National Study of Health Insurance Type and Reasons for Emergency Department Use

BACKGROUND

The rates of emergency department (ED) utilization vary substantially by type of health insurance, but the association between health insurance type and patient-reported reasons for seeking ED care is unknown.

OBJECTIVE

We evaluated the association between health insurance type and self-perceived acuity or access issues among individuals discharged from the ED.

DESIGN, PATIENTS

This was a cross-sectional analysis of the 2011 National Health Interview Survey. Adults whose last ED visit did not result in hospitalization (n?=?4,606) were asked structured questions about reasons for seeking ED care. We classified responses as 1) perceived need for immediate evaluation (acuity issues), or 2) barriers to accessing outpatient services (access issues).

MAIN MEASURES

We analyzed survey-weighted data using multivariable logistic regression models to test the association between health insurance type and reasons for ED visits, while adjusting for sociodemographic characteristics.

KEY RESULTS

Overall, 65.0 % (95 % CI 63.0–66.9) of adults reported ≥ 1 acuity issue and 78.9 % (95 % CI 77.3–80.5) reported ≥ 1 access issue. Among those who reported no acuity issue leading to the most recent ED visit, 84.2 % reported ≥ 1 access issue. Relative to those with private insurance, adults with Medicaid (OR 1.05; 95 % CI 0.79–1.40) and those with Medicare (OR 0.98; 95 % CI 0.66–1.47) were similarly likely to seek ED care due to an acuity issue. Adults with Medicaid (OR 1.50; 95 % CI 1.06–2.13) and Medicaid + Medicare (dual eligible) (OR 1.94; 95 % CI 1.18–3.19) were more likely than those with private insurance to seek ED care for access issues.

CONCLUSION

Variability in reasons for seeking ED care among discharged patients by health insurance type may be driven more by lack of access to alternate care, rather than by differences in patient-perceived acuity. Policymakers should focus on increasing access to alternate sites of care, particularly for Medicaid beneficiaries, as well as strategies to increase care coordination that involve ED patients and providers.     

Retail Clinic Visits and Receipt of Primary Care

BACKGROUND

An increasing number of patients are visiting retail clinics for simple acute conditions. Physicians worry that visits to retail clinics will interfere with primary care relationships. No prior study has evaluated the impact of retail clinics on receipt of primary care.

OBJECTIVE

To assess the association between retail clinic use and receipt of key primary care functions.

DESIGN

We performed a retrospective cohort analysis using commercial insurance claims from 2007 to 2009.

PATIENTS

We identified patients who had a visit for a simple acute condition in 2008, the “index visit”. We divided these 127,358 patients into two cohorts according to the location of that index visit: primary care provider (PCP) versus retail clinic.

MAIN MEASURES

We evaluated three functions of primary care: (1) where patients first sought care for subsequent simple acute conditions; (2) continuity of care using the Bice–Boxerman index; and (3) preventive care and diabetes management. Using a difference-in-differences approach, we compared care received in the 365 days following the index visit to care received in the 365 days prior, using propensity score weights to account for selection bias.

KEY RESULTS

Visiting a retail clinic instead of a PCP for the index visit was associated with a 27.7 visits per 100 patients differential reduction (p?< 0?.001) in subsequent PCP visits for new simple acute conditions. Visiting a retail clinic instead of a PCP was also associated with decreased subsequent continuity of care (10.9 percentage-point differential reduction in Bice–Boxerman index, p?< 0?.001). There was no differential change between the cohorts in receipt of preventive care or diabetes management.

CONCLUSIONS

Retail clinics may disrupt two aspects of primary care: whether patients go to a PCP first for new conditions and continuity of care. However, they do not negatively impact preventive care or diabetes management.     

Primary Care Utilization and Mental Health Diagnoses Among Adult Patients Requiring Interpreters: a Retrospective Cohort Study

BACKGROUND

Patients requiring interpreters may utilize the health care system differently or more frequently than patients not requiring interpreters; those with mental health issues may be particularly difficult to diagnose.

OBJECTIVE

To determine whether adult patients requiring interpreters exhibit different health care utilization patterns and rates of mental health diagnoses than their counterparts.

Design

Retrospective cohort study examining patient visits to primary care (PC), express care (EC), or the emergency department (ED) of a large group practice within 1 year.

PATIENTS

Adult outpatients (n?=?63,525) with at least one visit within the study interval and information regarding interpreter need.

MAIN MEASURES

Mean visit counts, counts of mental disorders, and somatic symptom diagnoses between patients requiring interpreters (IS patients) and not requiring interpreters (non-IS patients).

