Browsing by Subject "Primary Health Care"
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Item Open Access A Combined Patient and Provider Intervention for Management of Osteoarthritis in Veterans: A Randomized Clinical Trial.(Annals of internal medicine, 2016-01) Allen, Kelli D; Yancy, William S; Bosworth, Hayden B; Coffman, Cynthia J; Jeffreys, Amy S; Datta, Santanu K; McDuffie, Jennifer; Strauss, Jennifer L; Oddone, Eugene ZBackground
Management of osteoarthritis requires both medical and behavioral strategies, but some recommended therapies are underused.Objective
To examine the effectiveness of a combined patient and provider intervention for improving osteoarthritis outcomes.Design
Cluster randomized clinical trial with assignment to osteoarthritis intervention and usual care groups. (ClinicalTrials.gov: NCT01130740).Setting
Department of Veterans Affairs Medical Center in Durham, North Carolina.Participants
30 providers (clusters) and 300 outpatients with symptomatic hip or knee osteoarthritis.Intervention
The telephone-based patient intervention focused on weight management, physical activity, and cognitive behavioral pain management. The provider intervention involved delivery of patient-specific osteoarthritis treatment recommendations to primary care providers through the electronic medical record.Measurements
The primary outcome was total score on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) at 12 months. Secondary outcomes were WOMAC function and pain subscale scores, physical performance (Short Physical Performance Battery), and depressive symptoms (Patient Health Questionnaire-8). Linear mixed models that were adjusted for clustering of providers assessed between-group differences in improvement in outcomes.Results
At 12 months, WOMAC scores were 4.1 points lower (indicating improvement) in the osteoarthritis intervention group versus usual care (95% CI, -7.2 to -1.1 points; P = 0.009). WOMAC function subscale scores were 3.3 points lower in the intervention group (CI, -5.7 to -1.0 points; P = 0.005). WOMAC pain subscale scores (P = 0.126), physical performance, and depressive symptoms did not differ between groups. Although more patients in the osteoarthritis intervention group received provider referral for recommended osteoarthritis treatments, the numbers who received them did not differ.Limitation
The study was conducted in a single Veterans Affairs medical center.Conclusion
The combined patient and provider intervention resulted in modest improvement in self-reported physical function in patients with hip and knee osteoarthritis.Primary funding source
Department of Veterans Affairs, Health Services Research and Development Service.Item Open Access A health literacy pilot intervention to improve medication adherence using Meducation® technology.(Patient education and counseling, 2014-05) Zullig, Leah L; McCant, Felicia; Melnyk, S Dee; Danus, Susanne; Bosworth, Hayden BObjective
To determine whether antihypertensive medication adherence could improve using a Meducation® technology health literacy intervention.Methods
We conducted a six-month feasibility study among patients with cardiovascular disease (CVD) risk factors receiving care from hospital-based primary care clinics. All patients received a personalized Meducation® calendar listing CVD-related medications. We evaluated changes in medication adherence and clinical outcomes at six months.Results
There was a 42% enrollment rate (n=23). Forty percent had low health literacy, defined as less than 9th grade reading level. At three months, self-reported medication adherence improved. At six months, medication possession ratio improved 3.2%. Also, at six months there were decreases in patients' average systolic blood pressure (0.5 mmHg), diastolic blood pressure (1.5 mmHg), and body weight (3.6 pounds) (p>0.05).Conclusions
A health literacy intervention may be a feasible mechanism to improve cardiovascular-related medication adherence and outcomes.Practice implications
Health literacy interventions may improve adherence while requiring relatively few resources to implement.Item Open Access A Structured Approach to Detecting and Treating Depression in Primary Care: VitalSign6 Project.(Annals of family medicine, 2019-07) Jha, Manish K; Grannemann, Bruce D; Trombello, Joseph M; Clark, E Will; Eidelman, Sara Levinson; Lawson, Tiffany; Greer, Tracy L; Rush, A John; Trivedi, Madhukar HPurpose
This report describes outcomes of an ongoing quality-improvement project (VitalSign6) in a large US metropolitan area to improve recognition, treatment, and outcomes of depressed patients in 16 primary care clinics (6 charity clinics, 6 federally qualified health care centers, 2 private clinics serving low-income populations, and 2 private clinics serving patients with either Medicare or private insurance).Methods
Inclusion in this retrospective analysis was restricted to the first 25,000 patients (aged ≥12 years) screened with the 2-item Patient Health Questionnaire (PHQ-2) in the aforementioned quality-improvement project. Further evaluations with self-reports and clinician assessments were recorded for those with positive screen (PHQ-2 >2). Data collected from August 2014 though November 2016 were available at 3 levels: (1) initial PHQ-2 (n = 25,000), (2) positive screen (n = 4,325), and (3) clinician-diagnosed depressive disorder with 18 or more weeks of enrollment (n = 2,160).Results
