What Do High-Risk Patients Value? Perspectives on a Care Management Program

Background

There is growing interest in coordinating care for high-risk patients through care management programs despite inconsistent results on cost reduction. Early evidence suggests patient-centered benefits, but we know little about how participants engage with the programs and what aspects they value.

Objective

To explore care management program participants’ awareness and perceived utility of program offerings.

Design

Cross-sectional telephone survey administered December 2015–January 2016.

Participants

Patients enrolled in a Boston-area primary care-based care management program.

Main measures

Our main outcome was the number of topics in which patients reported having “very helpful” interactions with their care team in the past year. We analyzed awareness of one’s care manager as an intermediate outcome, and then as a primary predictor of the main outcome, along with patient demographics, years in the program, attitudes, and worries as secondary predictors.

Key results

The survey response rate was 45.8% (n = 1220); non-respondents were similar to respondents. More respondents reported worrying about family (72.8%) or financial issues (52.5%) than about their own health (41.6%). Seventy-four percent reported care manager awareness, particularly women (OR 1.33, 95% CI 1.01–1.77) and those with more years in the program (OR 1.16, 95% CI 1.03–1.30). While interaction rates ranged from 19.8% to 72.4% across topics, 81.3% rated at least one interaction as very helpful. Those who were aware of their care manager reported very helpful interactions on more topics (OR 2.77, 95% CI 2.15–3.56), as did women (OR 1.25, 95% CI 1.00–1.55), younger respondents (OR 0.98 for older age, 95% CI 0.97–0.99), and those with higher risk scores (OR 1.04, 95% CI 1.02–1.06), preference for deferring treatment decisions to doctors (OR 2.00, 95% CI 1.60–2.50), and reported control over their health (OR 1.67, 95% CI 1.33–2.10).

Conclusions

High-risk patients reported helpful interactions with their care team around medical and social determinants of health, particularly those who knew their care manager. Promoting care manager awareness may help participants make better use of the program.

     

Utilization of breast cancer screening with magnetic resonance imaging in community practice

Background

Breast cancer screening with magnetic resonance imaging (MRI) may be a useful adjunct to screening mammography in high-risk women, but MRI uptake may be increasing rapidly among low- and average-risk women for whom benefits are unestablished. Comparatively little is known about use of screening MRI in community practice.

Objective

To assess relative utilization of MRI among women who do and do not meet professional society guidelines for supplemental screening, and describe utilization according to breast cancer risk indications.

Design

Prospective cohort study conducted between 2007 and 2014.

Participants

In five regional imaging registries participating in the Breast Cancer Surveillance Consortium (BCSC), 348,955 women received a screening mammogram, of whom 1499 underwent screening MRI.

Main measures

Lifetime breast cancer risk (< 20% or ≥ 20%) estimated by family history of two or more first-degree relatives, and Gail model risk estimates. Breast Imaging Reporting and Data System breast density and benign breast diseases also were assessed. Relative risks (RR) for undergoing screening MRI were estimated using Poisson regression.

Key results

Among women with < 20% lifetime risk, which does not meet professional guidelines for supplementary MRI screening, and no first-degree breast cancer family history, screening MRI utilization was elevated among those with extremely dense breasts [RR 2.2; 95% confidence interval (CI) 1.7–2.8] relative to those with scattered fibroglandular densities and among women with atypia (RR 7.4; 95% CI 3.9–14.3.) or lobular carcinoma in situ (RR 33.1; 95% CI 18.0–60.9) relative to women with non-proliferative disease. Approximately 82.9% (95% CI 80.8%–84.7%) of screening MRIs occurred among women who did not meet professional guidelines and 35.5% (95% CI 33.1–37.9%) among women considered at low-to-average breast cancer risk.

Conclusion

Utilization of screening MRI in community settings is not consistent with current professional guidelines and the goal of delivery of high-value care.

     

Application of the qSOFA score to predict mortality in patients with suspected infection in a resource-limited setting in Malawi

Purpose

To determine the predictive value of qSOFA (quick Sequential Organ Failure Assessment) in Malawian patients with suspected infection.

Methods

Prospective observational study in a tertiary referral hospital in Malawi.

Results

Predictive ability of qSOFA was reasonable [AUROC 0.73 (95% CI 0.68–0.78)], increasing to 0.77 (95% CI 0.72–0.82) when classifying all patients with altered mental status as high risk. Adding HIV status as a variable to the qSOFA score did not improve predictive value.