KEY RESULTS

IS patients (n?=?1,566) had a higher mean number of visits overall (3.10 vs. 2.52), in PC (2.54 vs. 1.95), and in ED (0.53 vs. 0.44) than non-IS patients (all p?<?0.01). IS patients had a lower mean number of visits in EC than non-IS patients (0.03 vs. 0.13; p?<?0.01). Interpreter need remained a significant predictor of visit count in multivariate analyses including age, sex, insurance, and clinical complexity. A greater proportion of IS patients were high utilizers (10+ visits) than non-IS patients (3.6 % vs. 1.7 %; p?<?0.01). IS patients had a lower frequency of mental health diagnoses (13.9 % vs. 16.7 %), but a higher frequency of diagnoses recognized as potential somatic symptoms including diseases of the nervous (29.3 % vs. 24.2 %), digestive (22.6 % vs. 14.5 %), and musculoskeletal systems (43.2 % vs. 34.5 %), and ill-defined conditions (61 % vs. 49.9 %), all p?<?0.01.

CONCLUSIONS

IS patients visited PC more often than their counterparts and were more often high utilizers of care. Two sources of high utilization, mental health diagnoses and somatic symptoms, differed appreciably between our populations and may be contributing factors.     

Health Care Contacts in the Year Before Suicide Death

BACKGROUND

Suicide prevention is a public health priority, but no data on the health care individuals receive prior to death are available from large representative United States population samples.

OBJECTIVE

To investigate variation in the types and timing of health services received in the year prior to suicide, and determine whether a mental health condition was diagnosed.

DESIGN

Longitudinal study from 2000 to 2010 within eight Mental Health Research Network health care systems serving eight states.

PARTICIPANTS

In all, 5,894 individuals who died by suicide, and were health plan members in the year before death.

MAIN MEASURES

Health system contacts in the year before death. Medical record, insurance claim, and mortality records were linked via the Virtual Data Warehouse, a federated data system at each site.

KEY RESULTS

Nearly all individuals received health care in the year prior to death (83 %), but half did not have a mental health diagnosis. Only 24 % had a mental health diagnosis in the 4-week period prior to death. Medical specialty and primary care visits without a mental health diagnosis were the most common visit types. The individuals more likely to make a visit in the year prior to death (p?<?0.05) tended to be women, individuals of older age (65+ years), those where the neighborhood income was over $40,000 and 25 % were college graduates, and those who died by non-violent means.

CONCLUSIONS

This study indicates that opportunities for suicide prevention exist in primary care and medical settings, where most individuals receive services prior to death. Efforts may target improved identification of mental illness and suicidal ideation, as a large proportion may remain undiagnosed at death.     

Specialty Use Among Patients With Treated Hypertension in a Patient-Centered Medical Home

BACKGROUND

Little is known about how delivery of primary care in the patient-centered medical home (PCMH) influences outpatient specialty care use.

OBJECTIVE

To describe changes in outpatient specialty use among patients with treated hypertension during and after PCMH practice transformation.

DESIGN

One-group, 48-month interrupted time series across baseline, PCMH implementation and post-implementation periods.

PATIENTS

Adults aged 18–85 years with treated hypertension.

INTERVENTION

System-wide PCMH redesign implemented across 26 clinics in an integrated health care delivery system, beginning in January 2009.

MAIN MEASURES

Resource Utilization Band variables from the Adjusted Clinical Groups case mix software characterized overall morbidity burden (low, medium, high). Negative binomial regression models described adjusted annual differences in total specialty care visits. Poisson regression models described adjusted annual differences in any use (yes/no) of selected medical and surgical specialties.

KEY RESULTS

Compared to baseline, the study population averaged 7 % fewer adjusted specialty visits during implementation (P?<?0.001) and 4 % fewer adjusted specialty visits in the first post-implementation year (P?=?0.02). Patients were 12 % less likely to have any cardiology visits during implementation and 13 % less likely during the first post-implementation year (P?<?0.001). In interaction analysis, patients with low morbidity had at least 27 % fewer specialty visits during each of 3 years following baseline (P?<?0.001); medium morbidity patients had 9 % fewer specialty visits during implementation (P?<?0.001) and 5 % fewer specialty visits during the first post-implementation year (P?=?0.007); high morbidity patients had 3 % (P?=?0.05) and 5 % (P?=?0.009) higher specialty use during the first and second post-implementation years, respectively.