Overall, 17.3% (4,325/25,000) of patients screened positive for depression. Of positive screens, 56.1% (2,426/4,325) had clinician-diagnosed depressive disorder. Of those enrolled for 18 or more weeks, 64.8% were started on measurement-based pharmacotherapy and 8.9% referred externally. Of the 1,400 patients started on pharmacotherapy, 45.5%, 30.2%, 12.6%, and 11.6% had 0, 1, 2, and 3 or more follow-up visits, respectively. Remission rates were 20.3% (86/423), 31.6% (56/177), and 41.7% (68/163) for those with 1, 2, and 3 or more follow-up visits, respectively. Baseline characteristics associated with higher attrition were: non-white, positive drug-abuse screen, lower depression/anxiety symptom severity, and younger age.Conclusion
Although remission rates are high in those with 3 or more follow-up visits after routine screening and treatment of depression, attrition from care is a significant issue adversely affecting outcomes.Item Open Access Association between depression and hypertension using classic and revised blood pressure thresholds.(Family practice, 2020-10) DeMoss, Dustin S; Teigen, Kari J; Claassen, Cynthia A; Fisk, Mandy J; Blair, Somer E; Bakre, Sulaimon A; Hurd, Cheryl L; Rush, Augustus JBackground
In a primary care population, the relationship between treatment of depression and hypertension (HTN) under the recently revised American College of Cardiology and American Heart Association HTN thresholds for diagnosing HTN is unknown.Objective
To compare the association between changes in severity of co-occurring depression and HTN over time using the newly revised versus previous HTN guidelines.Methods
In this retrospective cohort study, outpatients ≥18 years (n = 3018) with clinically significant depressive symptoms and elevated blood pressure at baseline were divided into a 'revised' guideline group (baseline blood pressure ≥130/80 mmHg), a 'classic' guideline group (≥140/90 mmHg) and a 'revised-minus-classic' group (≥130/80 and <140/90 mmHg). Depressive symptom change was assessed using the Patient Health Questionnaire-9 (PHQ-9). Correlations between changes in PHQ-9 scores and HTN levels by group over a 6- to 18-month observation period were assessed using robust regression analysis.Results
There were demographic and clinical differences between groups. A total of 41% of study subjects (1252/3018) had a visit during the follow-up period where additional PHQ-9 and HTN results were available. Depressive symptom change was unrelated to change in blood pressure in the revised and revised-minus-classic groups. The classic HTN group demonstrated a clinically insignificant change in systolic blood pressure for each unit change in PHQ-9 score (β = 0.23, P-value =0.02).Conclusions
Although a statistically significant association between reduced HTN levels and improvement in depressive symptoms was demonstrated under classic HTN guidelines, there was no clinically meaningful association between treatment of depression and improved HTN levels under either guideline.Item Open Access Blood pressure control in a hypertension telemedicine intervention: does distance to primary care matter?(Journal of clinical hypertension (Greenwich, Conn.), 2013-10) Bowen, Michael E; Bosworth, Hayden B; Roumie, Christianne LAlthough telemedicine may help overcome geographic access barriers, it is unknown whether rural patients receive greater benefits. In a secondary analysis of 503 veterans participating in a hypertension telemedicine study, the authors hypothesized that patients with greater travel distances would have greater improvements in 18-month systolic blood pressure (SBP). Patients were categorized by telemedicine exposure and travel distance to primary care, derived from zip codes. Comparisons were (1) usual care (UC), distance <30 miles (reference); (2) UC, distance ≥30 miles; (3) telemedicine, distance <30 miles; (4) telemedicine, distance ≥30 miles. Compared with patients receiving UC, distance <30 miles (intercept=127.7), no difference in 18-month SBP was observed in patients receiving UC, distance ≥30 miles (0.13 mm Hg, 95% confidence interval [-6.6 to 6.8]); telemedicine, distance <30 miles (-1.1 mm Hg [-7.3 to 5.2]); telemedicine, distance ≥30 miles (-0.80 mm Hg [-6.6 to 5.1]). Although telemedicine may help overcome geographic access barriers, additional studies are needed to identify patients most likely to benefit.Item Open Access Building Capacity to Care for Refugees.(Family practice management, 2017-07) Walden, Jeffrey; Valdman, Olga; Mishori, Ranit; Carlough, MarthaItem Open Access Can caregivers report their care recipients' post-stroke hospitalizations and outpatient visits accurately? Findings of an Asian prospective stroke cohort.(BMC health services research, 2018-10-25) Tyagi, Shilpa; Koh, Gerald Choon-Huat; Luo, Nan; Tan, Kelvin Bryan; Hoenig, Helen; Matchar, David B; Yoong, Joanne; Finkelstein, Eric A; Lee, Kim En; Venketasubramanian, N; Menon, Edward; Chan, Kin Ming; De Silva, Deidre Anne; Yap, Philip; Tan, Boon Yeow; Chew, Effie; Young, Sherry H; Ng, Yee Sien; Tu, Tian Ming; Ang, Yan Hoon; Kong, Keng He; Singh, Rajinder; Merchant, Reshma A; Chang, Hui Meng; Yeo, Tseng Tsai; Ning, Chou; Cheong, Angela; Ng, Yu Li; Tan, Chuen SengBackground
