Accuracy of Race,Ethnicity, and Language Preference in an Electronic Health Record

BACKGROUND

Collection of data on race, ethnicity, and language preference is required as part of the “meaningful use” of electronic health records (EHRs). These data serve as a foundation for interventions to reduce health disparities.

OBJECTIVE

Our aim was to compare the accuracy of EHR-recorded data on race, ethnicity, and language preference to that reported directly by patients.

DESIGN/SUBJECTS/MAIN MEASURES

Data collected as part of a tobacco cessation intervention for minority and low-income smokers across a network of 13 primary care clinics (n = 569).

KEY RESULTS

Patients were more likely to self-report Hispanic ethnicity (19.6 % vs. 16.6 %, p < 0.001) and African American race (27.0 % vs. 20.4 %, p < 0.001) than was reported in the EHR. Conversely, patients were less likely to complete the survey in Spanish than the language preference noted in the EHR suggested (5.1 % vs. 6.3 %, p < 0.001). Thirty percent of whites self-reported identification with at least one other racial or ethnic group, as did 37.0 % of Hispanics, and 41.0 % of African Americans. Over one-third of EHR-documented Spanish speakers elected to take the survey in English. One-fifth of individuals who took the survey in Spanish were recorded in the EHR as English-speaking.

CONCLUSION

We demonstrate important inaccuracies and the need for better processes to document race/ ethnicity and language preference in EHRs.KEY WORDS: disparities, race, ethnicity, health information technology     

Association Between Study Quality and Publication Rates of Medical Education Abstracts Presented at the Society of General Internal Medicine Annual Meeting

Background

Studies reveal that 44.5 % of abstracts presented at national meetings are subsequently published in indexed journals, with lower rates for abstracts of medical education scholarship.

Objective

We sought to determine whether the quality of medical education abstracts is associated with subsequent publication in indexed journals, and to compare the quality of medical education abstracts presented as scientific abstracts versus innovations in medical education (IME).

Design

Retrospective cohort study.

Participants

Medical education abstracts presented at the Society of General Internal Medicine (SGIM) 2009 annual meeting.

Main Measures

Publication rates were measured using database searches for full-text publications through December 2013. Quality was assessed using the validated Medical Education Research Study Quality Instrument (MERSQI).

Key Results

Overall, 64 (44 %) medical education abstracts presented at the 2009 SGIM annual meeting were subsequently published in indexed medical journals. The MERSQI demonstrated good inter-rater reliability (intraclass correlation range, 0.77–1.00) for grading the quality of medical education abstracts. MERSQI scores were higher for published versus unpublished abstracts (9.59 vs. 8.81, p = 0.03). Abstracts with a MERSQI score of 10 or greater were more likely to be published (OR 3.18, 95 % CI 1.47–6.89, p = 0.003). ). MERSQI scores were higher for scientific versus IME abstracts (9.88 vs. 8.31, p < 0.001). Publication rates were higher for scientific abstracts (42 [66 %] vs. 37 [46 %], p = 0.02) and oral presentations (15 [23 %] vs. 6 [8 %], p = 0.01).

Conclusions

The publication rate of medical education abstracts presented at the 2009 SGIM annual meeting was similar to reported publication rates for biomedical research abstracts, but higher than publication rates reported for medical education abstracts. MERSQI scores were associated with higher abstract publication rates, suggesting that attention to measures of quality—such as sampling, instrument validity, and data analysis—may improve the likelihood that medical education abstracts will be published.KEY WORDS: medical education, medical education research, quality, publication     

The Effectiveness of a Physician-Only and Physician–Patient Intervention on Colorectal Cancer Screening Discussions Between Providers and African American and Latino Patients

BACKGROUND

Physician recommendation of colorectal cancer (CRC) screening is a critical facilitator of screening completion. Providing patients a choice of screening options may increase CRC screening completion, particularly among racial and ethnic minorities.

OBJECTIVE

Our purpose was to assess the effectiveness of physician-only and physician–patient interventions on increasing rates of CRC screening discussions as compared to usual care.

DESIGN

This study was quasi-experimental. Clinics were allocated to intervention or usual care; patients in intervention clinics were randomized to receipt of patient intervention.

PARTICIPANTS

Patients aged 50 to 75 years, due for CRC screening, receiving care at either a federally qualified health care center or an academic health center participated in the study.

INTERVENTION

Intervention physicians received continuous quality improvement and communication skills training. Intervention patients watched an educational video immediately before their appointment.

MAIN MEASURES

Rates of patient-reported 1) CRC screening discussions, and 2) discussions of more than one screening test.