CONCLUSIONS

Results suggest that more comprehensive primary care in this PCMH redesign enabled primary care teams to deliver more hypertension care, and that many needs of low morbidity patients were within the scope of primary care practice. New approaches to care coordination between primary care teams and specialists should prioritize high morbidity, clinically complex patients.     

Access to Care After Massachusetts’ Health Care Reform: A Safety Net Hospital Patient Survey

BACKGROUND

Massachusetts’ health care reform substantially decreased the percentage of uninsured residents. However, less is known about how reform affected access to care, especially according to insurance type.

OBJECTIVE

To assess access to care in Massachusetts after implementation of health care reform, based on insurance status and type.

DESIGN AND PARTICIPANTS

We surveyed a convenience sample of 431 patients presenting to the Emergency Department of Massachusetts’ second largest safety net hospital between July 25, 2009 and March 20, 2010.

MAIN MEASURES

Demographic and clinical characteristics, insurance coverage, measures of access to care and cost-related barriers to care.

KEY RESULTS

Patients with Commonwealth Care and Medicaid, the two forms of insurance most often newly-acquired under the reform, reported similar or higher utilization of and access to outpatient visits and rates of having a usual source of care, compared with the privately insured. Compared with the privately insured, a significantly higher proportion of patients with Medicaid or Commonwealth Care Type 1 (minimal cost sharing) reported delaying or not getting dental care (42.2 % vs. 27.1 %) or medication (30.0 % vs. 7.0 %) due to cost; those with Medicaid also experienced cost-related barriers to seeing a specialist (14.6 % vs. 3.5 %) or getting recommended tests (15.6 % vs. 5.9 %). Those with Commonwealth Care Types 2 and 3 (greater cost sharing) reported significantly more cost-related barriers to obtaining care than the privately insured (45.0 % vs. 16.0 %), to seeing a primary care doctor (25.0 % vs. 6.0 %) or dental provider (58.3 % vs. 27.1 %), and to obtaining medication (20.8 % vs. 7.0 %). No differences in cost-related barriers to preventive care were found between the privately and publicly insured.

CONCLUSIONS

Access to care improved less than access to insurance following Massachusetts’ health care reform. Many newly insured residents obtained Medicaid or state subsidized private insurance; cost-related barriers to access were worse for these patients than for the privately insured.     

Trends and Quality of Care in Outpatient Visits to Generalist and Specialist Physicians Delivering Primary Care in the United States, 1997–2010

BACKGROUND

Although many specialists serve as primary care physicians (PCPs), the type of patients they serve, the range of services they provide, and the quality of care they deliver is uncertain.

OBJECTIVE

To describe trends in patient, physician, and visit characteristics, and compare visit-based quality for visits to generalists and specialists self-identified as PCPs.

DESIGN

Cross-sectional study and time trend analysis.

DATA

Nationally representative sample of visits to office-based physicians from the National Ambulatory Medical Care Survey, 1997–2010.

MAIN MEASURES

Proportions of primary care visits to generalist and specialists, patient characteristics, principal diagnoses, and quality.

KEY RESULTS

Among 84,041 visits to self-identified PCPs representing an estimated 4.0 billion visits, 91.5 % were to generalists, 5.9 % were to medical specialists and 2.6 % were to obstetrician/gynecologists. The proportion of PCP visits to generalists increased from 88.4 % in 1997 to 92.4 % in 2010, but decreased for medical specialists from 8.0 % to 4.8 %, p?=?0.04). The proportion of medical specialist visits in which the physician self-identified as the patient’s PCP decreased from 30.6 % in 1997 to 9.8 % in 2010 (p?<?0.01). Medical specialist PCPs take care of older patients (mean age 61 years), and dedicate most of their visits to chronic disease management (51.0 %), while generalist PCPs see younger patients (mean age 55.4 years) most commonly for new problems (40.5 %). Obstetrician/gynecologists self-identified as PCPs see younger patients (mean age 38.3 p?<?0.01), primarily for preventive care (54.0 %, p?<?0.01). Quality of care for cardiovascular disease was better in visits to cardiologists than in visits to generalists, but was similar or better in visits to generalists compared to visits to other medical specialists.

CONCLUSIONS

Medical specialists are less frequently serving as PCPs for their patients over time. Generalist, medical specialist, and obstetrician/gynecologist PCPs serve different primary care roles for different populations. Delivery redesign efforts must account for the evolving role of generalist and specialist PCPs in the delivery of primary care.     