Health services research aimed at understanding service use and improving resource allocation often relies on collecting subjectively reported or proxy-reported healthcare service utilization (HSU) data. It is important to know the discrepancies in such self or proxy reports, as they have significant financial and policy implications. In high-dependency populations, such as stroke survivors, with varying levels of cognitive impairment and dysphasia, caregivers are often potential sources of stroke survivors' HSU information. Most of the work conducted on agreement analysis to date has focused on validating different sources of self-reported data, with few studies exploring the validity of caregiver-reported data. Addressing this gap, our study aimed to quantify the agreement across the caregiver-reported and national claims-based HSU of stroke patients.Methods
A prospective study comprising multi-ethnic stroke patient and caregiver dyads (N = 485) in Singapore was the basis of the current analysis, which used linked national claims records. Caregiver-reported health services data were collected via face-to-face and telephone interviews, and similar health services data were extracted from the national claims records. The main outcome variable was the modified intraclass correlation coefficient (ICC), which provided the level of agreement across both data sources. We further identified the amount of over- or under-reporting by caregivers across different service types.Results
We observed variations in agreement for different health services, with agreement across caregiver reports and national claims records being the highest for outpatient visits (specialist and primary care), followed by hospitalizations and emergency department visits. Interestingly, caregivers over-reported hospitalizations by approximately 49% and under-reported specialist and primary care visits by approximately 20 to 30%.Conclusions
The accuracy of the caregiver-reported HSU of stroke patients varies across different service types. Relatively more objective data sources, such as national claims records, should be considered as a first choice for quantifying health care usage before considering caregiver-reported usage. Caregiver-reported outpatient service use was relatively more accurate than inpatient service use over shorter recall periods. Therefore, in situations where objective data sources are limited, caregiver-reported outpatient information can be considered for low volumes of healthcare consumption, using an appropriate correction to account for potential under-reporting.Item Open Access Can Right-Sizing the Use of Virtual Care Improve Access to Equitable, Patient-Centered Care for Women Veterans?(Journal of general internal medicine, 2023-07) Goldstein, Karen M; Bosworth, Hayden B; Gierisch, Jennifer MItem Open Access Capacity of Primary Healthcare Facilities on Prevention and Management of Cardiovascular Diseases in a Resource-limited Area in Vietnam(2017) Tao, XuanchenBackground: Vietnam is in the process of an epidemiological transition, with cardiovascular diseases now ranked as the leading cause of death. This study assessed the commune health centers in selected rural and urban communities in Vietnam in terms of their capacity for prevention and management of cardiovascular diseases by using a mixed method approach.
Methods: The study was conducted in July 2016 in Chi Linh district, Hai Duong province – a mountainous area located in northern Vietnam. Structured questionnaire surveys and in-depth interviews were used to collect data on the current capacity of commune health centers in Chi Linh district. The capacity included six aspects: equipment and service availability, medicine, medical record system, service utilization and referral, financing and human resources. Ten facility staff members in the selected commune health centers were surveyed and interviewed. Five policy makers from the local level, the regional level, and the national level were also interviewed.
Results: A description of Chi Linh district’s commune health center capacity on CVD prevention and management was reported. (1) Equipment & Service Availability: Not all essential equipment and health services recommended by WHO was available at commune health centers. A few centers owned glucometers and no center had an ECG machine. (2) Medicine: No diabetic medicines were available in the commune health center; the essential medicines for other CVD conditions were inadequate in terms of quantity and diversity. (3) Medical record system: One fifth of the commune health centers had an electronic medical record system, others used a paper-based record. (4) Service Utilization & Referral: On average, each facility admitted 63 CVD out-patients per month (urban 152, rural 29); none of the facilities could provide in-patient service. (5) Financing: Government budget and social health insurance were the main sources of facility revenue. (6) Human resources: The human resources specialized in CVD were inadequate in commune health centers. On average, there were 0.328 medical doctors, 0.182 nurses and midwives and 0.009 pharmaceutical personnel per 1000 population.