KEY RESULTS

The physician–patient intervention (n = 167) resulted in higher rates of CRC screening discussions compared to both physician-only intervention (n = 183; 61.1 % vs.50.3 %, p = 0.008) and usual care (n = 153; 61.1 % vs. 34.0 % p = 0.03). More discussions of specific CRC screening tests and discussions of more than one test occurred in the intervention arms than in usual care (44.6 % vs. 22.9 %,p = 0.03) and (5.1 % vs. 2.0 %, p = 0.036), respectively, but discussion of more than one test was uncommon. Across all arms, 143 patients (28.4 %) reported discussion of colonoscopy only; 21 (4.2 %) reported discussion of both colonoscopy and stool tests.

CONCLUSIONS

Compared to usual care and a physician-only intervention, a physician–patient intervention increased rates of CRC screening discussions, yet discussions overwhelmingly focused solely on colonoscopy. In underserved patient populations where access to colonoscopy may be limited, interventions encouraging discussions of both stool tests and colonoscopy may be needed.KEY WORDS: colorectal cancer screening, health literacy, randomized trial, physician communication of preventive care     

Survival and Racial Differences of Non-Small Cell Lung Cancer in the United States Military

BACKGROUND

Lung cancer is the leading cause of cancer-related death in the United States (US) Military and worldwide, with non-small cell lung cancer (NSCLC) accounting for 87 % of cases.

OBJECTIVES

Using a US military cohort who receives equal and open access to healthcare, we sought to examine demographic, clinical features and outcomes with NSCLC.

DESIGN AND PARTICIPANTS

We conducted a retrospective cohort analysis of 4,751 patients, aged ≥ 18 years and diagnosed with a first primary NSCLC between 1 January 2003 and 31 December 2013 in the US Department of Defense (DoD) cancer registry.

MAIN MEASURES

Differences by patient and disease characteristics were compared using Chi-square and t-test. Kaplan Meier curves and Cox proportional hazards regression assessed overall survival.

RESULTS

The mean age at diagnosis was 66 years, 64 % were male, 72 % were Caucasian, 41 % were diagnosed at early stage, 77 % received treatment and 82 % had a history of tobacco use. Mean age at diagnosis was highest among Caucasians (67 years) and lowest among African Americans (AA; 62 years). Asian/Pacific Islanders (PI) were more likely to be female (p < 0.0001), have adenocarcinoma histology (p = 0.0003) and less likely to have a history of tobacco use (p < 0.0001) compared to other racial/ethnic groups. In multivariable survival analysis, older age, male gender, increasing stage, not receiving treatment, and tobacco history were associated with higher mortality risk. Untreated patients exhibited a 39 % higher mortality risk compared to treated patients (HR = 1.39; 95%CI = 1.23–1.57). Compared to Caucasian patients, Asian/PIs demonstrated a 20 % lower risk of death (HR = 0.80; 95%CI = 0.66–0.96). There was no difference in mortality risk between AAs and Hispanics compared to Caucasians.

CONCLUSION

The lack of significant outcome disparity between AAs and Caucasians and the earlier stage at diagnosis than usually seen in civilian populations suggest that equal access to healthcare may play a role in early detection and survival.KEY WORDS: military, lung cancer, survival outcomes     

The Relationship Between Food Insecurity and Depression,Diabetes Distress and Medication Adherence Among Low-Income Patients with Poorly-Controlled Diabetes

BACKGROUND

Food insecurity— lack of dependable access to adequate food—may play a role in poor diabetes control.

OBJECTIVE

We aimed to determine the relationship between food security status and depression, diabetes distress, medication adherence and glycemic control.

DESIGN

Secondary analysis of baseline data from Peer Support for Achieving Independence in Diabetes, a randomized controlled trial that enrolled patients from November 2011 to October 2013.

PARTICIPANTS

Participants had poorly controlled type 2 diabetes (A1c ≥ 8.0 % on eligibility screen), household income < 250 % of the federal poverty level, were 30–70 years old, and were recruited from a large public hospital, a VA medical center and a community-health center in King County, Washington.

MAIN MEASURES

We measured food insecurity determined by the Department of Agriculture’s 6-Item Food Security Module. Depression, diabetes distress and medication adherence measured by PHQ-8, Diabetes Distress Scale and Morisky Medication Adherence Scale, respectively. Diet was assessed through Summary of Diabetes Self-Care Activities and Starting the Conversation tool. Incidence of hypoglycemic episodes was by patient report. Glycemic control was assessed with glycosylated hemoglobin (A1c) values from fingerstick blood sample.

