respectively. Female sex (OR=1.16 [1.08-1.25]), Hispanic ethnicity (OR=2.01 [1.80-2.25]), "other" race (OR=2.19 [1.73-2.77]), and prior primary care provider (PCP; OR=1.51 [1.40-1.62]) were associated with increased likelihood of 90-day community residence. Patients aged 75+, prior NH residence, dual eligibility, prior TBI diagnosis, and moderate-to-severe injury severity were associated with decreased likelihood of 90-day community residence. Being non-Hispanic Black (HR=1.33 [1.20-1.46]), discharge to SNF (HR=1.56 [1.48-1.65]) or IRF (HR=1.49 [1.40-1.59]), having prior PCP (HR=1.23 [1.17-1.30]), dual eligibility (HR=1.11 [1.04-1.18]), and prior TBI diagnosis (HR=1.05 [1.01-1.10]) were associated with increased risk of 90-day readmission. Female sex and "other" race were associated with decreased risk of 90-day readmission. Most older adults with TBI return to the community following hospital discharge. Disparities exist in returning to the community and in risk of 90-day readmission following hospital discharge. Future studies should explore how having a PCP influences post-hospital outcomes in chronic care management of older patients with TBI.

Abstract A109: Colorectal cancer screen-up-to-date: 10-year prevalence in a regional safety-net health system

Abstract Introduction: Colorectal cancer (CRC) screening is an effective secondary prevention method with an increased probability of diagnosing CRC at an earlier stage, and a consequent improvement in survival post-treatment. This is especially true for individuals who undergo guideline recommended screening at appropriate intervals. Studies have reported a consistent rise in long-term trends of guideline-adherent screen-up-to-date (SUTD) rates among predominantly White and insured individuals. Here we use longitudinal data from 2011-2020 and report 10-year prevalence and correlates of CRC SUTD among patients in a safety-net health system. Methods: All patients aged 50-74 years who had a primary care encounter in any of the 12 community clinics in a large county safety-net health system were included. An individual was considered to be SUTD if he/she had a stool test during the calendar year, flexible sigmoidoscopy in the past 5 years, or colonoscopy in the past 10 years. To obtain a population health estimate (and not only examine frequencies), we included in the denominator patients with a primary care visit in the past 3 years. Multivariable generalized estimating equations (GEE) model was used to examine the association of SUTD status with time-varying demographic and clinical characteristics over the 10-year period. Results: Our analytical cohort had 50,647 patients in 2011, of which 40.9% (20,708) patients were SUTD. Annual rates of SUTD were largely unchanged until 2019, when the prevalence increased to 46.8% after initiation of a population health outreach mailed FIT program. The SUTD rate fell to the baseline level of 40.8% in 2020 after the pandemic-induced suspension of the mailed FIT program. Multivariable GEE model demonstrated that older patients, females, and Hispanics had higher odds of being SUTD compared to younger patients, males, and non-Hispanics, respectively. Additionally, patients who had prior interaction with the healthcare system (had prior stool tests or prior primary care encounters) had higher odds of being SUTD than those with no prior experience with the healthcare system (no prior stool tests or no prior primary care encounters). Conclusion: This study establishes contemporary evidence about the 10-year prevalence and correlates of CRC SUTD status among patients in a safety-net health system. Prevalence remained constant for most of the decade, except in 2019, when a population-based mailed FIT outreach program was implemented to complement usual visit-based screening. Despite the disruptions caused by the COVID-19 pandemic, screening rates in 2020 did not drop below pre-2019 levels (~40%), though the prior increases due to the mailed FIT program were lost. We believe that effective implementation of broad population-based, screening outreach efforts are instrumental in improving and sustaining CRC SUTD rates in safety-net health systems, and can consequently help to decrease CRC incidence and related mortality. Citation Format: Rasmi G. Nair, Ellen Hu, Lei Wang, Eric Kim, Cynthia Ortiz, Jacquelyn Lykken, Celette S. Skinner, Ethan Halm. Colorectal cancer screen-up-to-date: 10-year prevalence in a regional safety-net health system [abstract]. In: Proceedings of the 15th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2022 Sep 16-19; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr A109.