Conclusion: The capacity of commune health centers to prevent and manage cardiovascular diseases in Vietnam is inadequate. The results of this study show critical gaps in primary healthcare facilities in Vietnam in six key areas. They include service delivery, health workforce, health information system, access to essential medicine, financing and governance. Thus, there is an urgent need to improve the capacity of commune health centers.
Item Open Access Caring for Alaska Native prostate cancer survivors in primary care: a survey of Alaska Tribal Health System providers.(Int J Circumpolar Health, 2014) Tilburt, Jon C; Kelley, Stacy; DeCourtney, Christine A; Humeniuk, Katherine M; Latini, Jerilyn; Kim, Simon PBACKGROUND: Little is known about the constraints of optimizing health care for prostate cancer survivors in Alaska primary care. OBJECTIVE: To describe the experiences and attitudes of primary care providers within the Alaska Tribal Health System (ATHS) regarding the care of prostate cancer survivors. DESIGN: In late October 2011, we emailed a 22-item electronic survey to 268 ATHS primary care providers regarding the frequency of Prostate Specific Antigen (PSA) monitoring for a hypothetical prostate cancer survivor; who should be responsible for the patient's life-long prostate cancer surveillance; who should support the patient's emotional and medical needs as a survivor; and providers' level of comfort addressing recurrence monitoring, erectile dysfunction, urinary incontinence, androgen deprivation therapy, and emotional needs. We used simple logistic regression to examine the association between provider characteristics and their responses to the survivorship survey items. RESULTS: Of 221 individuals who were successfully contacted, a total of 114 responded (52% response rate). Most ATHS providers indicated they would order a PSA test every 12 months (69%) and believed that, ideally, the hypothetical patient's primary care provider should be responsible for his life-long prostate cancer surveillance (60%). Most providers reported feeling either "moderately" or "very" comfortable addressing topics such as prostate cancer recurrence (59%), erectile dysfunction (64%), urinary incontinence (63%), and emotional needs (61%) with prostate cancer survivors. These results varied somewhat by provider characteristics including female sex, years in practice, and the number of prostate cancer survivors seen in their practice. CONCLUSIONS: These data suggest that most primary care providers in Alaska are poised to assume the care of prostate cancer survivors locally. However, we also found that large minorities of providers do not feel confident in their ability to manage common issues in prostate cancer survivorship, implying that continued access to specialists with more expert knowledge would be beneficial.Item Open Access Characteristics of primary care and rates of pediatric hospitalizations in Brazil.(Revista de saude publica, 2020-01) Lisboa, Lívia Anniele Sousa; Queiroz, Rejane Christine de Sousa; Thomaz, Erika Bárbara Abreu Fonseca; Silva, Núbia Cristina da; Rocha, Thiago Augusto Hernandes; Vissoci, João Ricardo Nickenig; Staton, Catherine Ann; Lein, Adriana; Simões, Vanda Maria Ferreira; Thumé, Elaine; Facchini, Luiz AugustoObjective
To evaluate the association among characteristics of primary health care center (PHCC) with hospitalizations for primary care sensitive conditions (PCSC) in Brazil.Method
In this study, a cross-sectional ecological study was performed. This study analyzed the 27 capitals of Brazil's federative units. Data were aggregated from the following open access databases: National Program for Access and Quality Improvement in Primary Care, the Hospital Information System of Brazilian Unified Health System and Annual Population Census conducted by the Brazilian Institute of Geography and Statistics. Associations were estimated among characteristics of primary care with the number of three PCSC as the leading causes of hospitalization in children under-5 population in Brazil: asthma, diarrhea, and pneumonia.Results
In general, PHCC showed limited structural adequacy (37.3%) for pediatric care in Brazil. The capitals in South and Southeast regions had the best structure whereas the North and Northeast had the worst. Fewer PCSC hospitalizations were significantly associated with PHCC which presented appropriate equipment (RR: 0.98; 95%CI: 0.97-0.99), structural conditions (RR: 0.98; 95%CI: 0.97-0.99), and signage/identification of professionals and facilities (RR: 0.98; 95%CI: 0.97-0.99). Higher PCSC hospitalizations were significantly associated with PHCC with more physicians (RR: 1.23, 95%CI: 1.02-1.48), it forms (RR: 1.01, 95%CI: 1.01-1.02), and more medications (RR: 1.02, 95%CI: 1.01-1.03).Conclusion
Infrastructural adequacy of PHCC was associated with less PCSC hospitalizations, while availability medical professional and medications were associated with higher PCSC hospitalizations.Item Open Access Clinic variation in recruitment metrics, patient characteristics and treatment use in a randomized clinical trial of osteoarthritis management.(BMC musculoskeletal disorders, 2014-12) Allen, Kelli D; Bosworth, Hayden B; Chatterjee, Ranee; Coffman, Cynthia J; Corsino, Leonor; Jeffreys, Amy S; Oddone, Eugene Z; Stanwyck, Catherine; Yancy, William S; Dolor, Rowena JBackground
