Medication documentation in a primary care network serving North Carolina medicaid patients: results of a cross-sectional chart review

ABSTRACT: BACKGROUND: Medical records that do not accurately reflect the patient's current medication list are an open invitation to errors and may compromise patient safety. METHODS: This cross-sectional study compares primary care provider (PCP) medication lists and pharmacy claims for 100 patients seen in 8 primary care practices and examines the association of congruence with demographic, clinical, and practice characteristics. Medication list congruence was measured as agreement of pharmacy claims with the entire PCP chart, including current medication list, visit notes, and correspondence sections. RESULTS: Congruence between pharmacy claims and the PCP chart was 65%. Congruence was associated with large chronic disease burden, frequent PCP visits, group practice, and patient age [greater than or equal to]45 years. CONCLUSION: Agreement of medication lists between the PCP chart and pharmacy records is low. Medication documentation was more accurate among patients who have more chronic conditions, those who have frequent PCP visits, those whose practice has multiple providers, and those at least 45 years of age. Improved congruence among patients with multiple chronic conditions and in group practices may reflect more frequent visits and reviews by providers.     

Alcohol screening practices of primary care physicians in eastern North Carolina

In our study, 616 primary care physicians of eastern North Carolina were surveyed for screening practices for detection of alcoholism in their patient population. We defined primary care as Family Medicine, Internal Medicine, Obstetrics and Gynecology, Pediatrics and Psychiatry. We defined eastern North Carolina as the 29 counties that Pitt County Memorial Hospital serves. In our survey we found that eastern North Carolina is medically underserved as well as having less resources for referral and consultation. In response to the questionnaire, we found that most physicians agreed on some numerical value for drinks per day, social drinks, and drinks per week while pregnant. Values for drinks per week and weekend binges generally reflected significant tolerance for heavy drinking behavior. We also found that physicians of the same specialty commonly agreed on answers but when compared to other specialties they differed. Physicians preferred personal and clinical screening methods to questionnaires such as CAGE. Most physicians did not prescribe Antabuse but did suggest to their patients to cut down on drinking. Physicians felt that their patients needed more education and support from the community as well as intervention at an early age. We conclude that physicians should receive more education concerning alcoholism and substance abuse.     

Quality of diabetes care among low-income patients in North Carolina.

BACKGROUND: Diabetes is a leading cause of death and disability, disproportionately affecting most ethnic minority groups, people of low socioeconomic status, the elderly, and people in rural areas. Despite the availability of evidence-based clinical recommendations, barriers exist in the delivery of appropriate diabetes care. The purpose of this study is to examine the level of diabetes care among low-income populations in North Carolina. METHODS: Baseline medical record abstractions were performed (N=429) on diabetic patients at 11 agencies serving low-income populations (community health centers, free clinics, primary care clinics, and public health clinics) across the state participating in a quality-of-diabetes-care initiative. Data were collected for four process (measurement of glycosylated hemoglobin and lipids, dilated eye examination, nephropathy assessment) and two outcome (glycemic and lipid control) measures based on the Diabetes Quality Improvement Project (DQIP) and the Health Plan Employer Data and Information Set (HEDIS), and three additional indicators (blood pressure measurement and control, and lower limb assessment). Compliance rates to individual measures were calculated overall and by demographic and health characteristics. RESULTS: Diabetes care compliance rates ranged from 77.9% for blood pressure testing to 3.3% for complete foot examinations. Differences in care were observed by age, insulin use, and prevalent disease. CONCLUSIONS: This study indicates low compliance with diabetes care guidelines in underserved North Carolinians, and inconsistency of care according to some demographic and health characteristics. These results stress the need for quality improvement initiatives that enhance the level of care received by patients with diabetes, particularly those most vulnerable to diabetes and its complications.     