KEY RESULTS

The prevalence of food insecurity was 47.4 %. Chi-square tests revealed participants with food insecurity were more likely to be depressed (40.7 % vs. 15.4 %, p < 0.001), report diabetes distress (55.2 % vs. 33.8 %, p < 0.001) and have low medication adherence (52.9 % vs. 37.2 %, p = 0.02). Based on linear regression modeling, those with food insecurity had significantly higher mean A1c levels (β = 0.51; p = 0.02) after adjusting for sex, age, race/ethnicity, language, education, marital status, BMI, insulin use, depression, diabetes distress and low medication adherence.

CONCLUSIONS

Almost half of participants had food insecurity. Food insecurity was associated with depression, diabetes distress, low medication adherence and worse glycemic control. Even with adjustment, people with food insecurity had higher mean A1c levels than their food-secure counterparts, suggesting there may be other mediating factors, such as diet, that explain the relationship between food security status and diabetes control.KEY WORDS: food insecurity, diabetes, glycemic control     

Evaluating a Model to Predict Primary Care Physician-Defined Complexity in a Large Academic Primary Care Practice-Based Research Network

BACKGROUND

Improving the ability to risk-stratify patients is critical for efficiently allocating resources within healthcare systems.

OBJECTIVE

The purpose of this study was to evaluate a physician-defined complexity prediction model against outpatient Charlson score (OCS) and a commercial risk predictor (CRP).

DESIGN

Using a cohort in which primary care physicians reviewed 4302 of their adult patients, we developed a predictive model for estimated physician-defined complexity (ePDC) and categorized our population using ePDC, OCS and CRP.

PARTICIPANTS

143,372 primary care patients in a practice-based research network participated in the study.

MAIN MEASURES

For all patients categorized as complex in 2007 by one or more risk-stratification method, we calculated the percentage of total person time from 2008–2011 for which eligible cancer screening was incomplete, HbA1c was ≥ 9 %, and LDL was ≥ 130 mg/dl (in patients with cardiovascular disease). We also calculated the number of emergency department (ED) visits and hospital admissions per person year (ppy).

KEY RESULTS

There was modest agreement among individuals classified as complex using ePDC compared with OCS (36.7 %) and CRP (39.6 %). Over 4 follow-up years, eligible ePDC-complex patients had higher proportions (p < 0.001) of time with: incomplete cervical (17.8 % vs. 13.3 % for OCS; 19.4 % vs. 11.2 % for CRP), breast (21.4 % vs. 14.9 % for OCS; 22.7 % vs. 15.0 % for CRP), and colon (25.9 % vs. 18.7 % for OCS; 27.0 % vs. 18.2 % for CRP) cancer screening; HbA1c ≥ 9 % (15.6 % vs. 8.1 % for OCS; 15.9 % vs. 6.9 % for CRP); and LDL ≥ 130 mg/dl (12.4 % vs. 7.9 % for OCS; 11.8 % vs 9.0 % for CRP). ePDC-complex patients had higher rates (p < 0.003) of: ED visits (0.21 vs. 0.11 ppy for OCS; 0.17 vs. 0.15 ppy for CRP), and admissions in patients 45–64 and ≥ 65 years old (0.11 vs. 0.10 ppy AND 0.24 vs. 0.21 ppy for OCS).

CONCLUSION

Our measure for estimated physician-defined complexity compared favorably to commonly used risk-prediction approaches in identifying future suboptimal quality and utilization outcomes.

Electronic supplementary material

The online version of this article (doi:10.1007/s11606-015-3357-8) contains supplementary material, which is available to authorized users.     

Effectiveness of a Physical Activity and Weight Loss Intervention for Middle-Aged Women: Healthy Bodies,Healthy Hearts Randomized Trial

BACKGROUND

Physical inactivity is a significant risk factor for cardiovascular disease and remains highly prevalent in middle-aged women.

OBJECTIVE

We hypothesized that an interventionist-led (IL), primary-care–based physical activity (PA) and weight loss intervention would increase PA levels and decrease weight to a greater degree than a self-guided (SG) program.

DESIGN

We conducted a randomized trial.

PARTICIPANTS

Ninety-nine inactive women aged 45–65 years and with BMI ≥ 25 kg/m² were recruited from three primary care clinics.

INTERVENTIONS

The interventionist-led (IL) group (n = 49) had 12 weekly sessions of 30 min discussions with 30 min of moderate-intensity PA. The self-guided (SG) group (n = 50) received a manual for independent use.

