Specialty Care For Patients Research Articles

The role of primary care in rare disorders: A qualitative study of parents and patients managing complex vascular anomalies.

Patients with complex rare disorders often require the care of multiple specialists. Effective coordination between primary and specialty care is needed to ensure patients receive high-quality care. Previous research has documented the importance of primary care clinicians providing referrals to specialty care and the importance of specialists in helping patients reach a diagnosis. However, little is known about primary care clinicians' roles in the ongoing care of patients with rare disorders. In the current study, we explored the role of primary care clinicians in the care of rare and complex vascular anomalies. Data were collected using semi-structured qualitative interviews with 34 parents and 25 adult patients recruited from advocacy groups for patients with complex vascular anomalies participated. We asked participants about their diagnosis, care experiences, and communication with clinicians. We used thematic analysis to identify themes illustrating the roles of primary care clinicians. PCC roles were characterized by four behaviors. Supporting behaviors included learning more about vascular anomalies and asking participants about the care they received from specialists. Facilitating included providing referrals, ordering tests, and engaging in problem-solving. Interfering included failing to provide referrals or help participants coordinate care, ordering incorrect tests, or making inappropriate recommendations. Disregarding included focusing narrowly on primary care needs and not showing concern about the vascular anomaly. The results reveal opportunities to improve primary care for patients with vascular anomalies. Disregarding and interfering behaviors furthered the division between primary and specialty care for patients with vascular anomalies and prevented patients from receiving comprehensive primary care. Supporting and facilitating behaviors convey genuine interest in the care of the vascular anomaly and a commitment to helping the patient and parent.

Provider ankle brachial index and wound classification teaching as part of a comprehensive limb preservation outreach program

ObjectiveUtilization of evidence-based specialty guidelines is low in primary care settings. Early use of ankle-brachial index (ABI) testing and a validated wound classification system allows prompt referral of patients for specialty care. We implemented a program to teach providers ABI testing and the use of the Wound, Ischemia, and foot Infection (WIfI) classification tool. Here, we report program outcomes and provider perceptions. MethodsPhysicians and non-physicians from wound care centers, nursing and physician education programs, primary care offices, and federally qualified health centers were invited to participate in the educational program teaching ABI testing and the use of the WIfI tool. Pretest and posttest responses and intention to use content in the future were assessed with descriptive statistics. ResultsA total of 101 subjects completed the ABI module, and 84 indicated their occupation (59 physicians, 25 non-physicians). Seventy-nine subjects completed the WIfI module, and 89% indicated their occupation (50 physicians, 20 non-physicians). Physicians had lower pre-test knowledge scores for the ABI module than non-physicians (mean scores of 7.9 and 8.2, respectively). Both groups had improved knowledge scores on the post-test (physicians, 13.4; non-physicians, 13.8; P < .001). Non-physicians in practice longer than 10 years at wound care centers had the lowest baseline knowledge scores, whereas physicians in practice for over 10 years had the highest. In the ABI module, the largest knowledge gap included accurately calculating the ABI, followed by the correct use of the Doppler, and management of incompressible vessels. For the WIfI module, providers struggled to accurately score patients based on wound classification. The greatest barriers to the implementation of ABI testing were the availability of trained personnel, followed by limited time for testing. Barriers to the use of the WIfI tool for physicians included lack of time and national guideline support. For non-physicians, the most notable barrier was a lack of training. ConclusionsProvider understanding of ABI and WIfI tools are limited in wound care centers, primary care offices, and federally qualified health centers. Further barriers include a lack of training in the use of tools, limited potential for point-of-care testing reimbursement, and insufficient dissemination of WIfI guidelines. Such barriers discourage widespread adoption and result in delayed diagnosis of arterial insufficiency.