Comprehensive Primary Care Plus Did Not Improve Quality Or Lower Spending For The Privately Insured.

Comprehensive Primary Care Plus (CPC+) was a multipayer payment reform model that provided incentives for primary care practices to lower spending and improve quality performance. Although CPC+ has been evaluated in Medicare, little is known about its impact in the private sector. Using claims and enrollment data from the period 2013-20 from two large insurers in Michigan, we performed difference-in-differences analyses and found that CPC+ was not associated with changes in total spending (-$44.70 per year) or overall quality performance (-0.1percentage point). These changes did not vary systematically across CPC+ cohorts, tracks, regions, or participation in prior primary care innovations. We conclude that CPC+ did not improve spending or quality for private-plan enrollees in Michigan, even before accounting for payouts to providers. This analysis adds to existing evidence that CPC+ may cost payers money in the short term, without concomitant improvements to care quality.

Lung Cancer Inequalities in Stage of Diagnosis in Ontario, Canada.

Lung cancer is the most common cancer and cause of cancer death in Canada, with approximately 50% of cases diagnosed at stage IV. Sociodemographic inequalities in lung cancer diagnosis have been documented, but it is not known if inequalities exist with respect to immigration status. We used multiple linked health-administrative databases to create a cohort of Ontarians 40–105 years of age who were diagnosed with an incident lung cancer between 1 April 2012 and 31 March 2017. We used modified Poisson regression with robust standard errors to examine the risk of diagnosis at late vs. early stage among immigrants compared to long-term residents. The fully adjusted model included age, sex, neighborhood-area income quintile, number of Aggregated Diagnosis Group (ADG) comorbidities, cancer type, number of prior primary care visits, and continuity of care. Approximately 62% of 38,788 people with an incident lung cancer from 2012 to 2017 were diagnosed at a late stage. Immigrants to the province were no more likely to have a late-stage diagnosis than long-term residents (63.5% vs. 62.0%, relative risk (RR): 1.01 (95% confidence interval (CI): 0.99–1.04), adjusted relative risk (ARR): 1.02 (95% CI: 0.99–1.05)). However, in fully adjusted models, people with more comorbidities were less likely to have a late-stage diagnosis (adjusted relative risk (ARR): 0.82 (95% CI: 0.80–0.84) for those with 10+ vs. 0–5 ADGs). Compared to adenocarcinoma, small cell carcinoma was more likely to be diagnosed at a late stage (ARR: 1.29; 95% CI: 1.27–1.31), and squamous cell (ARR: 0.89; 95% CI: 0.87–0.91) and other lung cancers (ARR: 0.93; 95% CI: 0.91–0.94) were more likely to be diagnosed at an early stage. Men were also slightly more likely to have late-stage diagnosis in the fully adjusted model (ARR: 1.08; 95% CI: 1.05–1.08). Lung cancer in Ontario is a high-fatality cancer that is frequently diagnosed at a late stage. Having fewer comorbidities and being diagnosed with small cell carcinoma was associated with a late-stage diagnosis. The former group may have less health system contact, and the latter group has the lung cancer type most closely associated with smoking. As lung cancer screening programs start to be implemented across Canada, targeted outreach to men and to smokers, increasing awareness about screening, and connecting every Canadian with primary care should be system priorities.

Underutilization of primary medical care among men presenting for fertility evaluation

ObjectiveTo determine the proportion of men presenting for fertility evaluation who reported having an established primary care physician (PCP).DesignRetrospective, observational study.SettingAcademic health center.Patient(s)All men presenting for initial male factor infertility consultation with a single reproductive urologist between 2002 and 2018.Intervention(s)Men were asked to provide the name of their PCP at the time of initial visit.Main Outcome Measure(s)Descriptive statistics characterized the proportion of men with a PCP at the time of evaluation and associations between PCP status and clinical characteristics.Result(s)Among 4,127 men presenting for initial fertility consultation, 844 (20.5%) reported having an established PCP, 480 (11.6%) reported no PCP, and 2,803 (67.9%) did not have data available. Among 1,302 men who had a prior primary care visit within our healthcare system, 414 (31.8%) had been seen within 1 year before their fertility evaluation. Men with an established PCP were slightly older than those without a PCP, with higher body mass index, and lower systolic blood pressure. Hormonal profiles were similar across groups, but men with an established PCP had a significantly higher total motile sperm count than those without a PCP, median 53 (interquartile range, 11–109) versus 35 (interquartile range, 8–98).Conclusion(s)More than one third of men presenting for fertility evaluation did not have an established PCP. Reproductive urologists are uniquely positioned to facilitate the critical relationship between young men and PCPs, which should be a key component of the male fertility treatment paradigm.