MAIN MEASURES

Assessments were conducted at 0, 3, and 12 months; PA and weight were primary outcomes. Weight was measured with a standardized protocol. Leisure PA levels were assessed using the Modifiable Activity Questionnaire. Differences in changes by group were analyzed with a t-test or Wilcoxon rank-sum test. Mixed models were used to analyze differences in changes of outcomes by group, using an intention-to-treat principle.

KEY RESULTS

Data from 98 women were available for analysis. At baseline, mean (SD) age was 53.9 (5.4) years and 37 % were black. Mean weight was 92.3 (17.7) kg and mean BMI was 34.7 (5.9) kg/m². Median PA level was 2.8 metabolic equivalent hours per week (MET-hour/week) (IQR 0.0, 12.0). At 3 months, IL women had a significantly greater increase in PA levels (7.5 vs. 1.9 MET-hour/week; p = 0.02) than SG women; there was no significant difference in weight change. At 12 months, the difference between groups was no longer significant (4.7 vs. 0.7 MET-hour/week; p = 0.38). Mixed model analysis showed a significant (p = 0.048) difference in PA change between groups at 3 months only.

CONCLUSIONS

The IL intervention was successful in increasing the physical activity levels of obese, inactive middle-aged women in the short-term. No significant changes in weight were observed.

Electronic supplementary material

The online version of this article (doi:10.1007/s11606-014-3077-5) contains supplementary material, which is available to authorized users.KEY WORDS: physical activity, exercise, clinical trial, intervention     

Racial,Gender, and Socioeconomic Status Bias in Senior Medical Student Clinical Decision-Making: A National Survey

Background

Research suggests stereotyping by clinicians as one contributor to racial and gender-based health disparities. It is necessary to understand the origins of such biases before interventions can be developed to eliminate them. As a first step toward this understanding, we tested for the presence of bias in senior medical students.

Objective

The purpose of the study was to determine whether bias based on race, gender, or socioeconomic status influenced clinical decision-making among medical students.

Design

We surveyed seniors at 84 medical schools, who were required to choose between two clinically equivalent management options for a set of cardiac patient vignettes. We examined variations in student recommendations based on patient race, gender, and socioeconomic status.

Participants

The study included senior medical students.

Main Measures

We investigated the percentage of students selecting cardiac procedural options for vignette patients, analyzed by patient race, gender, and socioeconomic status.

Key Results

Among 4,603 returned surveys, we found no evidence in the overall sample supporting racial or gender bias in student clinical decision-making. Students were slightly more likely to recommend cardiac procedural options for black (43.9 %) vs. white (42 %, p = .03) patients; there was no difference by patient gender. Patient socioeconomic status was the strongest predictor of student recommendations, with patients described as having the highest socioeconomic status most likely to receive procedural care recommendations (50.3 % vs. 43.2 % for those in the lowest socioeconomic status group, p < .001). Analysis by subgroup, however, showed significant regional geographic variation in the influence of patient race and gender on decision-making. Multilevel analysis showed that white female patients were least likely to receive procedural recommendations.

Conclusions

In the sample as a whole, we found no evidence of racial or gender bias in student clinical decision-making. However, we did find evidence of bias with regard to the influence of patient socioeconomic status, geographic variations, and the influence of interactions between patient race and gender on student recommendations.KEY WORDS: students, medical; decision-making; health care disparities     

Reducing PSA-Based Prostate Cancer Screening in Men Aged?75?Years and Older with the Use of Highly Specific Computerized Clinical Decision Support

INTRODUCTION

In 2012, the Veterans Health Administration (VHA) implemented guidelines seeking to reduce PSA-based screening for prostate cancer in men aged 75 years and older.

OBJECTIVES

To reduce the use of inappropriate PSA-based prostate cancer screening among men aged 75 and over.

SETTING

The Veterans Affairs Greater Los Angeles Healthcare System (VA GLA)

PROGRAM DESCRIPTION

We developed a highly specific computerized clinical decision support (CCDS) alert to remind providers, at the moment of PSA screening order entry, of the current guidelines and institutional policy. We implemented the tool in a prospective interrupted time series study design over 15 months, and compared the trends in monthly PSA screening rate at baseline to the CCDS on and off periods of the intervention.

RESULTS

A total of 30,150 men were at risk, or eligible, for screening, and 2,001 men were screened. The mean monthly screening rate during the 15-month baseline period was 8.3 %, and during the 15-month intervention period, was 4.6 %. The screening rate declined by 38 % during the baseline period and by 40 % and 30 %, respectively, during the two periods when the CCDS tool was turned on. The screening rate ratios for the baseline and two periods when the CCDS tool was on were 0.97, 0.78, and 0.90, respectively, with a significant difference between baseline and the first CCDS-on period (p < 0.0001), and a trend toward a difference between baseline and the second CCDS-on period (p = 0.056).