Abstract 15537: Complex Congenital Heart Patients: Education Program for Advanced Practice Providers

Introduction: With appropriate training and support, Advanced Practice Providers (APPs) offer value in specialty patient care in a congenital heart program (CHP) providing continuity, cost effective, and specialized care. Hypothesis: We hypothesized that APPs caring for patients in a CHP lack standard curriculum to quantify success and improvement. Developing a dedicated education program allows identification of knowledge gaps and improves focused learning. Integrating a shared model for education with pre/post-tests increases proficiency and professional development. Methods: 20 APPs were included in our CHP education model including 63 focused learning modules in pediatric cardiology with complex congenital heart disease (CHD) and cardiac intensive care with aspects of post-operative management, multi-disciplinary, APP-specific teaching sessions, APP-led journal clubs, research/QI projects, interactive lectures, visuals, and key articles. Knowledge of the core CHP learning objectives were measured through 514 individual pre/post module tests by utilizing and strategically combining peer reviewed resources in CHD/critical care for each learning module. APPs satisfaction was evaluated using a 5-point scale (outstanding, good, acceptable, fair, unsatisfactory) for core education, faculty support, and translation to clinical practice. Results: Increase in knowledge was observed with pre/post test scores of 67.2% and 97.6%, respectively (P&lt;0.0001). Fetal, chest radiography, and cardiac output were identified with lower pre-test scores &lt; 50% allowing refocused education, resulting in post-test scores &gt; 96% (P&lt;0.0001). Core education program, faculty support, and translation to clinical practice were scored as outstanding (n=10, 50%) or good (n=10, 50%). Conclusions: In conclusion, our APPs and multi-disciplinary specialists have successfully integrated an education program, improving performance in a rapidly growing department. The success in identifying educational opportunities via pretests and adapting our educational focus has provided an infrastructure to improve patient care and safety. Our efforts and bidirectional feedback have resulted in satisfaction and ideally long-term APPs retention.

Association of Disparities in Family History and Family Cancer History in the Electronic Health Record With Sex, Race, Hispanic or Latino Ethnicity, and Language Preference in 2 Large US Health Care Systems

Clinical decision support (CDS) algorithms are increasingly being implemented in health care systems to identify patients for specialty care. However, systematic differences in missingness of electronic health record (EHR) data may lead to disparities in identification by CDS algorithms. To examine the availability and comprehensiveness of cancer family history information (FHI) in patients' EHRs by sex, race, Hispanic or Latino ethnicity, and language preference in 2 large health care systems in 2021. This retrospective EHR quality improvement study used EHR data from 2 health care systems: University of Utah Health (UHealth) and NYU Langone Health (NYULH). Participants included patients aged 25 to 60 years who had a primary care appointment in the previous 3 years. Data were collected or abstracted from the EHR from December 10, 2020, to October 31, 2021, and analyzed from June 15 to October 31, 2021. Prior collection of cancer FHI in primary care settings. Availability was defined as having any FHI and any cancer FHI in the EHR and was examined at the patient level. Comprehensiveness was defined as whether a cancer family history observation in the EHR specified the type of cancer diagnosed in a family member, the relationship of the family member to the patient, and the age at onset for the family member and was examined at the observation level. Among 144 484 patients in the UHealth system, 53.6% were women; 74.4% were non-Hispanic or non-Latino and 67.6% were White; and 83.0% had an English language preference. Among 377 621 patients in the NYULH system, 55.3% were women; 63.2% were non-Hispanic or non-Latino, and 55.3% were White; and 89.9% had an English language preference. Patients from historically medically undeserved groups-specifically, Black vs White patients (UHealth: 17.3% [95% CI, 16.1%-18.6%] vs 42.8% [95% CI, 42.5%-43.1%]; NYULH: 24.4% [95% CI, 24.0%-24.8%] vs 33.8% [95% CI, 33.6%-34.0%]), Hispanic or Latino vs non-Hispanic or non-Latino patients (UHealth: 27.2% [95% CI, 26.5%-27.8%] vs 40.2% [95% CI, 39.9%-40.5%]; NYULH: 24.4% [95% CI, 24.1%-24.7%] vs 31.6% [95% CI, 31.4%-31.8%]), Spanish-speaking vs English-speaking patients (UHealth: 18.4% [95% CI, 17.2%-19.1%] vs 40.0% [95% CI, 39.7%-40.3%]; NYULH: 15.1% [95% CI, 14.6%-15.6%] vs 31.1% [95% CI, 30.9%-31.2%), and men vs women (UHealth: 30.8% [95% CI, 30.4%-31.2%] vs 43.0% [95% CI, 42.6%-43.3%]; NYULH: 23.1% [95% CI, 22.9%-23.3%] vs 34.9% [95% CI, 34.7%-35.1%])-had significantly lower availability and comprehensiveness of cancer FHI (P < .001). These findings suggest that systematic differences in the availability and comprehensiveness of FHI in the EHR may introduce informative presence bias as inputs to CDS algorithms. The observed differences may also exacerbate disparities for medically underserved groups. System-, clinician-, and patient-level efforts are needed to improve the collection of FHI.