The Patient and PRovider Interventions for Managing Osteoarthritis (OA) in Primary Care (PRIMO) study is one of the first health services trials targeting OA in a multi-site, primary care network. This multi-site approach is important for assessing generalizability of the interventions. These analyses describe heterogeneity in clinic and patient characteristics, as well as recruitment metrics, across PRIMO study clinics.Methods
Baseline data were obtained from the PRIMO study, which enrolled n = 537 patients from ten Duke Primary Care practices. The following items were examined across clinics with descriptive statistics: (1) Practice Characteristics, including primary care specialty, numbers and specialties of providers, numbers of patients age 55+, urban/rural location and county poverty level; (2) Recruitment Metrics, including rates of eligibility, refusal and randomization; (3) Participants' Characteristics, including demographic and clinical data (general and OA-related); and (4) Participants' Self-Reported OA Treatment Use, including pharmacological and non-pharmacological therapies. Intraclass correlation coefficients (ICCs) were computed for participant characteristics and OA treatment use to describe between-clinic variation.Results
Study clinics varied considerably across all measures, with notable differences in numbers of patients age 55+ (1,507-5,400), urban/rural location (ranging from "rural" to "small city"), and proportion of county households below poverty level (12%-26%). Among all medical records reviewed, 19% of patients were initially eligible (10%-31% across clinics), and among these, 17% were randomized into the study (13%-21% across clinics). There was considerable between-clinic variation, as measured by the ICC (>0.01), for the following patient characteristics and OA treatment use variables: age (means: 60.4-66.1 years), gender (66%-88% female), race (16%-61% non-white), low income status (5%-27%), presence of hip OA (26%-68%), presence both knee and hip OA (23%-61%), physical therapy for knee OA (24%-61%) and hip OA (0%-71%), and use of knee brace with metal supports (0%-18%).Conclusions
Although PRIMO study sites were part of one primary care practice network in one health care system, clinic and patient characteristics varied considerably, as did OA treatment use. This heterogeneity illustrates the importance of including multiple, diverse sites in trials for knee and hip OA, to enhance the generalizability and evaluate potential for real-world implementation.Trial registration
Clinical trial registration number
NCT 01435109.Item Open Access Closing the Referral Loop: an Analysis of Primary Care Referrals to Specialists in a Large Health System.(Journal of general internal medicine, 2018-05) Patel, Malhar P; Schettini, Priscille; O'Leary, Colin P; Bosworth, Hayden B; Anderson, John B; Shah, Kevin PPURPOSE:Ideally, a referral from a primary care physician (PCP) to a specialist results in a completed specialty appointment with results available to the PCP. This is defined as "closing the referral loop." As health systems grow more complex, regulatory bodies increase vigilance, and reimbursement shifts towards value, closing the referral loop becomes a patient safety, regulatory, and financial imperative. OBJECTIVE/DESIGN:To assess the ability of a large health system to close the referral loop, we used electronic medical record (EMR)-generated data to analyze referrals from a large primary care network to 20 high-volume specialties between July 1, 2015 and June 30, 2016. MAIN MEASURES:The primary metric was documented specialist appointment completion rate. Explanatory analyses included documented appointment scheduling rate, individual clinic differences, appointment wait times, and geographic distance to appointments. KEY RESULTS:Of the 103,737 analyzed referral scheduling attempts, only 36,072 (34.8%) resulted in documented complete appointments. Low documented appointment scheduling rates (38.9% of scheduling attempts lacked appointment dates), individual clinic differences in closing the referral loop, and significant differences in wait times and distances to specialists between complete and incomplete appointments drove this gap. Other notable findings include high variation in wait times among specialties and correlation between high wait times and low documented appointment completion rates. CONCLUSIONS:The rate of closing the referral loop in this health system is low. Low appointment scheduling rates, individual clinic differences, and patient access issues of wait times and geographic proximity explain much of the gap. This problem is likely common among large health systems with complex provider networks and referral scheduling. Strategies that improve scheduling, decrease variation among clinics, and improve patient access will likely improve rates of closing the referral loop. More research is necessary to determine the impact of these changes and other potential driving factors.Item Open Access Cost-effectiveness analysis of the diagnosis of meniscus tears.