Pediatric asthma hospitalizations among urban minority children and the continuity of primary care

Objective: To examine the effect of ambulatory health care processes on asthma hospitalizations. Methods: A retrospective cohort study using electronic health records was completed. Patients aged 2–18 years receiving health care from 1 of 5 urban practices between Jan 1, 2004 and Dec 31, 2008 with asthma documented on their problem list were included. Independent variables were modifiable health care processes in the primary care setting: (1) use of asthma controller medications; (2) regular assessment of asthma symptoms; (3) use of spirometry; (4) provision of individualized asthma care plans; (5) timely influenza vaccination; (6) access to primary healthcare; and (7) use of pay for performance physician incentives. Occurrence of one or more asthma hospitalizations was the primary outcome of interest. We used a log linear model (Poisson regression) to model the association between the factors of interest and number of asthma hospitalizations. Results: 5,712 children with asthma were available for analysis. 96% of the children were African American. The overall hospitalization rate was 64 per 1,000 children per year. None of the commonly used asthma-specific indicators of high quality care were associated with fewer asthma hospitalizations. Children with documented asthma who experienced a lack of primary health care (no more than one outpatient visit at their primary care location in the 2 years preceding hospitalization) were at higher risk of hospitalization compared to those children with a greater number of visits (incidence rate ratio 1.39; 95% CI 1.09–1.78). Conclusions: In children with asthma, more frequent primary care visits are associated with reduced asthma hospitalizations.     

Electronic clinical reminder and quality of primary diabetes care

Aims

To study the association of EMR’s clinical reminder use on a comprehensive set of diabetes quality metrics in U.S. office-based physicians and within solo- versus multi-physician practices. We conducted a retrospective cohort study on visits made by adults with diabetes identified from the National Ambulatory Medical Care Survey (2012–2014).

Frequency of asthma education in primary care in the years 2007–2010

Objective: Recent research suggests that health disparities persist among asthmatic patients and receipt of asthma education, though recent guidelines have highlighted the importance of receiving asthma education. The purpose of this study was to identify trends in the receipt of asthma education as well as to identify disparities in asthma education using the most recently available data in National Ambulatory Medical Care Survey, 2007–2010. Methods: Weighted chi-square tests were conducted to identify associations between asthma education and variables of interest. A weighted multivariate logistic regression model was subsequently constructed to jointly assess the association of factors of interest on receipt of asthma education. Submission to the Campbell University Institutional Review Board resulted in expedited approval. Results: The percentage of patients who receive asthma education remains quite low. After adjusting for all variables of interest: no statistically significant difference in receipt of asthma education between year groups (2007–2008, 2009–2010) was found (odds ratio [OR] 0.84, 95% confidence interval [CI] 0.52–1.34); patients seen by pediatricians (vs. internal medicine physicians) and Hispanic or Latino patients (vs. non-Hispanic or Latino patients) were more likely to receive asthma education (OR 2.72, 95% CI 1.11–6.66 and OR 2.33, 95% CI 1.18–4.60, respectively); and patients not prescribed a controller medication were less likely to receive asthma education than those who were (OR 0.56, 95% CI 0.37–0.82). Conclusions: Combined with previously published results, it appears the provision of asthma education continues to be low, despite proven benefits. Additionally, some patient and physician characteristics may be associated with the delivery of asthma education.     

Relationship of medical home quality with school engagement and after-school participation among children with asthma

Objectives: To examine the relationship between medical home quality and measures of daily life experiences among children with asthma. Methods: A nationally representative sample of children from the 2007 National Survey of Children's Health (NSCH), aged 6–17 years (n = 6357), who have asthma was used to assess the relationship of a quality medical home and its features with their daily life experiences. Five medical home features – access, continuity, comprehensiveness, family-centered care, and coordination of care – were examined individually and in total in relation to measures of school engagement (missed school days, parents contacted about problems with the child, repeating a grade since kindergarten) and after-school activity participation (physical activity, sports participation, and community service or volunteer work). Results: Before and after adjustment for personal characteristics, health insurance status, family environment, neighborhood variables, and asthma severity, total medical home score was associated with more days exercised [beta (B) = 0.10, p < .05] and a greater likelihood of having performed community service or volunteer work [odds ratio (OR) = 1.16, CI: 1.02–1.31]. Additionally, the medical home features of access, comprehensiveness, and family-centered care remained favorably associated with three of the six measures of school engagement and after-school activity participation, even after adjustment. Conclusion: Medical home quality – particularly the features of access, comprehensiveness, and family-centered care – is positively associated with the daily life experiences of children with asthma. Working to enhance these aspects of primary care might be one place to start in improving the management of children's chronic conditions and their quality of life.     