Creating a single point of referral and standardized care pathway for patients with melanoma to improve access to care.

127 Background: Access to care is often a challenge for healthcare organizations – especially as pressures on time increase and workforce availability decreases – and is often complex to solve. In this quality improvement (QI) initiative, a team from a rural academic medical center deployed the Lean Six Sigma approach to develop a two-pronged method that reduced the median time to first visit for new melanoma patients. Methods: The project team deployed the Define, Measure, Analyze, Improve, and Control (DMAIC) processes to address access for melanoma patients after the healthcare organization set a goal that 55% of new specialty care patients be seen within 10 days. Define: Concern was raised by the melanoma clinical care team that the lack of a well-defined and standardized referral workflow for melanoma patients could delay patient care. Measure: Data from the electronic medical record (EMR) indicated that only 31% of incoming referrals were seen within 10 days, and the median number of days to first visit was 15, or 50% over the organizational standard. Analyze: Analysis found considerable waste in the existing referral system. First, untrained staff made referral and routing decisions, meaning patients could potentially be seen by inappropriate departments based on the assessment of those not specialized in melanoma care and treatment. This led to the second area of waste: rework. Every referral had to be reviewed by multiple staff in several departments to ensure the referral made was appropriate based on the characteristics of disease. This was a very labor-intensive processes that allowed too many patients to “slip through the cracks” of the system. Improve: Two interventions were deployed to address the identified waste. First, a centralized referral point for all melanomas monitored by the Program Coordinator. Second, a referral questionnaire developed by an interdisciplinary team to guide where routine cases should be referred. Early results show that the interventions had marked impact on the time to first appointment for all referrals, whether originating inside of the organization or out. After the intervention 54% of newly referred patients were seen within 10 days. Results: Control: A standard report was built to support the project team in monthly monitoring of the KPI, days from referral to patient seen. The report is monitored by a dedicated Program Coordinator who can escalate any issues during regular interdisciplinary care team meetings. Conclusions: Improvements in access can be achieved by adopting standard work that is targeted to reduce waste in the referral workflow. The model developed by this QI initiative is easily replicable and may be especially useful for interdisciplinary teams who provide care to complex diseases.[Table: see text]

Ankle Brachial Index and Wound Classification Teaching to Providers as Part of a Comprehensive Limb Preservation Outreach Program

The use of evidence-based specialty guidelines is low in primary care settings. However, the early use of ankle brachial index (ABI) testing and a validated wound classification system allows for the prompt referral of patients for specialty care. We implemented a program to teach providers ABI testing and the use of the WIfI (wound, ischemia, foot infection) classification tool. In the present report, we have described the program outcomes.

TeleWound Practice Within the Veterans Health Administration: Protocol for a Mixed Methods Program Evaluation