The prevalence and associated risk factors of sleep disorder-related symptoms in pregnant women in China

Purpose

The sleep disorder in pregnant women remains unfamiliar to perinatal care providers, resulting in lack of appropriate care. This study was designed to investigate the prevalence of sleep disorder-related symptoms in pregnant women and to identify the associated risk factors.

Methods

Married pregnant women were enrolled from their first trimester and followed up until delivery. Nonpregnant married healthy women were selected as controls. A survey questionnaire was administered to each of them.

Results

We successfully performed a survey to 1,993 pregnant women and 598 nonpregnant women. The overall prevalence of sleep disorder-related symptoms in pregnant women was significantly higher than the controls (56.1 vs. 29.9 %, P?<?0.05). There was higher prevalence of snoring (30.2 %), observed sleep apnea (1.1 %), mouth breathing (23.7 %), nocturnal arousal (46.5 %), insomnia (35.1 %), and daytime sleepiness (52.6 %) in pregnant women. There were no significant differences of the prevalence of bruxism (7.0 vs. 6.7 %), sleep talking (8.1 vs. 7.2 %), and sleep walking (0.4 vs. 0.2 %) between the two groups (P?>?0.05). Nocturnal sleep time (8.0?±?1.3 h) was less in the third trimester compared with the nonpregnant women (8.2?±?1.1 h) (P?<?0.05). Smoking (OR?=?3.39), drinking (OR?=?2.40), allergic rhinitis/asthma (OR?=?1.71), an obvious difference in neck circumference (OR?=?1.11), and waistline (OR?=?1.07) changes between the first and third trimesters were the risk factors for sleep disorder-related problems.

Conclusions

There is a high prevalence of sleep disorder-related symptoms in pregnant women. Our data may provide a baseline for prevention and treatment of sleep disturbances in pregnant women.     

Primary Care Careers Among Recent Graduates of Research-Intensive Private and Public Medical Schools

BACKGROUND

Despite a growing need for primary care physicians in the United States, the proportion of medical school graduates pursuing primary care careers has declined over the past decade.

OBJECTIVE

To assess the association of medical school research funding with graduates matching in family medicine residencies and practicing primary care.

DESIGN

Observational study of United States medical schools.

PARTICIPANTS

One hundred twenty-one allopathic medical schools.

MAIN MEASURES

The primary outcomes included the proportion of each school’s graduates from 1999 to 2001 who were primary care physicians in 2008, and the proportion of each school’s graduates who entered family medicine residencies during 2007 through 2009. The 25 medical schools with the highest levels of research funding from the National Institutes of Health in 2010 were designated as “research-intensive.”

KEY RESULTS

Among research-intensive medical schools, the 16 private medical schools produced significantly fewer practicing primary care physicians (median 24.1 % vs. 33.4 %, p?<?0.001) and fewer recent graduates matching in family medicine residencies (median 2.4 % vs. 6.2 %, p?<?0.001) than the other 30 private schools. In contrast, the nine research-intensive public medical schools produced comparable proportions of graduates pursuing primary care careers (median 36.1 % vs. 36.3 %, p?=?0.87) and matching in family medicine residencies (median 7.4 % vs. 10.0 %, p?=?0.37) relative to the other 66 public medical schools.

CONCLUSIONS

To meet the health care needs of the US population, research-intensive private medical schools should play a more active role in promoting primary care careers for their students and graduates.     

Insulin pump use in pregnancy is associated with lower HbA1c without increasing the rate of severe hypoglycaemia or diabetic ketoacidosis in women with type 1 diabetes

Aims/hypothesis

The aim of this study was to compare glycaemic control and maternal–fetal outcomes in women with type 1 diabetes managed on insulin pumps compared with multiple daily injections of insulin (MDI).

Methods

In a retrospective study, glycaemic control and outcomes of 387 consecutive pregnancies in women with type 1 diabetes who attended specialised clinics at three centres 2006–2010 were assessed.

Results

Women using insulin pumps (129/387) were older and had a longer duration of diabetes, more retinopathy, smoked less in pregnancy, and had more preconception care (p?<?0.01 for each). Among 113 pregnancies >20 weeks’ gestation in women on insulin pumps and 218 in women on MDI, there was a significant difference in HbA_1c in the first trimester (mean HbA_1c 6.90?±?0.71% (52?±?7.8 mmol/mol) vs 7.60?±?1.38% (60?±?15.1 mmol/mol), p?<?0.001), which persisted until the third trimester (mean HbA_1c 6.49?±?0.52% (47?±?5.7 mmol/mol) vs 6.81?±?0.85% (51?±?9.3 mmol/mol), p?=?0.002). Rates of diabetic ketoacidosis were similar in women on insulin pumps vs MDI (1.8% vs 3.0%, p?=?0.72). Despite lower HbA_1c, women on insulin pumps did not have an increased incidence of severe hypoglycaemia (8.0% vs 7.6%, p?=?0.90) or more weight gain (16.3?±?8.7 vs 15.2?±?6.2 kg, p?=?0.18). More large-for-gestational-age infants in the pump group (55.0% vs 39.2%, p?=?0.007) may have resulted from confounding by parity.