Development and implementation of an electronic asthma record for primary care: integrating guidelines into practice

Rationale: Evidence-based practice may be enhanced by integrating knowledge translation tools into electronic medical records (EMRs). We examined the feasibility of incorporating an evidence-based asthma care map (ACM) into Primary Care (PC) EMRs, and reporting on performance indicators. Methods: Clinicians and information technology experts selected 69 clinical and administrative variables from the ACM template. Four Ontario PC sites using EMRs were recruited to the study. Certified Asthma Educators used the electronic ACM for patient assessment and management. De-identified data from consecutive asthma patients were automatically transmitted to a secure central server for analysis. Results: Of the four sites recruited, two sites using “stand-alone” EMR systems were able to incorporate the selected ACM variables into an electronic format and participate in the pilot. Data were received on 161 visits by 130 patients aged 36.5?±?26.9 (mean?±?SD) (range 2–93) years. Ninety-four percent (65/69) of the selected ACM variables could be analyzed. Reporting capabilities included: individual patient, individual site and aggregate reports. Reports illustrated the ability to measure performance (e.g. number of patients in control, proportion of asthma diagnoses confirmed by an objective measure of lung function), benchmark and use EMR data for disease surveillance (e.g. number of smokers and the individuals with suspected work-related asthma). Conclusions: Integration of this evidence-based ACM into different EMRs was successful and permitted patient outcomes monitoring. Standardized data definitions and terminology are essential in order for EMR data to be used for performance measurement, benchmarking and disease surveillance.     

Antidiabetic treatment and COVID-19 Outcomes: A population-based cohort study in primary health care in Catalonia during the first wave of the pandemic

AimsTo analyse if antidiabetic treatment was associated with better COVID-19 outcomes in type 2 diabetic patients, measured by hospital admission and mortality rates as severe outcomes.MethodsCohort study including COVID-19 patients registered in the Primary Care electronic records, in March-June 2020, comparing exposed to metformin in monotherapy with exposed to any other antidiabetic. Data source: SIDIAP (Information System for Research in Primary Care), which captures clinical information of 5,8 million people from Catalonia, Spain.ResultsWe included 31,006 diabetic patients infected with COVID-19, 43.7% previously exposed to metformin, 45.5% of them in monotherapy. 16.4% were admitted to hospital and 15.1% died. Users of insulin in monotherapy (OR 1.29, 95% CI 1.11–1.50), combined with metformin (OR 1.38, 1.13–1.69) or IDPP4 alone (OR 1.29, 1.03–1.63) had higher risk of severe outcomes than those in metformin monotherapy. Users of any insulin (OR 1.61, 1.32–1.97) or combined with metformin (OR 1.69, 1.30–2.20) had a higher risk of mortality.ConclusionsPatients receiving metformin monotherapy in our study showed a lower risk of hospitalization and death in comparison to those treated with other frequent antidiabetic agents.We cannot distinguish if better outcomes are related with the antidiabetic therapy or with other factors, such as metabolic control or interventions applied during the hospital admission.     

Effectiveness of a Patient-Centre Medical Home model on diabetes and other clinically relevant outcomes among primary care patients diagnosed with type-2 diabetes in Sydney,Australia

AimWe aim to evaluate the effectiveness of patient-centred medical home (PCMH) model in improving diabetes and clinical outcomes among primary care patients diagnosed with T2D.MethodsThe WellNet study used cohort design with a concurrent comparison group to evaluate changes in clinical outcomes across six general practices in Sydney, Australia. The treatment group comprised of 279 patients who received PCMH care whereas the matched comparison group included 3671 patients who received standard care. t-tests with analysis of covariance were conducted to evaluate significant mean differences and multivariate logistic regression was performed to determine predictors of glycaemic control at follow-up.ResultsWellNet patients observed slightly larger within-group mean differences compared to comparison group patients (-0.2% vs -0.04%). Additionally, WellNet patients saw a larger increase in the percentage of patients achieving glycaemic control (7.9% vs 2.3%). A statistically significant mean difference was seen in waist circumference after adjusting for covariates (-2.41 cm, 95% CI -4.72 to -0.11; p < 0.05). Findings of multivariate logistic regression analysis showed that withdrawn patients and elevated HbA1c measures at baseline were associated with poor glycaemic control at follow-up.ConclusionThe study findings may be beneficial to patients in terms of improved clinical outcomes and self-management support.     