(Am J Sports Med, 2015-01) Mather, Richard C; Garrett, William E; Cole, Brian J; Hussey, Kristen; Bolognesi, Michael P; Lassiter, Tally; Orlando, Lori ABACKGROUND: Diagnostic imaging represents the fastest growing segment of costs in the US health system. This study investigated the cost-effectiveness of alternative diagnostic approaches to meniscus tears of the knee, a highly prevalent disease that traditionally relies on MRI as part of the diagnostic strategy. PURPOSE: To identify the most efficient strategy for the diagnosis of meniscus tears. STUDY DESIGN: Economic and decision analysis; Level of evidence, 1. METHODS: A simple-decision model run as a cost-utility analysis was constructed to assess the value added by MRI in various combinations with patient history and physical examination (H&P). The model examined traumatic and degenerative tears in 2 distinct settings: primary care and orthopaedic sports medicine clinic. Strategies were compared using the incremental cost-effectiveness ratio (ICER). RESULTS: In both practice settings, H&P alone was widely preferred for degenerative meniscus tears. Performing MRI to confirm a positive H&P was preferred for traumatic tears in both practice settings, with a willingness to pay of less than US$50,000 per quality-adjusted life-year. Performing an MRI for all patients was not preferred in any reasonable clinical scenario. The prevalence of a meniscus tear in a clinician's patient population was influential. For traumatic tears, MRI to confirm a positive H&P was preferred when prevalence was less than 46.7%, with H&P preferred above that. For degenerative tears, H&P was preferred until the prevalence reaches 74.2%, and then MRI to confirm a negative was the preferred strategy. In both settings, MRI to confirm positive physical examination led to more than a 10-fold lower rate of unnecessary surgeries than did any other strategy, while MRI to confirm negative physical examination led to a 2.08 and 2.26 higher rate than H&P alone in primary care and orthopaedic clinics, respectively. CONCLUSION: For all practitioners, H&P is the preferred strategy for the suspected degenerative meniscus tear. An MRI to confirm a positive H&P is preferred for traumatic tears for all practitioners. Consideration should be given to implementing alternative diagnostic strategies as well as enhancing provider education in physical examination skills to improve the reliability of H&P as a diagnostic test. CLINICAL RELEVANCE: Alternative diagnostic strategies that do not include the use of MRI may result in decreased health care costs without harm to the patient and could possibly reduce unnecessary procedures.Item Open Access Design of the NIDA clinical trials network validation study of tobacco, alcohol, prescription medications, and substance use/misuse (TAPS) tool.(Contemporary clinical trials, 2016-09) Wu, Li-Tzy; McNeely, Jennifer; Subramaniam, Geetha A; Sharma, Gaurav; VanVeldhuisen, Paul; Schwartz, Robert PSubstance use and its associated use disorders are under-detected and under-treated in primary care. There is a need for a clinically useful brief screening and assessment instrument to identify primary care patients with substance use, sub-threshold substance use disorder (SUD), and SUD to facilitate brief intervention and treatment.We describe the design of the recently completed National Drug Abuse Treatment Clinical Trials Network's tobacco, alcohol, prescription medications, and substance use/misuse screen and brief assessment tool validation study. Study aims included to: develop a 2-stage screening and brief assessment tool (TAPS Tool) to detect substance use, problem use, and SUD among adult primary care patients; examine the validity of both the screen component and the TAPS Tool by comparing them to reference standard screening and assessment measures of no use, problem use, and SUD; and determine the feasibility and acceptability of the self-administration and interviewer-administration of the tool. The design included a pilot testing phase (n=30) and the main study of 2000 adult primary care participants who were randomly assigned in counter-balanced order to have the interviewer-administration or the self-administration of the TAPS Tool followed by the other administration format. Participants' views of feasibility, acceptability and preference for format of self-administration versus interviewer-administration of the TAPS Tool were assessed. Criterion measures of use and DSM-5 SUDs were administered.The TAPS Tool study builds on prior work to develop a 2-stage clinical tool for facilitating the adoption of screening, brief assessment and treatment for SUDs in primary care.Item Open Access Detection of depression in low resource settings: validation of the Patient Health Questionnaire (PHQ-9) and cultural concepts of distress in Nepal.