Selective primary health care: a critical review of methods and results

In the aftermath of the Alma Ata conference, three types of Primary Health Care (PHC), have been identified. Comprehensive PHC (CPHC) and Basic PHC (BPHC) both have a wide scope of activities, BPHC however does not include water and sanitation activities. Only one year after the Alma Ata conference, CPHC was attacked as not 'feasible' and selective PHC (SPHC) was offered as an interim alternative. SPHC only addresses 5 to 8 diseases, almost all of them falling within the realm of pediatrics. Our article critically analyses the methods and results of SPHC. It contrasts the lack of supportive data for SPHC and its methodological deficiencies with the extent of its adoption by bilateral cooperation agencies, foundations, academic and research institutions, and international agencies. We suggest that rather than health factors, the major determinants of this adoption have been political and economical constraints acting upon decision makers exposed to a similar training in public health.     

High blood pressure knowledge among primary care patients with known hypertension: a North Carolina Family Medicine Research Network (NC-FM-RN) study.

BACKGROUND: We sought to assess primary care patients' current knowledge about various aspects of high blood pressure (BP). METHODS: We mailed a questionnaire to 700 hypertensive patients enrolled in a practice-based research network cohort from 24 practices in North Carolina. We determined percentages of respondents (total and by subgroups) incorrectly answering each of 6 questions pertaining to various aspects of high BP. We then examined bivariate and multivariate associations with answering 2 or more items incorrectly ("lower hypertension knowledge"). RESULTS: We received 530 completed surveys (76% response rate). Twenty-six percent (95% CI, 22-30) of respondents did not know that most of the time people with high BP do not feel it. Twenty-two percent (95% CI, 18-26) either were not sure whether anything could be done to prevent high BP or believe that there is nothing that can be done. Nineteen percent (95% CI, 16-22) either believe taking medications will cure high BP or are not sure whether it will. Twenty-two percent (95% CI, 19-26) of respondents had overall lower hypertension knowledge. Independent associations with lower hypertension knowledge were African-American race (odds ratio, 1.77; 95% CI, 1.10-2.86), having less than high school education (odds ratio, 2.43; 95% CI, 1.34-4.41), and history of stroke/mini-stroke (odds ratio, 1.94; 95% CI, 1.00-3.75). CONCLUSIONS: Patients may need to be taught the difference between curing hypertension and treating it with medications. Efforts to educate the public that lifestyle modifications can prevent hypertension and that it usually causes no symptoms need to continue. It seems especially important to develop messages that reach African-Americans and people with less education.     

The place of chiropractors in health care delivery: a case study of North Carolina

Three perspectives on the place of DCs in the United States health care delivery system were derived from the social science literature; system status, cultural congruence, and utilization patterns. North Carolina was used as a case study site to examine these perspectives from a geographical point of view. It was found that DCs were located in smaller places than MDs. DC/population ratios were associated with white populations and higher incomes, but were not associated with those aged 18-64, rural populations, and religious groups that used touch in healing. DCs were located in more rural and lower income areas than were MDs.     

Gender differences in the clinical management of patients with angina pectoris: a cross-sectional survey in primary care

Background  

Previous research suggests that women admitted to hospital with acute myocardial infarction (MI) are managed less intensively than men. Chronic stable angina is the commonest clinical manifestation of coronary heart disease in the community, but little information is available concerning its contemporary clinical management. The aim of this study is to assess the extent of gender differences in the clinical management of angina pectoris in primary care.     

Rickettsialpox in North Carolina: a case report

We report a case of rickettsialpox from North Carolina confirmed by serologic testing. To our knowledge, this case is the first to be reported from this region of the United States. Including rickettsialpox in the evaluation of patients with eschars or vesicular rashes is likely to extend the recognized geographic distribution of Rickettsia akari, the etiologic agent of this disease.     