E-Consult implementation success: lessons from 5 county-based delivery systems.

Electronic consultation, or e-consult, systems improve specialty care access by conveying specialist expertise to primary care clinicians (PCCs) without requiring specialist visits. Our study evaluates organizational factors for e-consult implementation across 5 publicly financed, county-based health systems in California. Each system serves 40,000 to 180,000 culturally and linguistically diverse patients across 4 to 19 primary care locations. We interviewed leaders whose systems received grant funding between 2015 and 2017 to plan and implement e-consult. Interviews discussed platform selection, electronic health record (EHR) compatibility, PCC and specialist opinions, and project governance. We also collected implementing systems' platform operations metrics. Mixed methods, including semistructured interviews and quantitative platform metrics. Interviews were analyzed in alignment with the Consolidated Framework for Implementation Research inner setting domain. Three of the 5 systems successfully implemented e-consults. System 1 sustained implementation across 27 specialties, system 2 achieved fragmented implementation, and system 3 reported early-stage implementation. Existing PCC-specialist relationships emerged as the strongest facilitator. E-consult-EHR technology integration was also important, although an add-on platform enabled e-consult expansion in system 2. Although all systems faced challenges, such as project management resourcing, systems 4 and 5 abandoned implementation amid compound climate and readiness barriers. Successful e-consult implementations in public delivery systems leveraged (1) prior primary care and specialty care clinician relationships and (2)integrated EHR and e-consult platforms. This contrasts with common expectations that new technology will overcome care delivery gaps. Findings add to existing e-consult implementation literature that emphasizes reimbursement and leadership champions.

Patient-Initiated Colonoscopy Scheduling Effectively Increases Colorectal Cancer Screening Adherence.

We identified patients without medical record evidence of up-to-date colorectal cancer (CRC) screening and sent an invitation letter to self-schedule a colonoscopy without requiring prior primary care or gastroenterologist consultation. The aim of the study was to evaluate the response rate to the letter and factors associated with colonoscopy completion. A computer algorithm invited patients not up to date with CRC screening, with an INR < 1.5, and living within 300 miles of the Cleveland Clinic main campus through a letter. Patients scheduled a colonoscopy through a dedicated phone line without any prior physician consultation. Clinical, demographic, and socioeconomic variables were extracted from the EMR through natural language algorithms. We analyzed the percentage of patients who completed a colonoscopy within 6months of sending the letter and factors associated with colonoscopy completion. A total of 145,717 letters were sent. 1451 patients were deceased and excluded from analysis. 3.8% (5442) of letter recipients completed a colonoscopy. The strongest factors associated with colonoscopy completion on multivariate analysis included family history of polyps (OR 3.1, 95% CI 2.3, 4.2) or CRC (OR 2.1, 95% CI 1.7, 2.5). Other factors included younger age, male gender, married status, closer distance to endoscopy center, number of visits in the year prior, statin use, and diabetes. There were no immediate procedural complications. Patient-initiated colonoscopy in response to letter invitation for CRC screening is effective and safe with safeguards established a priori. Consultation with a gastroenterologist or primary care physician is not necessary prior to colonoscopy. To our knowledge, this is the first study to evaluate patient-initiated colonoscopy for CRC cancer screening.

Factors associated with receiving surgical treatment for menorrhagia in England and Wales: findings from a cohort study of the National Heavy Menstrual Bleeding Audit

ObjectiveTo examine the factors associated with receiving surgery for heavy menstrual bleeding (HMB) in England and Wales.DesignNational cohort study.SettingNational Health Service hospitals.ParticipantsWomen with HMB aged 18–60 who had a new...

"That Can't Be!": Perceptions of HIV and Hepatitis C Screening during Admission to an Acute Care Surgery Service.