CONCLUSION

Implementation of a highly specific CCDS tool alone significantly reduced inappropriate PSA screening in men aged 75 years and older in a reproducible fashion. With this simple intervention, evidence-based guidelines were brought to bear at the point of care, precisely for the patients and providers for whom they were most helpful, resulting in more appropriate use of medical resources.KEY WORDS: electronic health records, physician decision support, cancer screening, applied informatics, implementation research, quality improvement     

Nurse-Led Behavioral Management of Diabetes and Hypertension in Community Practices: A Randomized Trial

Background

Several trials have demonstrated the efficacy of nurse telephone case management for diabetes (DM) and hypertension (HTN) in academic or vertically integrated systems. Little is known about the real-world potency of these interventions.

Objective

To assess the effectiveness of nurse behavioral management of DM and HTN in community practices among patients with both diseases.

Design

The study was designed as a patient-level randomized controlled trial.

Participants

Participants included adult patients with both type 2 DM and HTN who were receiving care at one of nine community fee-for-service practices. Subjects were required to have inadequately controlled DM (hemoglobin A1c [A1c] ≥ 7.5 %) but could have well-controlled HTN.

Interventions

All patients received a call from a nurse experienced in DM and HTN management once every two months over a period of two years, for a total of 12 calls. Intervention patients received tailored DM- and HTN- focused behavioral content; control patients received non-tailored, non-interactive information regarding health issues unrelated to DM and HTN (e.g., skin cancer prevention).

Main Outcomes and Measures

Systolic blood pressure (SBP) and A1c were co-primary outcomes, measured at 6, 12, and 24 months; 24 months was the primary time point.

Results

Three hundred seventy-seven subjects were enrolled; 193 were randomized to intervention, 184 to control. Subjects were 55 % female and 50 % white; the mean baseline A1c was 9.1 % (SD = 1 %) and mean SBP was 142 mmHg (SD = 20). Eighty-two percent of scheduled interviews were conducted; 69 % of intervention patients and 70 % of control patients reached the 24-month time point. Expressing model estimated differences as (intervention – control), at 24 months, intervention patients had similar A1c [diff = 0.1 %, 95 % CI (−0.3, 0.5), p = 0.51] and SBP [diff = −0.9 mmH g, 95% CI (−5.4, 3.5), p = 0.68] values compared to control patients. Likewise, DBP (diff = 0.4 mmHg, p = 0.76), weight (diff = 0.3 kg, p = 0.80), and physical activity levels (diff = 153 MET-min/week, p = 0.41) were similar between control and intervention patients. Results were also similar at the 6- and 12-month time points.

Conclusions

In nine community fee-for-service practices, telephonic nurse case management did not lead to improvement in A1c or SBP. Gains seen in telephonic behavioral self-management interventions in optimal settings may not translate to the wider range of primary care settings.KEY WORDS: Diabetes, Hypertension, Implementation     

Hospital Strategy Uptake and Reductions in Unplanned Readmission Rates for Patients with Heart Failure: A Prospective Study

BACKGROUND

Despite recent reductions in national unplanned readmission rates, we have relatively little understanding of which hospital strategies are most associated with changes in risk-standardized readmission rates (RSRR).

OBJECTIVE

We examined associations between the change in hospital 30-day RSRR for patients with heart failure and the uptake of strategies over 12–18 months in a national sample of hospitals.

DESIGN

We conducted a prospective study of hospitals using a Web-based survey at baseline (November 2010–May 2011, n = 599, 91.0 % response rate) and 12–18 months later (November 2011–October 2012, n = 501, 83.6 % response rate), with RSRR measured at the same time points. The final analytic sample included 478 hospitals.

PARTICIPANTS

The study included hospitals participating in the Hospital-to-Home (H2H) and State Action on Avoidable Rehospitalizations (STAAR) initiatives.

MAIN MEASURES

We examined associations between change in hospital 30-day RSRR for patients with heart failure and the uptake of strategies previously demonstrated to have increased between baseline and follow-up, using unadjusted and adjusted linear regression.

KEY RESULTS

The average number of strategies taken up from baseline to follow-up was 1.6 (SE = 0.06); approximately one-quarter (25.3 %) of hospitals took up at least three new strategies. Hospitals that adopted the strategy of routinely discharging patients with a follow-up appointment already scheduled experienced significant reductions in RSRR (reduction of 0.63 percentage point, p value < 0.05). Hospitals that took up three or more strategies had significantly greater reductions in RSRR compared to hospitals that took up only zero to two strategies (reduction of 1.29 versus 0.57 percentage point, p value < 0.05). Among the 117 hospitals that took up three or more strategies, 93 unique combinations of strategies were used.