A multidisciplinary program for delivering primary care to the underserved urban homebound: looking back, moving forward

The coming decades will see a dramatic rise in the number of homebound adults. These individuals will have multiple medical conditions requiring a team of caregivers to provide adequate care. Home-based primary care (HBPC) programs can coordinate and provide such multidisciplinary care. Traditionally, though, HBPC programs have been small because there has been little institutional support for growth. Three residents developed the Mount Sinai Visiting Doctors (MSVD) program in 1995 to provide multidisciplinary care to homebound patients in East Harlem, New York. Over the past 10 years, the program has grown substantially to 12 primary care providers serving more than 1,000 patients per year. The program has met many of its original goals, such as helping patients to live and die at home, decreasing caregiver burden, creating a home-based primary care training experience, and becoming a research leader. These successes and growth have been the result of careful attention to providing high-quality care, obtaining hospital support through the demonstration of an overall positive cost-benefit profile, and securing departmental and medical school support by shouldering significant teaching responsibilities. The following article will detail the development of the program and the current provision of services. The MSVD experience offers a model of growth for faculty and institutions interested in starting or expanding a HBPC program.     

A randomized trial using computerized decision support to improve treatment of major depression in primary care

OBJECTIVE: To examine whether feedback and treatment advice for depression presented to primary care physicians (PCPs) via an electronic medical record (EMR) system can potentially improve clinical outcomes and care processes for patients with major depression. DESIGN: Randomized controlled trial. SETTING: Academically affiliated primary care practice in Pittsburgh, PA. PATIENTS: Two hundred primary care patients with major depression on the Primary Care Evaluation of Mental Disorders (PRIME-MD) and who met all protocol-eligibility criteria. INTERVENTION: PCPs were randomly assigned to 1 of 3 levels of exposure to EMR feedback of guideline-based treatment advice for depression: "active care" (AC), "passive care" (PC), or "usual care" (UC). MEASUREMENTS AND MAIN RESULTS: Patients' 3- and 6-month Hamilton Rating Scale for Depression (HRS-D) score and chart review of PCP reports of depression care in the 6 months following the depression diagnosis. Only 22% of patients recovered from their depressive episode at 6 months (HRS-D /=3 contacts with usual PCP at 6 months: 31% AC, 31% PC, 18% UC; P =.09 and antidepressant medication suggested/prescribed or baseline regimen modified at 6 months: 59% AC, 57% PC, 52% UC; P =.3). CONCLUSIONS: Screening for major depression, electronically informing PCPs of the diagnosis, and then exposing them to evidence-based treatment recommendations for depression via EMR has little differential impact on patients' 3- or 6-month clinical outcomes or on process measures consistent with high-quality depression care.     

Hepatitis C risk assessment, testing and referral for treatment in urban primary care： Role of race and ethnicity

AIMTo determine rates of hepatitis C(HCV)risk factor ascertainment,testing,and referral in urban primary care practices,with particular attention to the effect of race and ethnicity.METHODSRetrospective chart review from four primary care sites in Philadelphia;two academic primary care practices and two community clinics was performed.Demographics,HCV risk factors,and other risk exposure information were collected.RESULTSFour thousand four hundred and seven charts were reviewed.Providers documented histories of injection drug use(IDU)and transfusion for less than 20% and 5% of patients,respectively.Only 55% of patients who admitted IDU were tested for HCV.Overall,minorities were more likely to have information regarding a risk factor documented than their white counterparts (79% vs 68%,P ＜ 0.0001).Hispanics were less likely to have a risk factor history documented,compared to blacks and whites(P ＜ 0.0001).Overall,minorities were less likely to be tested for HCV than whites in the presence of a known risk factor(23% vs 35%,P = 0.004).Among patients without documentation of risk factors,blacks and Hispanics were more likely to be tested than whites(20% and 24%,vs 13%,P ＜ 0.005,respectively).CONCLUSION(1)Documentation of an HCV risk factor history in urban primary care is uncommon,(2)Racial differences exist with respect to HCV risk factor ascertainment and testing,(3)Minority patients,positive for HCV,are less likely to be referred for subspecialty care and treatment.Overall,minorities are less likely to be tested for HCV than whites in the presence of a known risk factor.     