Background:A large number of patients live with undiagnosed HIV and/or hepatitis C despite broadened national screening guidelines. European studies, however, suggest many patients falsely believe they have been screened during a prior hospitalization. This study aims to define current perceptions among trauma and emergency general surgery (EGS) patients regarding HIV and hepatitis C screening practices.Methods:Prospective survey administered to adult (>18 years old) acute care surgery service (trauma and EGS) patients at a Level 1 academic trauma center. The survey consisted of 13 multiple choice questions: demographics, whether admission tests included HIV and hepatitis C at index and prior hospital visits and whether receiving no result indicated a negative result, prior primary care screening. Response percentages calculated in standard fashion.Results:One hundred and twenty-five patients were surveyed: 80 trauma and 45 EGS patients. Overall, 32% and 29.6% of patients believed they were screened for HIV and hepatitis C at admission. There was no significant difference in beliefs between trauma and EGS. Sixty-eight percent of patients had a hospital visit within 10 years of these, 49.3% and 44.1% believe they had been screened for HIV and hepatitis C. More EGS patients believed they had a prior screen for both conditions. Among patients who believed they had a prior screen and did not receive any results, 75.9% (HIV) and 80.8% (hepatitis C) believed a lack of results meant they were negative. Only 28.9% and 23.6% of patients had ever been offered outpatient HIV and hepatitis C screening.Conclusions:A large portion of patients believe they received admission or prior hospitalization HIV and/or hepatitis C screening and the majority interpreted a lack of results as a negative diagnosis. Due to these factors, routine screening of trauma/EGS patients should be considered to conform to patient expectations and national guidelines, increase diagnosis and referral for medical management, and decrease disease transmission.

Machine learning: how much does it improve the prediction of unplanned hospital admissions?

IntroductionRisk prediction models can be used to inform decision-making in clinical settings. With large and detailed electronic medical record data, machine learning may improve predictions. The objective of this work is to determine the feasibility and accuracy of machine learning versus logistic regression to predict unplanned hospital admissions.&#x0D; Objectives and ApproachData from primary care electronic medical records for community-dwelling adults in Alberta, Canada available from the Canadian Primary Care Sentinel Surveillance Network will be linked to acute care administrative health data held by Alberta Health Services. Two regression methods (forward stepwise logistic, LASSO logistic) will be compared with three machine learning methods (classification tree, random forest, gradient boosted trees). Prior primary and acute care use will be used to predict three outcomes: ≥1 unplanned admission within 1 year, ≥1 unplanned admission within 90 days, and ≥1 unplanned admission within 1 year due to an ambulatory care sensitive condition.&#x0D; ResultsThe results of this work in progress will be presented at the conference. 41,142 patients will have their primary and acute care data linked. We anticipate that the machine learning methods will improve predictive performance but will be more challenging for clinicians and patients to understand, including why a given patient is predicted to be at higher risk. The primary comparison of machine learning and regression methods will be based on positive predictive values corresponding to the top 5% predicted risk threshold, and estimated via 10-fold cross-validation.&#x0D; Conclusion/ImplicationsThis project aims to help researchers decide which statistical methods to use for risk prediction models. When considering machine learning methods the best approach may be to try multiple methods, compare their predictive accuracy and interpretability, and then choose a final method.

Health seeking behavior as a predictor of healthcare utilization in a population of patients with spinal pain.

BackgroundThe global burden of low back pain is growing rapidly, accompanied by increasing rates of associated healthcare utilization. Health seeking behavior (HSB) has been suggested as a mediator of healthcare utilization. The aims of this study were to: 1) develop a proxy HSB measure based on healthcare consumption patterns prior to initial consultation for spinal pain, and 2) examine associations between the proxy HSB measure and future healthcare utilization in a population of patients with spine disorders.MethodsA cohort of 1,691 patients seeking care for spinal pain at a single military hospital were included. Cluster analyses were performed for the identification of a proxy HSB measure. Logistic regression was used to identify the predictive capacity of HSB on eight different general and spine-related high healthcare utilization (upper 25%) outcomes variables.ResultsThe strongest proxy measure of HSB was prior primary care provider visits. In unadjusted models, HSB predicted healthcare utilization across all eight general and spine-related outcome variables. After adjusting for covariates, HSB still predicted general and spine-related healthcare utilization for most variables including total medical visits (OR = 2.48, 95%CI 1.09,3.11), total medical costs (OR = 2.72, 95%CI 2.16,3.41), and low back pain-specific costs (OR = 1.31, 95%CI 1.00,1.70).ConclusionHealth seeking behavior prior to initial consultation for spine pain was related to healthcare utilization after consultation for spine pain. HSB may be an important variable to consider when developing an individualized care plan and considering the prognosis of a patient.