Conclusion

qSOFA is a simple tool that can aid risk stratification in resource-limited settings.

     

Prognostic factors and scoring model of hematological malignancies patients with bloodstream infections

Purpose

Patients with hematological malignancies (HMs) are at a higher risk for bloodstream infections (BSIs), which pose significant burden on morbidity and mortality. Better risk stratification helps in medical decision making, increasing efficiency and reducing economic burden. The aim of this study was to develop and validate a reliable prediction model which can be used to identify HM patients at higher risk for BSIs.

Methods

We conducted a retrospective cohort study in three university-affiliated hospitals in Hunan Province, China, from January 2010 to April 2015. A total of 521 HMs patients with BSIs were finally included in this study and were divided into the derivation set and validation set. Survivors and non-survivors were compared to identify the predictors of 30-day mortality.

Results

The multivariate analysis yielded the following significant mortality-related risk factors: age?>?60 years (95% CI 1.047–5.474), relapsed or uncontrolled malignancy (95% CI 2.043–14.029), Pitt bacteremia score?>?3 (95% CI 1.614–6.35), prolonged neutropenia (95% CI 1.181–5.824), use of vasopressors (95% CI 3.009–12.210), acute respiratory failure (95% CI 3.061–14.911), fungemia (95% CI 1.334–12.121), inadequate antibiotic treatment (95% CI 1.682–7.591), albumin?<?30 g/L (95% CI 1.030–3.446), TBil?>?34.2 µmol/L (95% CI 1.109–5.438). In both derivation and validation sets, our model showed reliable prediction value with areas under the receiver operating curve of 0.876 and 0.873.

Conclusions

The risk factors in this study have the ability to identify patients with HMs and BSIs at high risk for mortality. Our model provides an excellent foundation for predicting 30-day morality in HM patients suffering from BSI and helps target high-risk patients for management decision making.

     

Association of Structured Virtual Visits for Hypertension Follow-Up in Primary Care with Blood Pressure Control and Use of Clinical Services

Background

Optimal management of hypertension requires frequent monitoring and follow-up. Novel, pragmatic interventions have the potential to engage patients, maintain blood pressure control, and enhance access to busy primary care practices. “Virtual visits” are structured asynchronous online interactions between a patient and a clinician to extend medical care beyond the initial office visit.

Objective

To compare blood pressure control and healthcare utilization between patients who received virtual visits compared to usual hypertension care.

Design

Propensity score-matched, retrospective cohort study with adjustment by difference-in-differences.

Participants

Primary care patients with hypertension.

Exposure

Patient participation in at least one virtual visit for hypertension. Usual care patients did not use a virtual visit but were seen in-person for hypertension.

Main measures

Adjusted difference in mean systolic blood pressure, primary care office visits, specialist office visits, emergency department visits, and inpatient admissions in the 180 days before and 180 days after the in-person visit.

Key results

Of the 1051 virtual visit patients and 24,848 usual care patients, we propensity score-matched 893 patients from each group. Both groups were approximately 61 years old, 44% female, 85% White, had about five chronic conditions, and about 20% had a mean pre-visit systolic blood pressure of 140–160 mmHg. Compared to usual care, virtual visit patients had an adjusted 0.8 (95% CI, 0.3 to 1.2) fewer primary care office visits. There was no significant adjusted difference in systolic blood pressure control (0.6 mmHg [95% CI, ??2.0 to 3.1]), specialist visits (0.0 more visits [95% CI, ??0.3 to 0.3]), emergency department visits (0.0 more visits [95% CI, 0.0 to 0.01]), or inpatient admissions (0.0 more admissions [95% CI, 0.0 to 0.1]).

Conclusions

Among patients with reasonably well-controlled hypertension, virtual visit participation was associated with equivalent blood pressure control and reduced in-office primary care utilization.

     

Characteristics and Long-Term Follow-Up of Participants with Peripheral Arterial Disease During ALLHAT

Background

Hypertension is a major risk factor for peripheral artery disease (PAD). Little is known about relative efficacy of antihypertensive treatments for preventing PAD.