BackgroundChronic wounds, such as pressure injuries and diabetic foot ulcers, are a significant predictor of mortality. Veterans who reside in rural areas often have difficulty accessing care for their wounds. TeleWound Practice (TWP), a coordinated effort to incorporate telehealth into the provision of specialty care for patients with skin wounds, has the potential to increase access to wound care by allowing veterans to receive this care at nearby outpatient clinics or in their homes. The Veterans Health Administration (VA) is championing the rollout of the TWP, starting with regional implementation.ObjectiveThis paper aims to describe the protocol for a mixed-methods program evaluation to assess the implementation and outcomes of TWP in VA.MethodsWe are conducting a mixed-methods evaluation of 4 VA medical centers and their community-based outpatient clinics that are participating in the initial implementation of the TWP. Data will be collected from veterans, VA health care team members, and other key stakeholders (eg, clinical leadership). We will use qualitative methods (ie, semistructured interviews), site visits, and quantitative methods (ie, surveys, national VA administrative databases) to assess the process and reach of TWP implementation and its impact on veterans’ clinical outcomes and travel burdens and costs.ResultsThis program evaluation was funded in October 2019 as a Partnered Evaluation Initiative by the US Department of Veterans Affairs, Diffusion of Excellence Office, and Office of Research and Development, Health Services Research and Development Service, Quality Enhancement Research Initiative Program (PEC 19-310).ConclusionsEvaluation of the TWP will identify barriers and solutions to TeleWound implementation in a small number of sites that can be used to inform successful rollout of the TWP nationally. Our evaluation work will inform future efforts to scale up the TWP across VA and optimize reach of the program to veterans across the nation.International Registered Report Identifier (IRRID)DERR1-10.2196/20139

1006 Non-Alcoholic Fatty Liver Disease Is an Increasing Reason for Referral to Gastroenterology

INTRODUCTION: Non-Alcoholic Fatty Liver Disease (NAFLD) is increasing in prevalence. In integrated healthcare systems with limited clinic access, prior studies have utilized care pathways to triage patients to clinic in situations of suspected advanced fibrosis. Our aim was to study clinic utilization for NAFLD over time and assess how many patients could avoid specialty care using predictive scores such as the FIB4 and NAFLD fibrosis score (NFS). METHODS: Consecutive consultations to GI, 200 from 2012 and 300 from 2017, at a large Veterans Administration Hospital in Texas were retrospectively reviewed to determine reason for consultation, final diagnosis, additional workup, and follow up utilization. Weight 1 year after consultation was compared to the initial weight. Chi square testing and Student’s t test were used to compare categorical and quantitative data, respectively, using R. RESULTS: Among the 500 patients, the mean age was 57.4 years (+/- 13.9), 86.2% were male and 18.4% Hispanic. Of the 200 consults in 2012, 18 (9.0%) were for NAFLD compared to 53 (17.7%) of 300 consults from 2017 (P &lt; 0.01). Comparatively, the number of consultations for Hepatitis C was not significantly different from 2012 to 2017 (19.5% vs. 16.7%, P = 0.42). Neither liver biopsy (27.8% vs. 17.0%, P = 0.32) nor MR elastography (11.1% vs. 28.9%, P = 0.20) use was significantly different between 2012 and 2017. Using the FIB4 score, 31 (43.7%) were classified as low risk and 11 (15.5%) were classified as high risk for advanced fibrosis. Using the NFS, 18 (25.4%) were classified as both low and high risk. 27 patients underwent MR elastography or liver biopsy and 13 (48%) were found to have advanced fibrosis. The performance characteristics of NFS and FIB4 compared to results of liver biopsy or MR elastography is presented in Table 1 and 2, respectively. Mean weight change 1 year later was -0.8% (+/-4.7%). There was no difference in weight change between those found to have advanced fibrosis or not (-0.3% [95%CI: -3.0- 2.3%] vs. -2.0% [95%CI:-4.1- 0.1], P = 0.29). CONCLUSION:: One of every 6 consultations to gastroenterology is for NAFLD, now exceeding Hepatitis C referrals in 2017. Using the NFS could save 25% of these referrals without missing cases of advanced fibrosis. GI care was not associated with weight loss. Prospective studies are needed to determine the efficacy of these strategies to triage NAFLD patients for specialty care.

1442Implementation and outcomes of systematic approaches to tobacco treatment: the Ottawa Model for Smoking Cessation