CONCLUSIONS

Although most individual strategies were not associated with RSRR reduction, hospitals that took up any three or more strategies showed significantly greater reduction in RSRR compared to hospitals that took up fewer than three strategies.

Electronic supplementary material

The online version of this article (doi:10.1007/s11606-014-3105-5) contains supplementary material, which is available to authorized users.KEY WORDS: readmissions, quality improvement, heart failure, discharge     

The Effect of a Care Transition Intervention on the Patient Experience of Older Multi-Lingual Adults in the Safety Net: Results of a Randomized Controlled Trial

Background

The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) and Care Transitions Measure (CTM-3) scores are patient experience measures used to determine hospital value-based purchasing reimbursement. Interventions to improve 30-day readmissions have met with mixed results, but less is known about their potential to improve the patient experience among older ethnically and linguistically diverse adults receiving care at safety-net hospitals. In this study, we assessed the effect of a nurse-led hospital-based care transition intervention on discharge-related patient experience in an older multilingual population of adults hospitalized at a safety-net hospital.

Methods

We randomized 700 inpatients aged 55 and older at an academic urban safety-net hospital. In addition to usual care, intervention participants received inpatient visits by a language-concordant study nurse and post-discharge phone calls from a language-concordant nurse practitioner to reinforce the care plan and to address acute complaints. We measured HCAHPS nursing, medication, and discharge communication domain scores and CTM-3 scores at 30 days after hospital discharge.

Results

Of 685 participants who survived to 30 days, 90 % (n = 616) completed follow-up interviews. The mean age was 66.2 years; over half (54.2 %) of the participants had cognitive impairment, and 33.8 % had moderate to severe depression. The majority (62.1 %) of interviews were conducted in English; 23.3 % were conducted in Chinese and 14.6 % in Spanish. Study nurses spent an average of 157 min with intervention participants. Between intervention and usual care participants, CTM-3 scores (80.5 % vs 78.5 %; p = 0.18) and HCAHPS discharge communication domain scores (74.8 % vs 68.7 %; p = 0.11) did not differ, nor did HCAHPS scores in medication (44.5 % vs 53.1 %; p = 0.13) and nursing domains (67.9 % vs 64.9 %; p = 0.43). When stratified by language, no significant differences were seen.

Conclusion

An inpatient standalone transition-of-care intervention did not improve patient discharge experience. Older multi-lingual and cognitively impaired populations may require higher-intensity interventions post-hospitalization to improve discharge experience outcomes.KEY WORDS: Transitions of care, Patient experience, Randomized controlled trial, Vulnerable populations     

Chronic Pain and DepressionAmong Primary Care Patients Treated with Buprenorphine

BACKGROUND

Pain and depression are each prevalent among opioid dependent patients receiving maintenance buprenorphine, but their interaction has not been studied in primary care patients.

OBJECTIVE

We set out to examine the relationship between chronic pain, depression, and ongoing substance use, among persons maintained on buprenorphine in primary care settings.

DESIGN

Between September 2012 and December 2013, we interviewed buprenorphine patients at three practice sites.

PARTICIPANTS

Opioid dependent persons at two private internal medicine offices and a federally qualified health center participated in the study.

MAIN MEASURES

Pain was measured in terms of chronicity, with chronic pain being defined as pain lasting at least 6 months; and in terms of severity, as measured by self-reported pain in the past week, measured on a 0–100 scale. We defined mild chronic pain as pain severity between 0 and 39 and lasting at least 6 months, and moderate/severe chronic pain as severity ≥ 40 and lasting at least 6 months. To assess depression, we used the Center for Epidemiologic Studies Depression (CESD) ten-item symptom scale and the two-item Patient Health Questionnaire (PHQ-2).

KEY RESULTS

Among 328 participants, 169 reported no chronic pain, 56 reported mild chronic pain, and 103 reported moderate/severe chronic pain. Participants with moderate/severe chronic pain commonly used non-opioid pain medications (56.3 %) and antidepressants (44.7 %), yet also used marijuana, alcohol, or cocaine (40.8 %) to help relieve pain. Mean CESD scores were 7.1 (±6.8), 8.3 (±6.0), and 13.6 (±7.6) in the no chronic, mild, and moderate/severe pain groups, respectively. Controlling for covariates, higher CESD scores were associated with a higher likelihood of moderate/severe chronic pain relative to both no chronic pain (OR = 1.09, p < 0.001) and mild chronic pain (OR = 1.06, p = 0.04).