Objectives

To compare, by randomized treatment groups, hospitalized or revascularized PAD rates and subsequent morbidity and mortality among participants in the Antihypertensive and Lipid-Lower Treatment to Prevent Heart Attack Trial (ALLHAT).

Design

Randomized, double-blind, active-control trial in high-risk hypertensive participants.

Participants

Eight hundred thirty participants with specified secondary outcome of lower extremity PAD events during the randomized phase of ALLHAT.

Interventions/events

In-trial PAD events were reported during ALLHAT (1994–2002). Post-trial mortality data through 2006 were obtained from administrative databases. Mean follow-up was 8.8 years.

Main Measures

Baseline characteristics and intermediate outcomes in three treatment groups, using the Kaplan-Meier method to calculate cumulative event rates and post-PAD mortality rates, Cox proportional hazards regression model for hazard ratios and 95 % confidence intervals, and multivariate Cox regression models to examine risk differences among treatment groups.

Key Results

Following adjustment for baseline characteristics, neither participants assigned to the calcium-channel antagonist amlodipine nor to the ACE-inhibitor lisinopril showed a difference in risk of clinically advanced PAD compared with those in the chlorthalidone arm (HR, 0.86; 95 % CI, 0.72–1.03 and HR, 0.98; 95 % CI, 0.83–1.17, respectively). Of the 830 participants with in-trial PAD events, 63 % died compared to 34 % of those without PAD; there were no significant treatment group differences for subsequent nonfatal myocardial infarction, coronary revascularizations, strokes, heart failure, or mortality.

Conclusions

Neither amlodipine nor lisinopril showed superiority over chlorthalidone in reducing clinically advanced PAD risk. These findings reinforce the compelling need for comparative outcome trials examining treatment of PAD in high-risk hypertensive patients. Once PAD develops, cardiovascular event and mortality risk is high, regardless of type of antihypertensive treatment.

     

Sleep disorders in pregnancy and their association with pregnancy outcomes: a prospective observational study

Purpose

Sleep disturbances such as insomnia, nocturnal awakenings, restless legs syndrome, habitual snoring, and excessive daytime sleepiness are frequent during pregnancy, and these have been linked to adverse maternal and fetal outcomes.

Methods

A prospective observational study was performed in high-risk Indian pregnant women. We used modified Berlin questionnaire (MBQ), Pittsburgh sleep quality index (PSQI), International Restless Legs Syndrome Study Group 2011 criteria, and Epworth sleepiness scale to diagnose various sleep disorders, such as symptomatic OSA, poor sleep quality and insomnia, RLS, and excessive daytime sleepiness, respectively, in successive trimesters of pregnancy. Outcome variables of interest were development of gestational hypertension (GH), gestational diabetes mellitus (GDM), and cesarean delivery (CS); the Apgar scores; and low birth weight (LBW). The relationship between sleep disorders and outcomes was explored using logistic regression analysis.

Results

Outcome data were obtained in 209 deliveries. As compared to nonsnorers, women who reported snoring once, twice, and thrice or more had odds ratios for developing GH—4.0 (95 % CI 1.3–11.9), 1.5 (95 % CI 0.5–4.5), and 2.9 (95 % CI 1.0–8.2) and for undergoing CS—5.3 (95 % CI 1.7–16.3), 4.9 (95 % CI 1.8–13.1), and 5.1 (95 % CI 1.9–14.9), respectively. Pregnant women who were persistently positive on MBQ had increased odds for GH and CS.

Conclusions

Snoring and high-risk MBQ in pregnant women are strong risk factors for GH and CS. In view of the significant morbidity and health care costs, simple screening of pregnant women with questionnaires such as MBQ may have clinical utility.

     

Care coordination and provider stress in primary care management of high-risk patients

Background

Care coordination is a critical component of managing high-risk patients, who tend to have complex and multiple medical and psychosocial problems and are typically at high risk for increased hospitalization and incur high health care expenditures. Primary care models such as the patient-centered medical homes (PCMHs) are designed to improve care coordination and reduce care fragmentation. However, little is known about how the burden of care coordination for high-risk patients influences PCMH team members’ stress.

Objective

To evaluate the relationship between provider stress and care coordination time in high-risk patient care and whether availability of help is associated with reduced stress.

Study design

Multivariable regression analysis of a cross-sectional survey of PCMH primary care providers (PCPs) and nurses.