Abstract Background/Introduction Tobacco use is a major risk factor for the leading chronic diseases, is a leading cause of preventable death worldwide, and is a large cost driver of healthcare spending. Quitting smoking is the single most effective thing a patient can do to improve their health. The Ottawa Model for Smoking Cessation (OMSC) is a systematic, comprehensive approach to clinical tobacco dependence treatment. It provides support to healthcare settings in establishing a high quality tobacco treatment protocol and addressing common barriers to ensure optimal delivery of evidence-based smoking cessation interventions. Purpose The OMSC assists healthcare professionals to transform clinical practices through knowledge translation, implementation support, and quality evaluation. It promotes the delivery of evidence-based interventions to a greater number of smokers using a systematic approach, ultimately increasing cessation rates. The OMSC assists providers to identify smoking status, provide strategic advice to quit, support patients in making a quit attempt, and provide follow-up support. Methods OMSC Outreach Facilitators work with healthcare setting to assist with implementing evidence-based smoking cessation interventions. This is guided by an OMSC workplan which covers planning, implementing, evaluating and sustainability. Pre and post implementation along with program-level data is collected and used to determine rates of smoking status documentation, brief advice to stop smoking, delivery of cessation support and patient quit rates. Results The OMSC program has worked with approximately 450 healthcare settings, trained over 20,000 healthcare professionals, and supported approximately 500,000 patients with quitting smoking. Of those not ready to quit, 45% of patients seen in primary care were supported in reducing the amount they smoke. For OMSC hospital and specialty care patients receiving follow-up support, the six month responder-quit rate was 48%. For OMSC primary care patients, the two month responder-quit rate was 57%. Patients who had previously been supported by their OMSC primary care practice but had not presented to their provider in at least 6 months were contacted to assess their smoking status. Of those reached, 44% were smoke-free. Of those who relapsed, 53% indicated they would be willing to make another quit attempt, 37% of which went back to their healthcare provider to try again. Conclusion The OMSC has shown to be a simple, systematic step-by-step approach to addressing tobacco use in healthcare settings. It provides a way to create clinical efficiencies while increasing the rates at which evidence-based smoking cessation interventions are being delivered to patients, which leads to more patients making further quit attempts. The OMSC continues to expand across Canada and internationally in hopes of creating a wider smoking cessation network to support more patients with quitting smoking. Acknowledgement/Funding Ontario Ministry of Health and Long-Term Care

Abstract P5-09-17: Risk reducing interventions among BRCA 1 and 2 female carriers in Newfoundland and Labrador: A provincial analysis

Abstract Introduction Germline mutations in the tumour suppressor genes BRCA 1 and 2 result in a significant increase in cancer predisposition. Female carriers can have up to a 50-70% chance of developing a breast malignancy in their life time and a risk of 20-40% for ovarian cancer. Management options for women with a BRCA mutation include screening with annual mammography and magnetic resonance imaging (MRI), prophylactic surgery and chemoprevention. There is substantial evidence that preventative strategies may reduce the risk of developing breast and ovarian cancer and in some cases improve survival. Newfoundland and Labrador (NL) is the most easterly province in Canada with a population of 525 983. It is geographically and genetically isolated with the majority of residents from English and Irish ancestry. While no one single founder effect has been identified, geographically distinct mutations for both BRCA 1 and 2 have been described. The objective of this study is to characterize the population of BRCA mutation carriers in NL and to evaluate their uptake of risk reducing interventions. Methods All BRCA 1 and 2 carriers tested through the Provincial Medical Genetics program between 1996 - 2018 were captured. Inclusion criteria for this study were females ≥ 18 years of age residing in the province. Demographic, clinical history and information on uptake of risk reducing interventions were abstracted from the electronic medical record. Descriptive statistical analysis was performed. Results One hundred and sixty one women were identified that met inclusion criteria (38% of patients had BRCA1 and 62% had BRCA 2 mutations). Of those unaffected carriers eligible for mammography and MRI screening, only 58% were adherent in the last 18 months. Consultation with a medical or gynecological oncologist increased mammogram screening within the last 18 months to 71% compared with 29% of women who did not see an oncologist. MRI screening increased to 80% for those assessed by oncology versus 20% who did not. For those women who underwent prophylactic surgeries, 27% had bilateral mastectomies with the majority having breast reconstruction (&amp;gt;70%). Fifty two percent of carriers had bilateral salpingo-oophorectomies (BSO) at a median age of 45 years in BRCA 1 and 51 years in BRCA 2. Fifty-three women had a diagnosis of breast cancer and 8 had ovarian cancer. In this cohort, most underwent genetic testing after their diagnosis of cancer (&amp;gt;80%). Median age at presentation of breast cancer was 44 years versus 54 years for ovarian cancer. Conclusion This study demonstrates that women with BRCA 1 and 2 mutations are not adequately availing of risk reducing interventions for breast and ovarian cancer. Furthermore, most patients with malignancy did not undergo genetic testing until after they were diagnosed with cancer. Patient focused research designed to explore factors which may contribute is planned. Consultation with an oncologist increased the likelihood of adherence to breast cancer screening. This highlights the importance of specialty care for patients with a hereditary predisposition to breast and ovarian cancer. Citation Format: Seal MD, Roebothan A, Gabriel A, Dawson L. Risk reducing interventions among BRCA 1 and 2 female carriers in Newfoundland and Labrador: A provincial analysis [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-09-17.