Conclusions/interpretation

In this large multicentre study, women using insulin pumps in pregnancy had lower HbA_1c without increased risk of severe hypoglycaemia or diabetic ketoacidosis but no improvement in other pregnancy outcomes. This information can help inform care providers and patients about the glycaemic effectiveness and safety of insulin pumps in pregnancy.     

Evaluation of the impact of a clinical pathway on the organization of a multidisciplinary dental sleep clinic

Purpose

Clinical pathways are used to organize complex care processes by providing structure and standardization. The multidisciplinary approach of oral appliance (OA) therapy for sleep-disordered breathing (SDB) is a complex and dynamic process suitable for such a structured pathway approach.

Methods

A clinical pathway for patients referred for OA therapy was developed and implemented. The aim of this study was to evaluate the impact of this clinical pathway on the time to delivery of the OA and the organization of the multidisciplinary dental sleep clinic (MDSC). The latter was achieved using the care process self-evaluation tool (CPSET).

Results

First, development and implementation of the clinical pathway gave structure and shortened the mean time to delivery by 102 days (240?±?70 vs. 138?±?33 days) (Mann–Whitney U: P?<?0.001). Second, the CPSET scores were obtained in a cohort of 49 healthcare professionals involved in the pathway. Overall, patient-focused organization received the highest scores (80.5?±?9.0 %), whereas cooperation with primary care received the lowest score (66.7?±?12.4 %).

Conclusions

This is the first project on clinical pathways in OA therapy for SDB. The implementation of the pathway in our MDSC has created a significant shortening of the time to delivery. A first evaluation of the clinical pathway using the CPSET scores indicates that all disciplines involved should be thoroughly informed in an ongoing approach.     

Randomized, Controlled Trial of a Multimodal Intervention to Improve Cancer Screening Rates in a Safety-Net Primary Care Practice

Background

Cancer screening rates are suboptimal for low-income patients.

Objective

To assess an intervention to increase cancer screening among patients in a safety-net primary care practice.

Design

Patients at an inner-city family practice who were overdue for cancer screening were randomized to intervention or usual care. Screening rates at 1 year were compared using the chi-square test, and multivariable analysis was performed to adjust for patient factors.

Subjects

All average-risk patients at an inner-city family practice overdue for mammography or colorectal cancer (CRC) screening. Patients’ ages were 40 to 74 years (mean 53.9, SD 8.7) including 40.8 % African Americans, 4.2 % Latinos, 23.2 % with Medicaid and 10.9 % without any form of insurance.

Intervention

The 6-month intervention to promote cancer screening included letters, automated phone calls, prompts and a mailed Fecal Immunochemical Testing (FIT) Kit.

Main Measures

Rates of cancer screening at 1 year.

Key Results

Three hundred sixty-six patients overdue for screening were randomly assigned to intervention (n?=?185) or usual care (n?=?181). Primary analysis revealed significantly higher rates of cancer screening in intervention subjects: 29.7 % vs. 16.7 % for mammography (p?=?0.034) and 37.7 % vs. 16.7 % for CRC screening (p?=?0.0002). In the intervention group, 20 % of mammography screenings and 9.3 % of CRC screenings occurred at the early assessment, while the remainder occurred after repeated interventions. Within the CRC intervention group 44 % of screened patients used the mailed FIT kit. On multivariable analysis the CRC screening rates remained significantly higher in the intervention group, while the breast cancer screening rates were not statistically different.

Conclusions

A multimodal intervention significantly increased CRC screening rates among patients in a safety-net primary care practice. These results suggest that relatively inexpensive letters and automated calls can be combined for a larger effect. Results also suggest that mailed screening kits may be a promising way to increase average-risk CRC screening.     

Characteristics, Management, and Depression Outcomes of Primary Care Patients Who Endorse Thoughts of Death or Suicide on the PHQ-9

BACKGROUND

With increasing emphasis on integrating behavioral health services, primary care providers play an important role in managing patients with suicidal thoughts.