Participants

A total of 164 PCPs and 272 nurses in primary care practices at five geographically diverse Veteran Health Administration (VA) medical center health systems.

Main measures

The main outcome variable was provider stress due to high-risk patient care. Independent variables were the reported proportion of high-risk patients in PCP/nurse patient panels, time spent coordinating care for these patients, and provider satisfaction with help received in caring for them.

Key results

The response rate was 44%. Spending more than 8 h per week coordinating care was significantly associated with a 0.21-point increase in reported provider stress compared to spending 8 h or less per week (95% CI: 0.04–0.39; p = 0.015). The magnitude of the association between stress and care coordination time was diminished when provider satisfaction with help received was included in the model.

Conclusions

Perceived provider stress from care of high-risk patients may arise from challenges related to coordinating their care. Our findings suggest that the perception of receiving help for high-risk patient care may be valuable in reducing provider stress.

     

Impact of a Population Health Management Intervention on Disparities in Cardiovascular Disease Control

Background

Healthcare systems use population health management programs to improve the quality of cardiovascular disease care. Adding a dedicated population health coordinator (PHC) who identifies and reaches out to patients not meeting cardiovascular care goals to these programs may help reduce disparities in cardiovascular care.

Objective

To determine whether a program that used PHCs decreased racial/ethnic disparities in LDL cholesterol and blood pressure (BP) control.

Design

Retrospective difference-in-difference analysis.

Participants

Twelve thousdand five hundred fifty-five primary care patients with cardiovascular disease (cohort for LDL analysis) and 41,183 with hypertension (cohort for BP analysis).

Intervention

From July 1, 2014–December 31, 2014, 18 practices used an information technology (IT) system to identify patients not meeting LDL and BP goals; 8 practices also received a PHC. We examined whether having the PHC plus IT system, compared with having the IT system alone, decreased racial/ethnic disparities, using difference-in-difference analysis of data collected before and after program implementation.

Main Measures

Meeting guideline concordant LDL and BP goals.

Key Results

At baseline, there were racial/ethnic disparities in meeting LDL (p?=?0.007) and BP (p?=?0.0003) goals. Comparing practices with and without a PHC, and accounting for pre-intervention LDL control, non-Hispanic white patients in PHC practices had improved odds of LDL control (OR 1.20 95% CI 1.09–1.32) compared with those in non-PHC practices. Non-Hispanic black (OR 1.15 95% CI 0.80–1.65) and Hispanic (OR 1.29 95% CI 0.66–2.53) patients saw similar, but non-significant, improvements in LDL control. For BP control, non-Hispanic white patients in PHC practices (versus non-PHC) improved (OR 1.13 95% CI 1.05–1.22). Non-Hispanic black patients (OR 1.17 95% CI 0.94–1.45) saw similar, but non-statistically significant, improvements in BP control, but Hispanic (OR 0.90 95% CI 0.59–1.36) patients did not. Interaction testing confirmed that disparities did not decrease (p?=?0.73 for LDL and p?=?0.69 for BP).

Conclusions

The population health management intervention did not decrease disparities. Further efforts should explicitly target improving both healthcare equity and quality.Clinical Trials #: NCT02812303 (ClinicalTrials.gov).

     

The Role of Spirituality Healing with Perceptions of the Medical Encounter among Latinos

Background

Little is known about the relationship between spirituality healing and perceptions about the medical encounter among Latinos.

Objectives

To examine the association between spirituality healing and attitudes of self-reported perceptions about the medical encounter.

Design

A cross-sectional telephone survey.

Participants

3,728 Latinos aged ≥18 years residing in the United States from Wave 1 of the Pew Hispanic Center/Robert Wood Johnson Foundation Latino Health Survey.

Measurements

Dependent variables were ever prayed for healing (yes/no), ever asked others to pray for healing (yes/no), considered important spiritual healing (very vs. somewhat or not important), and ever consulted a ‘curandero’ (folk healer in Latin America) (yes/no). The primary independent variables were feelings about the last time seeing a Doctor (confused by information given, or frustrated by lack of information) and perception of quality of medical care (excellent, good, fair or poor) within the past 12 months.