Abusive behaviour experienced by primary care receptionists: a cross-sectional survey

BACKGROUND: Receptionists act as gatekeepers to GPs, and thus are often placed in situations of conflict. However, there is a lack of research in this area. OBJECTIVE: The purpose of this study was to identify the incidence and associations of verbal and physical abuse against primary care receptionists, both pre- and post-'zero tolerance'. METHODS: A postal questionnaire was designed, piloted and sent to all reception staff in 50 randomly selected general practices in Leeds. The primary purpose was to identify any verbal or physical abuse experienced in the 12 months prior to the survey and assess the association between abuse experienced and deprivation. RESULTS: Seventy percent of receptionists completed and returned the questionnaire. Over two-thirds of receptionists had experienced verbal abuse in the last year. During the same time period, 60% reported telephone abuse and 55% reported face to face abuse. The incidence of abuse was higher in the year prior to the study than in the preceding period. Practice deprivation was identified as a significant factor for verbal abuse (P = 0.003). CONCLUSION: Verbal abuse against receptionists is significantly associated with the level of deprivation of the practice area. There is no evidence that 'zero tolerance' led to a reduction in abuse experienced by primary care receptionists. All primary care receptionists should receive adequate training on managing abuse.     

Chronic pain in type 2 diabetic patients: A cross-sectional study in primary care setting

Background: Although diabetes mellitus (DM) is often associated with painful neuropathic syndromes, a significant number of DM patients suffer from non-neuropathic (nociceptive) pain. Unfortunately, there is insufficient data on the epidemiology of nociceptive pain in DM patients and its effect on their quality of life.

Objective: To characterize pain in type 2 DM patients, and assess its effect on their quality of life.

Methods: The study population included 342 type 2 DM patients, 18 years of age and above (mean age 70.7 ± 9.7), who reported having pain. The study questionnaires included the Brief Pain Inventory (BPI), the S-LANSS scale to assess pain with neuropathic features, life impact, and socio-demographic data.

Results: One hundred and fifty-five DM patients (46.5%) reported having pain of predominantly neuropathic origin. Almost 75% of patients with neuropathic pain were females, compared to 57.8% of patients with nociceptive pain (P = 0.002). More patients with neuropathic pain reported constant daily pain (57.6% vs. 42.4%, P < 0.0001), and worse pain during the night (53.3% vs. 46.7%, P = 0.045). The pain affected daily activities, walking capacity, and mood. Patients with neuropathic pain reported a greater negative effect of pain on their quality of life than those with nociceptive pain (41.0% vs. 15.3%, P < 0.0001).

Conclusion: The impact of neuropathic pain in DM patients is much more significant than nociceptive pain and affects their quality of life and daily function to a greater degree.     

Day care center illness: policy and practice in North Carolina.

We surveyed 62 North Carolina day care centers (DCCs) to determine their policies for excluding children. We found that the addition of a temperature of 100-101 degrees F to each of eight symptoms was associated with an increase in the percentage of DCCs choosing "immediate pick-up." Non-profit centers were more likely to send children home (70 per cent) than for-profit centers (48 per cent). Centers with and without written illness policies did not differ in their management of sick children.     

Scattering of primary care: Doctor switching and utilization of health care by children on fee-for-service medicaid