MyVA Access: An Evaluation of Changes in Access for a System-Wide Program Implemented in the Veterans Health Administration.

The current study evaluates changes in access as a result of the MyVA Access program-a system-wide effort to improve patient access in the Veterans Health Administration. Data on 20 different measures were collected, and changes were analyzed using t tests and Chow tests. Additionally, organizational health-how able a system is to create health care practice change-was evaluated for a sample of medical centers (n = 36) via phone interviews and surveys conducted with facility staff and technical assistance providers. An organizational health variable was created and correlated with the access measures. Results showed that, nationally, average wait times for urgent consults, new patient wait times for mental health and specialty care, and slot utilization for primary and specialty care patients improved. Patient satisfaction measures also improved, and patient complaints decreased. Better organizational health was associated with improvements in patient access.

Effects of Medical Transport on Outcomes in Children Requiring Intensive Care.

The need to centralize patients for specialty care in the setting of regionalization may delay access to specialist services and compromise outcomes, particularly in a large geographic area. The aim of this study was to explore the effects of interhospital transferring of children requiring intensive care in a Canadian regionalization model. A retrospective cohort design with a matched pair analysis was adopted to compare the outcomes in children younger than 17 years admitted to a pediatric intensive care unit (PICU) of a Canadian children's hospital by a specialized transport team (pediatric critical care transported [PCCT] group) and those children admitted directly to PICU from its pediatric emergency department (PED group). The outcomes of interest included mortality 72 hours from initial contact with the critical care team (ie, either PICU transport team or intrahospital PICU team). In total, 680 (27%) transports met our inclusion criteria, whereas 866 (7%) cases of 11 570 total PICU admissions were admitted directly from the emergency department. A total of 493 pairs were formed for the matched analyses. Odds of mortality within 72 hours in the PCCT group were significantly higher than in the PED group (odds ratio [OR]: 2.18, 95% confidence interval [CI]: 1.07-4.45; P = .032). When excluding cases who had at least one episode of cardiac arrest before involvement of the pediatric critical care (PCC) transport team, the OR dropped to 1.66 (95% CI: 0.77-3.46). Children transported from nonpediatric hospitals had a higher 72-hour mortality when compared to those children admitted directly to a children's hospital PICU from its own PED in a Canadian regionalized health-care model.

The Importance of Relevance: Willingness to Share eHealth Data for Family Medicine Research.

Objective: To determine the proportion of family medicine patients unwilling to allow their eHealth data to be used for research purposes, and evaluate how patient characteristics and the relevance of research impact that decision.Design: Cross-sectional questionnaire.Setting: Acute care respiratory clinic or an outpatient family medicine clinic in Montreal, Quebec.Participants: Four hundred seventy-four waiting room patients recruited via convenience sampling.Main Outcome Measures: A self-administered questionnaire collected data on age, gender, employment status, education, mother tongue and perceived health status. The main outcome of was self-reported relevance of three research scenarios and willingness or refusal to share their anonymized data. Responses were compared for family practice vs. specialty care patients.Results: The questionnaire was completed by 229 family medicine respondents and 245 outpatient respondents. Almost a quarter of all respondents felt the research was not relevant. Family medicine patients (15.7%) were unwilling to allow their data to be used for at least one scenario vs. 9.4% in the outpatient clinic. Lack of relevance (OR 11.55; 95% CI 5.12–26.09) and being in family practice (OR 2.13; 95% CI 1.06–4.27) increased the likelihood of refusal to share data for research.Conclusion: Family medicine patients were somewhat less willing to share eHealth data, but the overall refusal rate indicates a need to better engage patients in understanding the significance of full access to eHealth data for the purposes of research. Personal relevance of the research had a strong impact on the responses arguing for better efforts to make research more pertinent to patients.