Results

Six percent of individuals reported that they had ever consulted a curandero, 60% prayed for healing, 49% asked others to pray for healing, and 69% considered spiritual healing as very important. In multivariable analyses, feeling confused was associated with increased odds of consulting a curandero (OR?=?1.58; 95% CI, 1.02–2.45), praying for healing (OR?=?1.30; 95% CI, 1.03–1.64), asking others to pray for healing (OR?=?1.29; 95% CI, 1.03–1.62), and considering spiritual healing as very important (OR?=?1.30; 95% CI, 1.01–1.66). Feeling frustrated by a lack of information was associated with asking others to pray for healing (OR?=?1.29; 95% CI, 1.04–1.60). A better perception of quality of medical care was associated with lower odds of consulting a curandero (OR?=?0.83; 95% CI, 0.70–0.98).

Conclusion

Feelings about the medical encounter were associated with spirituality healing, praying for healing, and asking others to pray for healing. Feeling confused and perception of poor quality of medical care were associated with consulting a curandero.

     

The product of triglycerides and glucose in comparison with fasting plasma glucose did not improve diabetes prediction

Aims

Previous study has reported that triglycerides-glucose (TyG) index, a product of triglycerides and fasting plasma glucose (FPG), might be useful in the prediction of incident type 2 diabetes (T2D). We evaluated the ability of the TyG index compared to FPG and OGTT as possible diabetes predictor in nondiabetic first-degree relatives (FDRs) of patients with T2D.

Methods

A total of 1,488 FDRs without diabetes of consecutive patients with T2D 30–70 years old (361 men and 1,127 women) were examined and followed for a mean (SD) of 6.9 (1.7) years for diabetes incidence. We examined the incidence of diabetes across quartiles of the TyG index and plotted a receiver operating characteristic (ROC) curve to assess discrimination. At baseline and through follow-up, participants underwent a standard 75-g two-hour oral glucose tolerance test.

Results

During 10,124 person-years of follow-up, 41 men and 154 women developed T2D. Those in the top quartile of TyG index were 3.4 times more likely to develop T2D than those in the bottom quartile (odds ratio 3.36; 95 % CI 1.83, 6.19). On ROC curve analysis, a higher area under the ROC was found for FPG (76.2; 95 % CI 71.9, 80.6), 1-hPG (81.0, 95 % CI 77.2, 84.9) and 2-hPG (76.5; 95 % CI 72.3, 80.8) than for TyG index (65.1; 95 % CI 60.5, 69.7).

Conclusions

TyG index is predicted T2D in high-risk individuals in Iran but FPG, 1-hPG and 2-hPG appeared to be more robust predictor of T2D in our study population.

     

Characteristics and Disparities among Primary Care Practices in the United States

Background

Despite new incentives for US primary care, concerns abound that patient-centered practice capabilities are lagging.

Objective

Describe the practice structure, patient-centered capabilities, and payment relationships of US primary care practices; identify disparities in practice capabilities.

Design

Analysis of the 2015 Medical Organizations Survey (MOS), part of the nationally representative Medical Expenditure Panel Survey (MEPS).

Setting

Practice-reported information from primary care practices of MEPS respondents who reported receiving primary care and made at least one visit in 2015 to that practice.

Participants

Surveyed primary care practices (n?=?4318; 77% response rate) providing primary care to 7161 individuals, representing 101,159,263 Americans.

Main Measures

Practice structure (ownership and personnel); practice capabilities (certification as a patient-centered medical home [PCMH], electronic health record [EHR] use, and x-ray capability); and payment orientation (accountable care organization [ACO] and capitation).

Key Results

Independently owned practices served 55% of patients, hospital-owned practices served 19%, and nonprofit/government/academic-owned served 20%. Solo practices served 25% of patients and practices with 2–10 physicians served 53% of patients. Forty-one percent of patients were served by practices certified as PCMHs. Practices with EHRs cared for 90% of patients and could exchange secure messages with 78% of patients. Practices with in-office x-ray capability cared for 34% of patients. Practices participating in ACOs and capitation served 44% and 46% of patients, respectively. Primary care patients in the South, compared to the rest of the country, had less access to nearly all practice capabilities, including patient care coordination (adjusted difference, 13% [95% CI, 8–18]) and secure EHR messaging (adjusted difference, 6% [95% CI, 1–10]). Uninsured patients were less likely to be served at a practice that used an EHR (adjusted difference, 9% [95% CI, 2–16]).