Navigating the Uncharted Waters of a Lifestyle Medicine Fellowship.

Lifestyle medicine (LM) is now recognized as a first-line treatment and disease reversal program for many chronic diseases. More providers are encouraged to prescribe lifestyle treatments, yet lack of training, inadequate time, and poor reimbursement hinder many physicians from actually following through, and few LM specialists are available for counsel or referral. With great strides in resolving these dilemmas, the American College of Lifestyle Medicine has created standards and competencies, and the American Board of Lifestyle Medicine will be holding its first exam for certification in LM in October 2017. Still no residency or fellowship program exists to train providers to become LM specialists. This article describes one physician's journey through an unaccredited fellowship in lifestyle medicine at Black Hills Health and Education Center under Dr John Kelly, founding president of the American College of Lifestyle Medicine. Highlighting the differences of her lifestyle medicine training from her prior primary care and preventive medicine training, the author advocates for the formation of an accredited LM training program in intensive lifestyle medicine interventions.

Comorbidities treated in primary care in children with chronic fatigue syndrome / myalgic encephalomyelitis: A nationwide registry linkage study from Norway.

BackgroundChronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) is a complex condition. Causal factors are not established, although underlying psychological or immunological susceptibility has been proposed. We studied primary care diagnoses for children with CFS/ME, with children with another hospital diagnosis (type 1 diabetes mellitus [T1DM]) and the general child population as comparison groups.MethodsAll Norwegian children born 1992–2012 constituted the study sample. Children with CFS/ME (n = 1670) or T1DM (n = 4937) were identified in the Norwegian Patient Register (NPR) (2008-2014). Children without either diagnosis constituted the general child population comparison group (n = 1337508). We obtained information on primary care diagnoses from the Norwegian Directorate of Health. For each primary care diagnosis, the proportion and 99 % confidence interval (CI) within the three groups was calculated, adjusted for sex and age by direct standardization.ResultsChildren with CFS/ME were more often registered with a primary care diagnosis of weakness/general tiredness (89.9 % [99 % CI 88.0 to 91.8 %]) than children in either comparison group (T1DM: 14.5 % [99 % CI: 13.1 to 16.0 %], general child population: 11.1 % [99 % CI: 11.0 to 11.2 %]). Also, depressive disorder and anxiety disorder were more common in the CFS/ME group, as were migraine, muscle pain, and infections. In the 2 year period prior to the diagnoses, infectious mononucleosis was registered for 11.1 % (99 % CI 9.1 to 13.1 %) of children with CFS/ME and for 0.5 % (99 % CI (0.2 to 0.8 %) of children with T1DM. Of children with CFS/ME, 74.6 % (1292/1670) were registered with a prior primary care diagnosis of weakness / general tiredness. The time span from the first primary care diagnosis of weakness / general tiredness to the specialist health care diagnosis of CFS/ME was 1 year or longer for 47.8 %.ConclusionsThis large nationwide registry linkage study confirms that the clinical picture in CFS/ME is complex. Children with CFS/ME were frequently diagnosed with infections, supporting the hypothesis that infections may be involved in the causal pathway. The long time span often observed from the first diagnosis of weakness / general tiredness to the diagnosis of CFS/ME might indicate that the treatment of these patients is sometimes not optimal.

Serious Mental Illness and Risk for Hospitalizations and Rehospitalizations for Ambulatory Care-sensitive Conditions in Denmark: A Nationwide Population-based Cohort Study.