Screening Positive for Cognitive Impairment: Impact on Healthcare Utilization and Provider Action in Primary and Specialty Care Practices.

Alzheimer's disease, the most common cause of dementia, goes unrecognized in half of patients presenting to healthcare providers and is associated with increased acute care utilization. Routine cognitive screening of older adults in healthcare settings could improve rates of dementia diagnosis and patterns of healthcare utilization. To evaluate the impact of screening positive for cognitive impairment on provider action in primary and specialty care practices and patient healthcare utilization. Individuals asymptomatic for cognitive impairment completed cognitive screening with the Mini-Cog (MC). Outcomes included MC screen-positive rates, provider follow-up actions, and healthcare utilization for all participants over a period of 36months (18months prior to and following MC screening). Data were extracted from the electronic medical record (EMR). Healthcare provider interventions and healthcare utilization for screen-positive and -negative groups, before and after screening, were compared. Primary and specialty care patients (n = 787) aged ≥ 65 without history of cognitive impairment seen in HealthPartners, an integrated healthcare system in Minnesota and Western Wisconsin. In primary care and neurology practices combined, over the entire 36-month study window, individuals screening positive showed 32% higher rates of ED visits (p < 0.05) pre and post-screening compared to those screening negative. Screen positive also showed 39% higher rates of hospitalizations pre-screening (p < 0.05) and 58% higher rates post-screening (p < 0.01). While screen-detected cognitive impairment was associated with some relevant provider follow-up action in 32% of individuals, subsequent healthcare utilization did not change between the 18-month pre- and post-screening periods. Despite being associated with higher rates of healthcare utilization, screening positive on the MC led to a change in provider action in a minority of cases and did not reduce post-screening healthcare utilization. Screening for cognitive impairment alone is not sufficient to alter patterns of provider practice or patient healthcare utilization.

Defense and Veterans Brain Injury Center: The First 25 Years

Defense and Veterans Brain Injury Center: The First 25 Years

Pharmacists providing care in the outpatient setting through telemedicine models: a narrative review.

Telemedicine refers to the delivery of clinical services using technology that allows two-way, real time, interactive communication between the patient and the clinician at a distant site. Commonly, telemedicine is used to improve access to general and specialty care for patients in rural areas. This review aims to provide an overview of existing telemedicine models involving the delivery of care by pharmacists via telemedicine (including telemonitoring and video, but excluding follow-up telephone calls) and to highlight the main areas of chronic-disease management where these models have been applied. Studies within the areas of hypertension, diabetes, asthma, anticoagulation and depression were identified, but only two randomized controlled trials with adequate sample size demonstrating the positive impact of telemonitoring combined with pharmacist care in hypertension were identified. The evidence for the impact of pharmacist-based telemedicine models is sparse and weak, with the studies conducted presenting serious threats to internal and external validity. Therefore, no definitive conclusions about the impact of pharmacist-led telemedicine models can be made at this time. In the Unites States, the increasing shortage of primary care providers and specialists represents an opportunity for pharmacists to assume a more prominent role managing patients with chronic disease in the ambulatory care setting. However, lack of reimbursement may pose a barrier to the provision of care by pharmacists using telemedicine.