OBJECTIVE

To evaluate whether Patient Health Questionnaire-9 (PHQ-9) Item 9 scores are associated with patient characteristics, management, and depression outcomes in a primary care-based mental health program.

DESIGN

Observational analysis of data collected from a patient registry.

PARTICIPANTS

Eleven thousand fifteen adults enrolled in the Mental Health Integration Program (MHIP).

INTERVENTIONS

MHIP provides integrated mental health services for safety-net populations in over 100 community health centers across Washington State. Key elements of the team-based model include: a disease registry; integrated care management; and organized psychiatric case review.

MAIN MEASURES

The independent variable, suicidal ideation (SI), was assessed by PHQ-9 Item 9. Depression severity was assessed with the PHQ-8. Outcomes included four indicators of depression treatment process (care manager contact, psychiatric case review, psychotropic medications, and specialty mental health referral), and two indicators of depression outcomes (50 % reduction in PHQ-9 score and PHQ-9 score?<?10).

KEY RESULTS

SI was common (45.2 %) at baseline, with significantly higher rates among men and patients with greater psychopathology. Few patients with SI (5.4 %) lacked substantial current depressive symptoms. After adjusting for age, gender, and severity of psychopathology, patients with SI received follow-up earlier (care manager contact HR?=?1.05, p?<?0.001; psychiatric review HR?=?1.02, p?<?0.05), and were more likely to receive psychotropic medications (OR?=?1.11, p?=?0.001) and specialty referral (OR?=?1.23, p?<?0.001), yet were less likely to achieve a PHQ-9 score?<?10 (HR?=?0.87, p?<?0.001).

CONCLUSIONS

Suicidal thoughts are common among safety-net patients referred by primary care providers for behavioral health care. Scores on Item 9 of the PHQ-9 are easily obtainable in primary care, may help providers initiate conversations about suicidality, and serve as useful markers of psychiatric complexity and treatment-resistance. Patients with positive scores should receive timely and comprehensive psychiatric evaluation and follow-up.     

A Randomized Trial of Treatments for High-Utilizing Somatizing Patients

BACKGROUND

Somatization and hypochondriacal health anxiety are common sources of distress, impairment, and costly medical utilization in primary care practice. A range of interventions is needed to improve the care of these patients.

OBJECTIVE

To determine the effectiveness of two cognitive behavioral interventions for high-utilizing, somatizing patients, using the resources found in a routine care setting.

DESIGN

Patients were randomly assigned to a two-step cognitive behavioral treatment program accompanied by a training seminar for their primary care physicians, or to relaxation training. Providers routinely working in these patients’ primary care practices delivered the cognitive behavior therapy and relaxation training. A follow-up assessment was completed immediately prior to treatment and 6 and 12 months later.

SUBJECTS

Eighty-nine medical outpatients with elevated levels of somatization, hypochondriacal health anxiety, and medical care utilization.

MEASUREMENTS

Somatization and hypochondriasis, overall psychiatric distress, and role impairment were assessed with well-validated, self-report questionnaires. Outpatient visits and medical care costs before and after the intervention were obtained from the encounter claims database.

RESULTS

At 6 month and 12 month follow-up, both intervention groups showed significant improvements in somatization (p?< 0.01), hypochondriacal symptoms (p?<?0.01), overall psychiatric distress (p?< 0.01), and role impairment (p?<?0.01). Outcomes did not differ significantly between the two groups. When both groups were combined, ambulatory visits declined from 10.3 to 8.8 (p?=?0.036), and mean ambulatory costs decreased from $3,574 to $2,991 (p?=?0.028) in the year preceding versus the year following the interventions. Psychiatric visits and costs were unchanged.

CONCLUSIONS

Two similar cognitive behavioral interventions, delivered with the resources available in routine primary care, improved somatization, hypochondriacal symptoms, overall psychiatric distress, and role function. They also reduced the ambulatory visits and costs of these high utilizing outpatients.     

Exercise as a Vital Sign: A Quasi-Experimental Analysis of a Health System Intervention to Collect Patient-Reported Exercise Levels

BACKGROUND

Lack of regular physical activity is highly prevalent in U.S. adults and significantly increases mortality risk.

OBJECTIVE

To examine the clinical impact of a newly implemented program (“Exercise as a Vital Sign” [EVS]) designed to systematically ascertain patient-reported exercise levels at the beginning of each outpatient visit.