Conclusions

Participants’ primary care practices were mostly independently owned, nearly always used EHRs (albeit of varying capability), and frequently participated in innovative payment arrangements for a portion of their patients. Patient practices in the South had fewer capabilities than the rest of the country.

     

Prediction Model for Two-Year Risk of Opioid Overdose Among Patients Prescribed Chronic Opioid Therapy

Background

Naloxone is a life-saving opioid antagonist. Chronic pain guidelines recommend that physicians co-prescribe naloxone to patients at high risk for opioid overdose. However, clinical tools to efficiently identify patients who could benefit from naloxone are lacking.

Objective

To develop and validate an overdose predictive model which could be used in primary care settings to assess the need for naloxone.

Design

Retrospective cohort.

Setting

Derivation site was an integrated health system in Colorado; validation site was a safety-net health system in Colorado.

Participants

We developed a predictive model in a cohort of 42,828 patients taking chronic opioid therapy and externally validated the model in 10,708 patients.

Main Measures

Potential predictors and outcomes (nonfatal pharmaceutical and heroin overdoses) were extracted from electronic health records. Fatal overdose outcomes were identified from state vital records. To match the approximate shelf-life of naloxone, we used Cox proportional hazards regression to model the 2-year risk of overdose. Calibration and discrimination were assessed.

Key Results

A five-variable predictive model showed good calibration and discrimination (bootstrap-corrected c-statistic?=?0.73, 95% confidence interval [CI] 0.69–0.78) in the derivation site, with sensitivity of 66.1% and specificity of 66.6%. In the validation site, the model showed good discrimination (c-statistic?=?0.75, 95% CI 0.70–0.80) and less than ideal calibration, with sensitivity and specificity of 82.2% and 49.5%, respectively.

Conclusions

Among patients on chronic opioid therapy, the predictive model identified 66–82% of all subsequent opioid overdoses. This model is an efficient screening tool to identify patients who could benefit from naloxone to prevent overdose deaths. Population differences across the two sites limited calibration in the validation site.

     

External Validation of a Tool Predicting 7-Year Risk of Developing Cardiovascular Disease,Type 2 Diabetes or Chronic Kidney Disease

Background

Chronic cardiometabolic diseases, including cardiovascular disease (CVD), type 2 diabetes (T2D) and chronic kidney disease (CKD), share many modifiable risk factors and can be prevented using combined prevention programs. Valid risk prediction tools are needed to accurately identify individuals at risk.

Objective

We aimed to validate a previously developed non-invasive risk prediction tool for predicting the combined 7-year-risk for chronic cardiometabolic diseases.

Design

The previously developed tool is stratified for sex and contains the predictors age, BMI, waist circumference, use of antihypertensives, smoking, family history of myocardial infarction/stroke, and family history of diabetes. This tool was externally validated, evaluating model performance using area under the receiver operating characteristic curve (AUC)—assessing discrimination—and Hosmer–Lemeshow goodness-of-fit (HL) statistics—assessing calibration. The intercept was recalibrated to improve calibration performance.

Participants

The risk prediction tool was validated in 3544 participants from the Australian Diabetes, Obesity and Lifestyle Study (AusDiab).

Key Results

Discrimination was acceptable, with an AUC of 0.78 (95% CI 0.75–0.81) in men and 0.78 (95% CI 0.74–0.81) in women. Calibration was poor (HL statistic: p?<?0.001), but improved considerably after intercept recalibration. Examination of individual outcomes showed that in men, AUC was highest for CKD (0.85 [95% CI 0.78–0.91]) and lowest for T2D (0.69 [95% CI 0.65–0.74]). In women, AUC was highest for CVD (0.88 [95% CI 0.83–0.94)]) and lowest for T2D (0.71 [95% CI 0.66–0.75]).

Conclusions

Validation of our previously developed tool showed robust discriminative performance across populations. Model recalibration is recommended to account for different disease rates. Our risk prediction tool can be useful in large-scale prevention programs for identifying those in need of further risk profiling because of their increased risk for chronic cardiometabolic diseases.

     

Diagnostic Evaluation of Patients Presenting to Primary Care with Rectal Bleeding

Background

Rectal bleeding is a common, frequently benign problem that can also be an early sign of colorectal cancer. Diagnostic evaluation for rectal bleeding is complex, and clinical practice may deviate from available guidelines.