Hospitalizations for ambulatory care-sensitive conditions (ACSCs) and early rehospitalizations increase health care costs. To determine if individuals with serious mental illnesses (SMIs) (eg, schizophrenia or bipolar disorder) are at increased risk for hospitalizations for ACSCs, and rehospitalization for the same or another ACSC, within 30 days. Population-based cohort study. A total of 5.9 million Danish persons aged 18 years and older between January 1, 1999 and December 31, 2013. The Danish Psychiatric Central Register provided information on SMI diagnoses and the Danish National Patient Register on hospitalizations for ACSCs and 30-day rehospitalizations. SMI was associated with increased risk for having any ACSC-related hospitalization after adjusting for demographics, socioeconomic factors, comorbidities, and prior primary care utilization [incidence rate ratio (IRR): 1.41; 95% confidence interval (95% CI), 1.37-1.45]. Among individual ACSCs, SMI was associated with increased risk for hospitalizations for angina (IRR: 1.14, 95% CI, 1.04-1.25), chronic obstructive pulmonary disease/asthma exacerbation (IRR: 1.87; 95% CI, 1.74-2.00), congestive heart failure exacerbation (IRR: 1.25; 95% CI, 1.16-1.35), and diabetes (IRR: 1.43; 95% CI, 1.31-1.57), appendiceal perforation (IRR: 1.49; 95% CI, 1.30-1.71), pneumonia (IRR: 1.72; 95% CI, 1.66-1.79), and urinary tract infection (IRR: 1.70; 95% CI, 1.62-1.78). SMI was also associated with increased risk for rehospitalization within 30 days for the same (IRR: 1.28; 95% CI, 1.18-1.40) or for another ACSC (IRR: 1.62; 95% CI, 1.49-1.76). Persons with SMI are at increased risk for hospitalizations for ACSCs, and after discharge, are at increased risk for rehospitalizations for ACSCs within 30 days.

International medical graduates as physician assistants.

This study describes the MEDEX physician assistant (PA) program's experience with screening, educating, and graduating PA students who were international medical graduates (IMGs). The study reviewed IMG-PA demographics including country of origin; prior primary care practice; and current practice location, specialty, and medically underserved designation. Descriptive statistics and chi-square analysis or Fisher exact test summarize outcomes. Thirty-nine IMG-PAs were graduated from 1991 through 2013. IMGs came from central and eastern Europe (48.7%), Asia (33.3%), and other regions. Most (69.2%) are women. Almost all (91.7%) practice in urban settings, 55.6% are in primary care, and 30.6% work in medically underserved areas. IMG-PAs in primary care were more likely to practice in underserved areas (P=0.009). MEDEX has graduated IMG-PAs who possess appropriate clinical and professional PA skills.

Translating What Works: A New Approach to Improve Diabetes Management.

The most efficacious strategies to improve diabetes control include case management, health care team changes, patient education, and facilitated transmission of patient data to clinicians ("facilitated relay"), but these strategies have not been translated to permit general use in clinical practice. A web-based decision support program was developed to include these features, and assessed in patients who had A1c ≥7.0% despite using metformin with/without sulfonylureas or insulin. Staff entered patients' glucose data, obtained management recommendations, reviewed the plan with a clinician, and discussed the new plan with patients. 113 subjects were 96% male and 32% black, with average age 65.6 years and BMI 32.8. During prior primary care, A1c averaged 8.32 ± 0.16% (SEM). In all patients, baseline A1c was 8.18 ± 0.11%, and decreased to 7.54 ± 0.12%, 7.16 ± 0.13%, and 7.54 ± 0.16% at 3, 6, and 12 months, respectively, all P < .001. In 42 subjects who provided glucose data and made requested changes in medications, A1c was 8.12 ± 0.09% at baseline and fell to 7.29 ± 0.11%, 6.98 ± 0.10%, and 7.05 ± 0.10% at 3, 6, and 12 months, respectively, all P < .001. Chart review of 16 subjects followed for 12 months demonstrated that hypoglycemia (symptoms and/or glucose <70 mg/dl) averaged less than 1 episode/patient/month, and there was no severe hypoglycemia. A novel decision support program improved A1c with little hypoglycemia. Use of this approach should allow primary care teams to keep patients well controlled, and reduce the need for specialist referrals.