DESIGN AND PARTICIPANTS

The EVS program was implemented in four of 11 medical centers between April 2010 and October 2011 within a single health delivery system (Kaiser Permanente Northern California). We used a quasi-experimental analysis approach to compare visit-level and patient-level outcomes among practices with and without the EVS program. Our longitudinal observational cohort included over 1.5 million visits by 696,267 adults to 1,196 primary care providers.

MAIN MEASURES

Exercise documentation in physician progress notes; lifestyle-related referrals (e.g. exercise programs, nutrition and weight loss consultation); patient report of physician exercise counseling; weight change among overweight/obese patients; and HbA1c changes among patients with diabetes.

KEY RESULTS

EVS implementation was associated with greater exercise-related progress note documentation (26.2 % vs 23.7 % of visits, aOR 1.12 [95 % CI: 1.11–1.13], p?<?0.001) and referrals (2.1 % vs 1.7 %; aOR 1.14 [1.11–1.18], p?<?0.001) compared to visits without EVS. Surveyed patients (n?=?6,880) were more likely to report physician exercise counseling (88 % vs. 76 %, p?<?0.001). Overweight patients (BMI 25–29 kg/m², n?=?230,326) had greater relative weight loss (0.20 [0.12 – 0.28] lbs, p?<?0.001) and patients with diabetes and baseline HbA1c?>?7.0 % (n?=?30,487) had greater relative HbA1c decline (0.1 % [0.07 %–0.13 %], p?<?0.001) in EVS practices compared to non-EVS practices.

CONCLUSIONS

Systematically collecting exercise information during outpatient visits is associated with small but significant changes in exercise-related clinical processes and outcomes, and represents a valuable first step towards addressing the problem of inadequate physical activity.     

Impact of Information Leaflets on Behavior of Patients with Gastroenteritis or Tonsillitis: A Cluster Randomized Trial in French Primary Care

OBJECTIVE

To assess the impact of four patient information leaflets on patients’ behavior in primary care.

DESIGN

Cluster randomized multicenter controlled trial between November 2009 and January 2011.

PARTICIPANTS

French adults and children consulting a participating primary care physician and diagnosed with gastroenteritis or tonsillitis. Patients were randomized to receive patient information leaflets or not, according to the cluster randomization of their primary care physician.

INTERVENTION

Adult patients or adults accompanying a child diagnosed with gastroenteritis or tonsillitis were informed of the study. Physicians in the intervention group gave patients an information leaflet about their condition. Two weeks after the consultation patients (or their accompanying adult) answered a telephone questionnaire on their behavior and knowledge about the condition.

MAIN MEASURES

The main and secondary outcomes, mean behavior and knowledge scores respectively, were calculated from the replies to this questionnaire.

RESULTS

Twenty-four physicians included 400 patients. Twelve patients were lost to follow-up (3 %). In the group that received the patient information leaflet, patient behavior was closer to that recommended by the guidelines than in the control group (mean behavior score 4.9 versus 4.2, p?<?0.01). Knowledge was better for adults receiving the leaflet than in the control group (mean knowledge score 4.2 versus 3.6, p?<?0.01). There were fewer visits for the same symptoms by household members of patients given leaflets (23.4 % vs. 56.2 %, p?<?0.01).

CONCLUSION

Patient information leaflets given by the physician during the consultation significantly modify the patient’s behavior and knowledge of the disease, compared with patients not receiving the leaflets, for the conditions studied.     

Weight Loss Success in Metabolic Syndrome by Telephone Interventions: Results from the SHINE Study

BACKGROUND

The Diabetes Prevention Program (DPP) intensive lifestyle intervention resulted in significant weight loss, reducing the development of diabetes, but needs to be adapted to primary care provider (PCP) practices.

OBJECTIVES

To compare a DPP-translation using individual (IC) vs. conference (CC) calls delivered by PCP staff for the outcome of percent weight loss over 2 years.

DESIGN

Randomized clinical trial.

SETTING

Five PCP sites.

PARTICIPANTS

Obese patients with metabolic syndrome, without diabetes (IC, n?=?129; CC, n?=?128).

INTERVENTION

Telephone delivery of the DPP Lifestyle Balance intervention [16-session core curriculum in year 1, 12-session continued telephone contact in year 2 plus telephone coaching sessions (dietitians).

MAIN MEASURES

Weight (kg), body mass index (BMI), and waist circumference.