Objective To determine whether children on fee-for-service Medicaid who switch primary care doctors use less health care and are less up to date with preventive care visits than children who do not switch primary care doctors. Design Retrospective cohort study using Medicaid claims data. Setting 51,027 children enrolled on Medicaid in Monroe County, New York. Patients 14,187 children enrolled continuously on fee-for-service Medicaid between January 1992 and December 1994. Main Outcome Measures Utilization of primary care, emergency department (ED) services, and specialty care and proportion up to date with preventive care visits according to American Academy of Pediatrics guidelines. Results During the 2-year study period, 22% of children switched primary care doctors. Compared with children who did not switch primary care doctors, those who switched had more primary care visits (4.7 vs. 3.2 visits/year,P<.01), age-adjusted preventive care visits (1.2 vs. 1.0 visits/year), ED visits (0.72 vs. 0.47 visits/year,P<.01), and specialist visits (0.99 vs. 0.31,P<.01). On multivariate analysis, doctor switching was associated with increased odds of being up to date with preventive care visits (odds ratio [OR]=1.7; 95% confidence interval [CI] 1.3 to 2.1). However, on multivariate analysis stratified by age, the association was significant only for older children (ages 11 to 14). Altogether, 68% of all children and 44% of infants less than 1 year old made the recommended number of preventive care visits during the study period. Conclusions All groups of children received less preventive care than recommended by the American Academy of Pediatrics. Children who switched primary care doctors had higher utilization of health care, including primary care, ED, and specialty care. Contrary to expectations, they were more likely to be up to date with preventive care visits. The heavy utilization of health services by doctor switchers indicates that this subgroup of children on Medicaid may not be at risk for poor access to health care, but additional research is needed to determine whether the quality of care is related to doctor switching. Presented in part at the Pediatric Academic Societies 1996 Annual Meeting, Washington, DC, May 8, 1996. This work was supported in part by a Frank Disney Scholarship through the Strong Children's Research Center, University of Rochester School of Medicine and Dentistry, and by National Research Service Award 1F32 HS00089-01 from the Agency for Health Care Policy and Research.     

Predictors of complementary therapy use among asthma patients: results of a primary care survey

Patients with chronic conditions are increasingly using complementary therapies. Asthma is the most common chronic disease in the UK. Qualitative research has suggested reasons why asthma patients use complementary therapies. However, there is little reliable quantitative evidence regarding the prevalence of complementary therapy use among asthma patients and predictors of use. A postal survey of complementary therapy use among asthma patients was therefore conducted via 27 general practices across seven Primary Care Trusts within the South West Strategic Health Authority (England), during August 2005 to May 2006. A total of 14,833 asthma patients were identified. A 1-in-4 random sample generated 3693 potential respondents, of whom 1320 (36%) returned questionnaires. Taking full account of the survey design, 14.5% (190/1308; 95% confidence interval 12.5% to 16.6%) had used complementary therapies for asthma; 54% of these patients had not disclosed their complementary therapy use to a health professional. The three therapies most commonly used were homeopathy, herbal medicine and relaxation. Just over half of those using complementary therapies for asthma reported that they usually or always helped; the most common reported benefits were symptom reduction, calming breathing and reducing panic. Multivariable analyses indicated an inverted U-shaped relationship between complementary therapy use for asthma and age, and increased likelihood of use among women, those with educational qualifications, those not usually helped by asthma medication, and those who have difficulty sleeping because of asthma symptoms. Dissatisfaction with conventional care was not associated with complementary therapy use for asthma. Asthma patients may use complementary therapies with or without the knowledge of their healthcare providers. Open communication between professionals and patients about complementary therapies may be valuable to give patients enhanced opportunities to discuss the impact of asthma on their quality of life and the effectiveness of their conventional treatment.     

Health care during pregnancy and childbirth: results of two cross-sectional surveys in poor areas of North and Northeast Brazil

In 2002 and 2005, two surveys were conducted in poor areas of North and Northeast Brazil to evaluate prenatal care received by mothers of children under five years old. The study covered 1,528 and 1,529 children in 2002 and 2005, respectively. In this three-year period, maternal schooling and monthly family income increased by 1.5 years and US$ 50.00, respectively, availability of safe drinking water increased from 23% to 41%, the proportion of pregnant woman with six or more prenatal visits increased from 42% to 52%, and immunization against neonatal tetanus increased from 54% to 77%. Coverage of uterine height evaluation increased from 54% to 77%. Testing for HIV and syphilis virtually doubled, from 8% to 16%. Meanwhile, gynecological examinations dropped from 41% to 31% and counseling for breastfeeding decreased from 66% to 55%. Despite improvements, the study's results show that the target indicators in these areas fall short of those in more developed regions of Brazil. Efforts should be made to reduce this gap.