CONCLUSION

Many buprenorphine patients are receiving over-the-counter or prescribed pain medications, as well as antidepressants, and yet continue to have significant and disabling pain and depressive symptoms. There is a clear need to address the pain–depression nexus in novel ways.KEY WORDS: buprenorphine, chronic pain, depression     

A randomized comparison of a commercially available portion-controlled weight-loss intervention with a diabetes self-management education program

Objective:

This study examined the efficacy of a commercially available, portion-controlled diet (PCD) on body weight and HbA_1c over 6 months in obese patients with type 2 diabetes.

Research Design and Methods:

One-hundred participants with a mean±s.d. age of 55.6±10.6 year, body weight of 102.9±18.4 kg and HbA_1c of 7.7±1.3% were randomly assigned to a 9-session group lifestyle intervention that included a PCD or to a 9-session group program of diabetes self-management education (DSME). Participants in the two groups were prescribed the same goals for energy intake (1250–1550 kcal per day) and physical activity (200 min per week).

Results:

While both groups produced significant improvements in weight and HbA_1c after 6 months of treatment, PCD participants lost 7.3 kg [95% confidence interval (CI): −5.8 to −8.8 kg], compared with 2.2 kg (95% CI: −0.7 to −3.7 kg) in the DSME group (P<0.0001). Significantly more PCD than DSME participants lost ⩾5% of initial weight (54.0% vs 14.0%, P<0.0001) and ⩾10% (26.0% vs 6.0%, P<0.0001). HbA_1c declined by 0.7% (95% CI: −0.4 to −1.0%) in the PCD group, compared with 0.4% (95% CI: −0.1 to −0.7%) in DSME (P<0.026). Across both groups, larger weight losses were associated with greater reductions in HbA_1c (r=0.52, P<0.0001).

Conclusions:

These findings demonstrate that a commercially available portion-controlled meal plan can induce clinically meaningful improvements in weight and glycemic control in obese individuals with type 2 diabetes. These data have implications for the management of obesity in primary care, as now provided by the Centers for Medicare and Medicaid Services.     

Teaching Basic Life Support to Students of Public and Private High Schools

Background

Despite being recommended as a compulsory part of the school curriculum, the teaching of basic life support (BLS) has yet to be implemented in high schools in most countries.

Objectives

To compare prior knowledge and degree of immediate and delayed learning between students of one public and one private high school after these students received BLS training.

Methods

Thirty students from each school initially answered a questionnaire on cardiopulmonary resuscitation (CPR) and use of the automated external defibrillator (AED). They then received theoretical-practical BLS training, after which they were given two theory assessments: one immediately after the course and the other six months later.

Results

The overall success rates in the prior, immediate, and delayed assessments were significantly different between groups, with better performance shown overall by private school students than by public school students: 42% ± 14% vs. 30.2% ± 12.2%, p = 0.001; 86% ± 7.8% vs. 62.4% ± 19.6%, p < 0.001; and 65% ± 12.4% vs. 45.6% ± 16%, p < 0.001, respectively. The total odds ratio of the questions showed that the private school students performed the best on all three assessments, respectively: 1.66 (CI95% 1.26-2.18), p < 0.001; 3.56 (CI95% 2.57-4.93), p < 0.001; and 2.21 (CI95% 1.69-2.89), p < 0.001.

Conclusions

Before training, most students had insufficient knowledge about CPR and AED; after BLS training a significant immediate and delayed improvement in learning was observed in students, especially in private school students.     

Patient Perceptions of Whom is Most Involved in Their Care with Successive Duty Hour Limits

BACKGROUND

Although direct patient care is necessary for experiential learning during residency, inpatient perceptions of the roles of resident and attending physicians in their care may have changed with residency duty hours.

OBJECTIVE

We aimed to assess if patients’ perceptions of who is most involved in their care changed with residency duty hours.

DESIGN

This was a prospective observational study over 12 years at a single institution.

PARTICIPANTS

Participants were 22,408 inpatients admitted to the general medicine teaching service from 2001 to 2013, who completed a 1-month follow-up phone interview.

MAIN MEASURES

Percentage of inpatients who reported an attending, resident, or intern as most involved in their care by duty hour period (pre-2003, post-2003–pre-2011, post-2011).