(BMC Psychiatry, 2016-03-08) Kohrt, Brandon A; Luitel, Nagendra P; Acharya, Prakash; Jordans, Mark JDBACKGROUND: Despite recognition of the burden of disease due to mood disorders in low- and middle-income countries, there is a lack of consensus on best practices for detecting depression. Self-report screening tools, such as the Patient Health Questionnaire (PHQ-9), require modification for low literacy populations and to assure cultural and clinical validity. An alternative approach is to employ idioms of distress that are locally salient, but these are not synonymous with psychiatric categories. Therefore, our objectives were to evaluate the validity of the PHQ-9, assess the added value of using idioms of distress, and develop an algorithm for depression detection in primary care. METHODS: We conducted a transcultural translation of the PHQ-9 in Nepal using qualitative methods to achieve semantic, content, technical, and criterion equivalence. Researchers administered the Nepali PHQ-9 to randomly selected patients in a rural primary health care center. Trained psychosocial counselors administered a validated Nepali depression module of the Composite International Diagnostic Interview (CIDI) to validate the Nepali PHQ-9. Patients were also assessed for local idioms of distress including heart-mind problems (Nepali, manko samasya). RESULTS: Among 125 primary care patients, 17 (14 %) were positive for a major depressive episode in the prior 2 weeks based on CIDI administration. With a Nepali PHQ-9 cutoff ≥ 10: sensitivity = 0.94, specificity = 0.80, positive predictive value (PPV) =0.42, negative predictive value (NPV) =0.99, positive likelihood ratio = 4.62, and negative likelihood ratio = 0.07. For heart-mind problems: sensitivity = 0.94, specificity = 0.27, PPV = 0.17, NPV = 0.97. With an algorithm comprising two screening questions (1. presence of heart-mind problems and 2. function impairment due to heart-mind problems) to determine who should receive the full PHQ-9, the number of patients requiring administration of the PHQ-9 could be reduced by 50 %, PHQ-9 false positives would be reduced by 18 %, and 88 % of patients with depression would be correctly identified. CONCLUSION: Combining idioms of distress with a transculturally-translated depression screener increases efficiency and maintains accuracy for high levels of detection. The algorithm reduces the time needed for primary healthcare staff to verbally administer the tool for patients with limited literacy. The burden of false positives is comparable to rates in high-income countries and is a limitation for universal primary care screening.Item Open Access Developing integration among stakeholders in the primary care networks of Singapore: a qualitative study.(BMC health services research, 2022-06-15) Surendran, Shilpa; Foo, Chuan De; Matchar, David Bruce; Ansah, John Pastor; Car, Josip; Koh, Gerald Choon HuatBackground
Integrating healthcare services across and between the different health system levels can be achieved in a few ways; however, examining the social side of integration is essential and challenging. This paper explores the concept of integration perceived by general practitioners (GPs) and primary care network (PCN) representatives from the regional health systems (RHS) in a GP-RHS PCN and their perceived partnership success.Methods
In this study, we explored three GP-RHS PCNs in Singapore. We used a qualitative research design and, overall, performed 17 semi-structured in-depth interviews with GPs (n = 11) and PCN representatives (n = 6) from the RHS. All interviews were audiotaped and transcribed verbatim. We conducted thematic analysis to inductively identify themes from the data. Singer's conceptual model of integration types was used as guiding principles to derive relevant and salient themes for integration.Results
GPs and the RHS perceived the concept of integration through a series of interrelated strategies. Within the normative dimension, a sense of urgency motivated GPs to integrate improvements into their general practice. Participants perceived teamwork and relational climate as appropriate enablers for achieving interpersonal integration in a primary care partnership. While developing a trusted relationship was a perceived success of this partnership across the network, developing camaraderie and gaining knowledge in chronic disease management through the components of functional integration was a perceived success at an individual general practice level. The data also revealed some operational challenges within the structural dimension and some inabilities of the PCN to achieve complete process integration.Conclusions