Evaluation of a statewide medical home program on children and young adults with asthma

Objective: Asthma, the most common chronic condition among children, accounts for significant healthcare utilization and impact on quality of life. Care coordination in a medical home is considered standard practice, but has not been rigorously evaluated. Methods: We initiated this pilot study of children/young adults with asthma (n?=?967), ages: birth to 24 years, receiving care from a subset of pediatric practices (n?=?20) participating in the Pennsylvania Medical Home Initiative, Educating Practices in Community-Integrated Care (92 practices statewide). We hypothesized children and youth with asthma receiving care coordination in the context of a formal medical home program would experience favorable associations with healthcare utilization and quality of life measures. Results: A total of 9240 care coordination encounters for this cohort of children/youth occurred over 100 days. The average length of care coordination encounter was 20.7 minutes. The most common care coordination activity was referral management (21%) and the care coordinator in the practice most often contacted parent/family and specialists (75%). Children with more severe asthma had more hospitalizations and emergency department (ED) visits than children with less severe asthma. There was a significant decrease in school absences, ED visits and acute care visits for children/youth with asthma with increasing length of time in a medical home program (p?<?0.05). Conclusion: Care coordination for children/youth with asthma is feasible and may yield improvements in healthcare utilization, expenditures and quality of life. Larger-scale implementation of care coordination and medical home models for children/youth with asthma and other diagnoses are warranted.     

Individual and county level predictors of asthma related emergency department visits among children on Medicaid: A multilevel approach

Objective: Disparities in asthma outcomes are well documented in the United States. Interventions to promote equity in asthma outcomes could target factors at the individual and community levels. The objective of this analysis was to understand the effect of individual (race, gender, age, and preventive inhaler use) and county-level factors (demographic, socioeconomic, health care, air-quality) on asthma emergency department (ED) visits among Medicaid-enrolled children. This was a retrospective cohort study of Medicaid-enrolled children with asthma in 29 states in 2009. Multilevel regression models of asthma ED visits were constructed utilizing individual-level variables (race, gender, age, and preventive inhaler use) from the Medicaid enrollment file and county-level variables reflecting population and health system characteristics from the Area Resource File (ARF). County-level measures of air quality were obtained from Environmental Protection Agency (EPA) data. Results: The primary modifiable risk factor at the individual level was found to be the ratio of long-term controller medications to total asthma medications. County-level factors accounted for roughly 6% of the variance in the asthma ED visit risk. Increasing county-level racial segregation (OR=1.04, 95% CI=1.01-1.08) was associated with increasing risk of asthma ED visits. Greater supply of pulmonary physicians at the county level (OR=0.81, 95% CI=0.68-0.97) was associated with a reduction in risk of asthma ED visits. Conclusions: At the patient care level, proper use of controller medications is the factor most amenable to intervention. There is also a societal imperative to address negative social determinants, such as residential segregation.     

Patient Experiences with Coordination of Care: The Benefit of Continuity and Primary Care Physician as Referral Source

BACKGROUND  Coordination across a patient’s health needs and providers is important to improving the quality of care. OBJECTIVES  (1) Describe the extent to which adults report that their care is coordinated between their primary care physician (PCP) and specialists and (2) determine whether visit continuity with one’s PCP and the PCP as the referral source for specialist visits are associated with higher coordination ratings. DESIGN  Cross-sectional study of the 2007 Health Tracking Household Survey. PARTICIPANTS  A total of 3,436 adults with a PCP and one or more visits to a specialist in the past 12 months. MEASUREMENTS  Coordination measures were patient perceptions of (1) how informed and up to date the PCP was about specialist care received, (2) whether the PCP talked with the patient about what happened at the recent specialist visit and (3) how well different doctors caring for a patient’s chronic condition work together to manage that care. RESULTS  Less than half of respondents (46%) reported that their PCP always seemed informed about specialist care received. Visit continuity with the PCP was associated with better coordination of specialist care. For example, 62% of patients who usually see the same PCP reported that their PCP discussed with them what happened at their recent specialist visit vs. 48% of those who do not usually see the same PCP (adjusted percentages, p < 0.0001). When a patient’s recent specialist visit was based on PCP referral (vs. self-referral or some other source), 50% reported that the PCP was informed and up to date about specialist care received (vs. 35%, p < 0.0001), and 66% reported that their PCP discussed with them what happened at their recent specialist visit (vs. 47%, p < 0.0001). CONCLUSIONS  Facilitating visit continuity between the patient and PCP, and encouraging the use of the PCP as the referral source would likely enhance care coordination.     

Medical education: meeting the challenge of implementing primary health care in sub-Saharan Africa

Medical education in sub-Saharan Africa must be defined by its health needs and the health care services required. The sociodemographic milieu that determines the disease pattern makes a compelling case for primary health care in the context of community participation and multisector community development as the driver of a plan for medical education, in tandem with clinicians' role in continuity of care. Such ideas have been derived from the experience of planning for undergraduate medical education at the Aga Khan University Medical College, Nairobi, whose curriculum incorporates broad-based general education and liberal arts principles.     