KEY RESULTS

Baseline data: age?=?52 years, BMI?=?39 kg/m², 75 % female, 85 % non-Hispanic White, 13 % non-Hispanic Black, and 48 % annual incomes <$40,000/year. In the intention-to-treat analyses at year 2, mean percent weight loss was ?5.6 % (CC, p?<?0.001) and ?1.8 % (IC, p?=?0.046) and was greater for CC than for IC (p?=?0.016). At year 2, mean weight loss was 6.2 kg (CC) and 2.2 kg (IC) (p?<?0.001). There was similar weight loss at year 1, but between year 1 and year 2 CC participants continued to lose while IC participants regained. At year 2, 52 % and 43 % (CC) and 29 % and 22 % (IC) of participants lost at least 5 % and 7 % of initial weight. BMI also decreased more for CC than IC (?2.1 kg/m² vs. ?0.8 kg/m² p?<?0.001). Waist circumference decreased by 3.1 cm (CC) and 2.4 cm (IC) at year 2. Completers (≥9 of 16 sessions; mean 13.3 sessions) lost significantly more weight than non-completers (mean 4.3 sessions).

CONCLUSIONS

PCP staff delivery of the DPP lifestyle intervention by telephone can be effective in achieving weight loss in obese people with metabolic syndrome. Greater weight loss may be attained with a group telephone intervention.     

Impact of 4 + 1 Block Scheduling on Patient Care Continuity in Resident Clinic

BACKGROUND

Leaders in medical education have called for redesign of internal medicine training to improve ambulatory care training. 4?+?1 block scheduling is one innovative approach to enhance ambulatory education.

AIM

To determine the impact of 4?+?1 scheduling on resident clinic continuity.

SETTING

Resident continuity clinic in traditional scheduling in which clinics are scheduled intermittently one-half day per week, compared to 4?+?1 in which residents alternate 1 week of clinic with 4 weeks of an inpatient rotation or elective.

PARTICIPANTS

First-year internal medicine residents.

PROGRAM DESCRIPTION

We measured patient–provider visit continuity, phone triage encounter continuity, and lab follow-up continuity.

PROGRAM EVALUATION

In traditional scheduling as opposed to 4?+?1 scheduling, patients saw their primary resident provider a greater percentage; 71.7 % vs. 63.0 % (p?=?0.008). In the 4?+?1 model, residents saw their own patients a greater percentage; 52.1 % vs. 37.1 % (p?=?0.0001). Residents addressed their own labs more often in 4?+?1 model; 90.7 % vs. 75.6 % (p?=?0.001). There was no significant difference in handling of triage encounters; 42.3 % vs. 35.8 % (p?=?0.12).

DISCUSSION

4?+?1 schedule improves visit continuity from a resident perspective, and may compromise visit continuity from the patient perspective, but allows for improved laboratory follow-up, which we pose should be part of an emerging modern definition of continuity.     

Sleep-disordered breathing and daytime napping are associated with maternal hyperglycemia

Objectives

Sleep disturbances in pregnancy may impair glucose mechanism. This study aimed to examine associations of sleep-disordered breathing, sleep, and nap duration with 1-h glucose challenge test (GCT) levels in pregnant women after controlling for known risk factors for gestational diabetes.

Methods

This is a case–control study of 104 pregnant women. All women underwent full polysomnography and a GCT and completed the multivariable apnea prediction and Pittsburgh Sleep Quality indexes. The primary outcome was maternal hyperglycemia measured by GCT. Bivariate and multivariable logistic regression analyses were performed.

Results

Over 13 % subjects reported habitual snoring in the first trimester. Only 9.3 % women with normoglycemia (GCT?<?135) were habitual snorers, whereas 45.5 % women with hyperglycemia (GCT?≥?135) had habitual snoring (p?<?0.001). Sleep-disordered breathing symptoms (loud snoring, snorting/gasping, and apneas) (odds ratio (OR) 2.85; 95 % confidence interval (CI) 1.50–5.41; p?=?0.001) and total nap duration (OR 1.48; 95 % CI 0.96–2.28; p?=?0.08) were associated with hyperglycemia. After adjusting for confounders, sleep-disordered breathing symptoms (OR 3.37; 95 % CI 1.44–8.32; p?=?0.005) and nap duration (OR 1.64; 95 % CI 1.00–2.681.02; p?=?0.05) continued to be associated with hyperglycemia. However, the primary exposure measure, the apnea/hypopnea index in the first trimester was not significantly associated with hyperglycemia (OR 1.03; 95 % CI 0.83–1.28; p?=?0.77).

Conclusions

Sleep-disordered breathing symptoms and nap duration are associated with hyperglycemia. Sleep duration was not associated with hyperglycemia. Research is needed concerning whether women with sleep-disordered breathing and/or daytime napping are at risk for gestational diabetes.