Our study points to multi-faceted integration, comprising various forms that need to be manifested at all levels of care to achieve coordinated, seamless, and comprehensive care for patients suffering from chronic conditions. The present iteration of the PCN has been shown to offer integration at a level that warrants praise but still requires structural and process integration improvement.Item Open Access Diagnosing and Treating Chronic Pain: Are We Doing This Right?(Journal of primary care & community health, 2021-01) Carnago, Lisa; O'Regan, Amy; Hughes, Jaime MThe diagnosis, treatment, and management of chronic pain is complex, nuanced, and challenging in primary care settings. These challenges often give rise to internal provider conflicts around appropriate management strategies, perhaps avoiding diagnosis all together. Factors that contribute to internal provider conflict include knowledge, responsibility, and uncertainties surrounding chronic pain management. This piece acknowledges the complexity and competing priorities of chronic pain management from a provider perspective. We advocate for coordinated and committed care of patients with chronic pain and a sense of shared responsibility among providers to adequately address patient needs.Item Open Access Digital health competencies for primary healthcare professionals: A scoping review.(International journal of medical informatics, 2020-11) Jimenez, Geronimo; Spinazze, Pier; Matchar, David; Koh Choon Huat, Gerald; van der Kleij, Rianne MJJ; Chavannes, Niels H; Car, JosipBackground
Despite digital health providing opportunities to enhance the quality, efficiency and safety of primary healthcare, the adoption of digital tools and technologies has been slow, partly because of poor digital health literacy. For primary healthcare systems to take full advantage of these technologies, a capable, digitally literate workforce is necessary. Still, the essential digital health competencies (DHCs) for primary healthcare have not been explored. This review aims to examine the broad literature on DHCs as it applies to Primary Care (PC) settings.Methods
We performed a scoping review on all types of research linking DHCs to PC. We searched all major databases including Medline, Embase, CINAHL, and Cochrane Library in November 2019. Concurrently, a thorough grey literature search was performed through OpenGrey, ResearchGate, Google Scholar, and key government and relevant professional associations' websites. Screening and selection of studies was performed in pairs, and data was analysed and presented using a narrative, descriptive approach. Thematic analysis was performed to identify key DHC domains.Results
A total of 28 articles were included, most of them (54 %) published before 2005. These articles were primarily aimed at PC physicians or general practitioners, and focused on improving knowledge about information technologies and medical informatics, basic computer and information literacy, and optimal use of electronic medical records. We identified 17 DHC domains, and important knowledge gaps related to digital health education and curriculum integration, the need for evidence of the impact of services, and the importance of wider support for digital health.Conclusions
Literature explicitly linking DHCs to PC was mostly published over a decade ago. There is a need for an updated and current set of DHCs for PC professionals to more consistently reap the benefits of digital technologies. This review identified key DHC domains and statements that may be used to guide on the development of a set of DHC for PC, and critical knowledge gaps and needs to be considered. Such a DHC set may be used for curricula development and for ensuring that the essential DHC for PC are met at a clinical or organizational level, and eventually improve health outcomes.Item Open Access DSM-5 substance use disorders among adult primary care patients: Results from a multisite study.(Drug and alcohol dependence, 2017-10) Wu, Li-Tzy; McNeely, Jennifer; Subramaniam, Geetha A; Brady, Kathleen T; Sharma, Gaurav; VanVeldhuisen, Paul; Zhu, He; Schwartz, Robert PBACKGROUND:There are limited data about the extent of DSM-5 substance use disorders (SUDs) among primary care patients. METHODS:This study analyzed data from a multisite validation study of a substance use screening instrument conducted in a diverse sample of 2000 adults aged ≥18 years recruited from five primary care practices in four states. Prevalence and correlates of 12-month DSM-5 SUDs were examined. RESULTS:Overall, 75.5% of the sample used any substance, including alcohol (62.0%), tobacco (44.1%), or illicit drugs/nonmedical medications (27.9%) in the past 12 months (marijuana 20.8%, cocaine 7.3%, opioids 4.8%, sedatives 4.1%, heroin 3.9%). The prevalence of any 12-month SUD was 36.0% (mild disorder 14.2%, moderate/severe disorder 21.8%): tobacco 25.3% (mild 11.5%, moderate/severe 13.8%); alcohol 13.9% (mild 6.9%, moderate/severe 7.0%); and any illicit/nonmedical drug 14.0% (mild 4.0%, moderate/severe 10.0%). Among past 12-month users, a high proportion of tobacco or drug users met criteria for a disorder: tobacco use disorder 57.4% (26.1% mild, 31.3% moderate/severe) and any drug use disorder 50.2% (14.3% mild, 35.8% moderate/severe); a lower proportion of alcohol users (22.4%) met criteria for alcohol use disorder (11.1% mild, 11.3% moderate/severe). Over 80% of adults with opioid/heroin use disorder met criteria for a moderate/severe disorder. Younger ages, male sex, and low education were associated with increased odds of having SUD. CONCLUSION:These findings reveal the high prevalence of SUDs in primary care and underscore the need to identify and address them.