Meeting the Needs of Patients for Specialty Care

Meeting the Needs of Patients for Specialty Care

Sleep disturbances and substance use disorders: An international study of primary care and mental health specialty care patients

IntroductionThere is no comprehensive evidence on the influence of sleep disturbances (SD) on substance use disorders (SUD) or treatment use patterns of individuals with comorbid disturbances.Objective/aimTo better understand comorbidities and treatment use patterns of individuals with SD and SUD.MethodsWe combine 2010–2012 electronic health record (EHR) data from healthcare system in Boston (n = 131,966 person-years) and Madrid, Spain (n = 43,309 person-years). Patients with sleep disturbances (SD) were identified in the EHR through ICD-9 codes and medical records and substance use disorders (SUD) identified by documented treatment for drug or alcohol abuse or dependence. Rates of SUD are compared between individuals with and without SD. Among those with both, adequacy of mental health treatment (defined as eight or more outpatient visits or four or more outpatient visits with a psychotropic prescription) and ER use is compared.ResultsAmong the individuals, 21.1% with SD also report SUD, compared to only 10.6% of individuals without SD (P &lt; .01). Those with comorbidities were more likely than their specialty care counterparts without comorbidities to be seen in the ER (57.1% vs. 36.6%, respectively, P &lt; .05). Limiting the sample to only those with both SD and SUD in specialty mental health care (n = 268 in Boston and n = 28 in Madrid), 49.2% of Boston patients received adequate care compared to 38.5% of Madrid patients, and 57.8% of Boston patients had any ER use in the last year vs. 50% of Madrid patients.ConclusionsSD is correlated with SUD and comorbid patients are more likely to use emergency services.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Patterns of health care utilization for low back pain.

BackgroundThe purpose of this study was to determine if primary care patients with low back pain (LBP) cluster into definable care utilization subgroups that can be explained by patient and provider characteristics.Materials and methodsAdult primary care patients with an incident LBP encounter were identified from Geisinger Clinic electronic health records over 5 years. Two-thirds of the cohort had only one to two encounters. Principal component analysis was applied to the data from the remaining one-third on use of ambulatory, inpatient, emergency department, and surgery care and use of magnetic resonance imaging, injections, and opioids in 12 months following the incident encounter. Groups were compared on demographics, health behaviors, chronic and symptomatic disease burden, and a measure of physician efficiency.ResultsSix factors with eigenvalues >1.5 explained 71% of the utilization variance. Patient subgroups were defined as: 1–2 LBP encounters; 2+ surgeries; one surgery; specialty care without primary care; 3+ opioid prescriptions; laboratory dominant care; and others. The surgery and 3+ opioid subgroups, while accounting for only 10.4% of the cohort, had used disproportionately more magnetic resonance imaging, emergency department, inpatient, and injectable resources. The specialty care subgroup was characterized by heavy use of inpatient care and the lowest use of injectables. Anxiety disorder and depression were not more prevalent among the surgery patients than in the others. Surgery patients had features in common with specialty care patients, but were older, had higher prevalence of Fibromyalgia, and were associated primary care physicians with worse efficiency scores.ConclusionLBP care utilization is highly variable and concentrated in small subgroups using disproportionate amounts of potentially avoidable care that reflect both patient and provider characteristics.

Referring Periodontal Patients: Clinical Decision Making by Dental and Dental Hygiene Students

Referral of periodontal patients requires development of a complex set of decision making skills. This study was conducted to determine criteria used by dental and dental hygiene students regarding the referral of periodontal patients for specialty care. Using mixed methods, a thirteen-item survey was developed to elicit the students' perceptions of their knowledge, confidence regarding managing patients, and clinical reasoning related to periodontal patients. The instrument was administered during the summer prior to (T1) and at the end of the students' final year (T2) of training. Seventy-nine dental students (81 percent of total class) and thirty dental hygiene students (83 percent of total class) completed T1. At T2, forty-two dental (44 percent of total class) and twenty-six dental hygiene students (87 percent of total class) completed the questionnaire. While 90 percent of dental and 96 percent of dental hygiene respondents reported a willingness to refer patients with active disease to specialists, only 40 percent of dental and 36 percent of dental hygiene respondents reported confidence in diagnosing, treating, and appropriately referring such patients. The students' ability to recognize critical disease and risk factors influencing referral was good; however, clinical application of that knowledge indicated a gap between knowledge and applied reasoning. The students' attitudes about the importance of periodontal disease and their perceived competence to identify critical disease risk factors were not significantly related (p>0.05) to correct clinical decisions in the case scenarios. The study concludes that dental and dental hygiene curricula should emphasize both the acquisition and application of knowledge regarding criteria for referral of periodontal patients.