Standardizing assessment of elderly people in acute care: the interRAI Acute Care instrument

OBJECTIVES: To examine the frequency distributions and interrater reliability of individual items of the interRAI Acute Care instrument.
DESIGN: Observational study of a representative sample of older inpatients; duplicate assessments conducted on a subsample by independent assessors to examine interrater reliability.
SETTING: Acute medical, acute geriatric and orthopedic units in 13 hospitals in nine countries.
PARTICIPANTS: Five hundred thirty-three patients aged 70 and older (mean age 82.4, range 70–102) with an anticipated stay of 48 hours or longer of whom 161 received duplicate assessments.
MEASUREMENTS: Sixty-two clinical items across 11 domains. Premorbid (3-day observation period before onset of the acute illness) and admission (the first 24 hours of hospital stay) assessments were conducted.
RESULTS: The frequency of deficits exceeded 30% for most items, ranging from 1% for physically abusive behavior to 86% for the need for support in activities of daily living after discharge. Common deficits were in cognitive skills for daily decision-making (38% premorbid, 54% at admission), personal hygiene (37%, 65%), and walking (39%, 71%). Interrater reliability was substantial in the premorbid period (average κ=0.61) and admission period (average κ=0.66). Of the 69 items tested, less than moderate agreement (κ<0.4) was recorded for six (9%), moderate agreement (κ=0.41–0.6) for 14 (20%), substantial agreement (κ=0.61–0.8) for 40 (58%), and almost perfect agreement (κ>0.8) for nine (13%).
CONCLUSION: Initial assessment of the psychometric properties of the interRAI Acute Care instrument provided evidence that item selection and interrater reliability are appropriate for clinical application. Further studies are required to examine the validity of embedded scales, diagnostic algorithms, and clinical protocols.     

San Francisco childcare centers' preparedness in the prevention and management of asthma among preschool-aged children

Introduction: Asthma is a common health condition for children in childcare. National recommendations for asthma in childcare exist. However, no studies have investigated the extent to which childcare centers adhere to these recommendations. We aimed to assess childcare center adherence to National Asthma Education and Prevention Program (NAEPP) recommendations for asthma care and preparedness and to identify characteristics associated with increased adherence to national asthma recommendations. Methods: We developed a standardized instrument. Each childcare center received a score of 0 through 7 based on number of recommendations met. We conducted t-tests, chi square tests and linear regression to identify childcare center factors associated with increased asthma preparedness. Results: 36 out of 40 eligible childcare centers (90%) participated. These sites served 1570 children primarily between the ages of 2 to 5 years. On average, centers met 3.8 out of 7 (SD = 1.3) recommendations. Staff familiarity caring for children with asthma (p?<?0.001) and the center's asthma prevalence (p = 0.01) was positively associated with the center's asthma preparedness. The 3 areas most in need of improvement related to asthma medications, asthma action plans and asthma policies. None of the managers reported being familiar with the NAEPP recommendations. Discussion: There is room for improvement in the asthma care and preparedness of childcare centers. The 3 areas in which centers performed poorly (appropriate asthma medication management, use of asthma action plans, and presence of appropriate asthma policies) suggest that closer collaboration between clinicians and childcare centers may be a key to improving asthma management for young children.     

Factors associated with the frequency of house calls by primary care physicians

Objective:To evaluate factors associated with the frequency of house calls by primary care physicians. Design:A cross-sectional design with a self-administered mailed survey. Setting/participants:751 primary care physicians who care for Medicaid patients in Virginia. Results:Among 389 physician respondents (52%), regular house callers (n=216) were compared with occasional house callers (n=162). Among physician characteristics, specialty and practice duration were associated with house call frequency. Regular house callers also more often cited chronic illness (67% vs. 20%, p<0.01) and terminal illness (67% vs. 40%, p<0.01) as indications for house calls, compared with occasional house callers. Use of visiting nurses to substitute for physician house calls was less often considered appropriate by frequent house callers (7% vs. 24%, p<0.01), and regular house callers were less likely to report being “too busy” to make house calls (71% vs. 29%, p<0.01). Multivariate analysis confirmed the association of these attitudes with house call frequency. Conclusion:These data suggest that specific attitudes among primary care physicians are associated with house call frequency. Presented in part at the annual meeting of the Society of General Internal Medicine, May 2–4, 1990, Arlington, Virginia. Supported in part by a grant from Virgina Commonwealth University.