KEY RESULTS

With successive duty hour limits, the percentage of patients who reported the attending as most involved in their care increased (pre-2003 20 %, post-2003–pre-2011 29 %, post-2011 37 %, p < 0.001). Simultaneously, fewer patients reported a housestaff physician (resident or intern) as most involved in their care (pre-2003 20 %, post-2003–pre-2011 17 %, post-2011 12 %, p < 0.001). In multinomial regression models controlling for patient age, race, gender and hospitalist as teaching attending, the relative risk ratio of naming the resident versus the attending was higher in the pre-2003 period (1.44, 95 % CI 1.28-1.62, p < 0.001) than the post-2003–pre-2011 (reference group). In contrast, the relative risk ratio for naming the resident versus the attending was lower in the post-2011 period (0.79, 95 % CI 0.68-0.93, p = 0.004) compared to the reference group.

CONCLUSIONS

After successive residency duty hours limits, hospitalized patients were more likely to report the attending physician and less likely to report the resident or intern as most involved in their hospital care. Given the importance of experiential learning to the formation of clinical judgment for independent practice, further study on the implications of these trends for resident education and patient safety is warranted.KEY WORDS: resident duty hours, patient perceptions, hospital care     

Building Equity Improvement into Quality Improvement: Reducing Socioeconomic Disparities in Colorectal Cancer Screening as Part of Population Health Management

BACKGROUND

Improving colorectal cancer (CRC) screening rates for patients from socioeconomically disadvantaged backgrounds is a recognized public health priority.

OBJECTIVE

Our aim was to determine if implementation of a system-wide screening intervention could reduce disparities in the setting of improved overall screening rates.

DESIGN

This was an interrupted time series (ITS) analysis before and after a population management intervention.

PARTICIPANTS

Patients eligible for CRC screening (age 52–75 years without prior total colectomy) in an 18-practice research network from 15 June 2009 to 15 June 2012 participated in the study.

INTERVENTION

The Technology for Optimizing Population Care (TopCare) intervention electronically identified patients overdue for screening and facilitated contact by letter or telephone scheduler, with or without physician involvement. Patients identified by algorithm as high risk for non-completion entered into intensive patient navigation.

MAIN MEASURES

Patients were dichotomized as ≤ high school diploma (≤ HS), an indicator of socioeconomic disadvantage, vs. >HS diploma (> HS). The monthly disparity between ≤ HS and > HS with regard to CRC screening completion was examined.

KEY RESULTS

At baseline, 72 % of 47,447 eligible patients had completed screening, compared with 75 % of 51,442 eligible patients at the end of follow-up (p < 0.001). CRC screening completion was lower in ≤ HS vs. >HS patients in June 2009 (65.7 % vs. 74.5 %, p < 0.001) and remained lower in June 2012 (69.4 % vs. 76.7 %, p < 0.001). In the ITS analysis, which accounts for secular trends, TopCare was associated with a significant decrease in the CRC screening disparity (0.7 %, p < 0.001). The effect of TopCare represents approximately 99 additional ≤ HS patients screened above prevailing trends, or 26 life-years gained had these patients remained unscreened.

CONCLUSIONS

A multifaceted population management intervention sensitive to the needs of vulnerable patients modestly narrowed disparities in CRC screening, while also increasing overall screening rates. Embedding interventions for vulnerable patients within larger population management systems represents an effective approach to increasing overall quality of care while also decreasing disparities.KEY WORDS: colorectal cancer, cancer screening, health status disparities, socioeconomic factors, quality improvementColorectal cancer (CRC), the third leading cause of cancer mortality for women and men in the United States,^1,2 can be effectively prevented through several screening strategies.³ Though colorectal cancer screening rates have improved over the past decade, screening in most healthcare systems remains suboptimal.⁴ In 2010, approximately 65 % of eligible patients reported being up to date on screening,⁵ and it is estimated that almost 19,000 lives per year could be saved if population CRC screening goals were obtained.⁶ This is particularly true for socioeconomically disadvantaged patients, who are less likely to be screened and more likely to die from CRC.^4,7–9 As a result, improving CRC screening for patients with low educational attainment, an indicator of low socioeconomic status, has been identified as a public health priority.^4,5Previous studies have demonstrated that several approaches for increasing overall CRC screening and reducing disparities in CRC screening are possible, such as mailed interventions, telephone outreach, and patient navigation.^10–21 However, it is unclear whether a pragmatic intervention targeting screening in large healthcare delivery systems with diverse practice types can simultaneously achieve these twin aims of quality and equity improvement. Programs targeting population-level screening rates may actually increase disparities if they are more successful in well-off groups,¹³ while interventions meant to improve equity may not increase overall screening rates.²²We conducted a pragmatic, multifaceted intervention in a large, urban, academic primary care network to improve overall cancer screening rates; the intervention included efforts to target individuals at increased risk for not completing screening.²³ In this current analysis, we examined whether this targeted approach was able to reduce disparities while overall CRC screening increased.