Objective

To assess the degree to which primary care physicians document risk factors for colorectal cancer among patients with rectal bleeding and order colonoscopies when indicated, and the likelihood of physicians ordering and patients receiving recommended colonoscopies based on demographic characteristics, visit patterns, and clinical presentations.

Design

Cross-sectional study using explicit chart abstraction methods.

Participants

Three hundred adults, 40–80 years of age, presenting with rectal bleeding to 15 academically affiliated primary care practices between 2012 and 2016.

Main Measures

1) The frequency at which colorectal cancer risk factors were documented in patients’ charts, 2) the frequency at which physicians ordered colonoscopies and patients received them, and 3) the odds of ordering and patients receiving recommended colonoscopies based on patient demographic characteristics, visit patterns, and clinical presentations.

Key Results

Risk factors for colorectal cancer were documented between 9% and 66% of the time. Most patients (89%) with rectal bleeding needed a colonoscopy according to a clinical guideline. Physicians placed colonoscopy orders for 74% of these patients, and 56% completed the colonoscopy within a year (36% within 60 days). The odds of physicians ordering recommended colonoscopies were significantly higher in patients aged 50–64 years of age than in those aged 40–50 years (OR?=?2.23, 95% CI: 1.04, 4.80), and for patients whose most recent colonoscopy was 5 or more years ago (OR?=?4.04, 95% CI: 1.50, 10.83). The odds of physicians ordering and patients receiving recommended colonoscopies were significantly lower for each primary care visit unrelated to rectal bleeding (OR?=?0.85, 95% CI: 0.75, 0.96).

Conclusions

Diagnostic evaluation of patients presenting to primary care with rectal bleeding may be suboptimal because of inadequate risk factor assessment and prioritization of patients’ other concurrent medical problems.

     

Correlates of Suicide Among Veterans Treated in Primary Care: Case–Control Study of a Nationally Representative Sample

BACKGROUND

Veterans receiving Veterans Affairs (VA) healthcare have increased suicide risk compared to the general population. Many patients see primary care clinicians prior to suicide. Yet little is known about the correlates of suicide among patients who receive primary care treatment prior to death.

OBJECTIVE

Our aim was to describe characteristics of veterans who received VA primary care in the 6 months prior to suicide; and to compare these to characteristics of control patients who also received VA primary care.

DESIGN

This was a retrospective case–control study.

SUBJECTS

The investigators partnered with VA operations leaders to obtain death certificate data from 11 states for veterans who died by suicide in 2009. Cases were matched 1:2 to controls based on age, sex, and clinician.

MAIN MEASURES

Demographic, diagnosis, and utilization data were obtained from VA’s Corporate Data Warehouse. Additional clinical and psychosocial context data were collected using manual medical record review. Multivariate conditional logistic regression was used to examine associations between potential predictor variables and suicide.

KEY RESULTS

Two hundred and sixty-nine veteran cases were matched to 538 controls. Average subject age was 63 years; 97 % were male. Rates of mental health conditions, functional decline, sleep disturbance, suicidal ideation, and psychosocial stressors were all significantly greater in cases compared to controls. In the final model describing men in the sample, non-white race (OR?=?0.51; 95 % CI?=?0.27–0.98) and VA service-connected disability (OR?=?0.54; 95 % CI?=?0.36–0.80) were associated with decreased odds of suicide, while anxiety disorder (OR?=?3.52; 95 % CI?=?1.79–6.92), functional decline (OR?=?2.52; 95 % CI?=?1.55–4.10), depression (OR?=?1.82; 95 % CI?=?1.07–3.10), and endorsement of suicidal ideation (OR?=?2.27; 95 % CI?=?1.07–4.83) were associated with greater odds of suicide.

CONCLUSIONS

Assessment for anxiety disorders and functional decline in addition to suicidal ideation and depression may be especially important for determining suicide risk in this population. Continued development of interventions that support identifying and addressing these conditions in primary care is indicated.

     

Clinician Referrals for Non-opioid Pain Care Following Discontinuation of Long-term Opioid Therapy Differ Based on Reasons for Discontinuation

Background

Little is known about pain care offered to patients discontinued from long-term opioid therapy (LTOT) by their prescriber due to aberrant behaviors versus other reasons.

Objective

This study aimed to compare rates of non-opioid analgesic pharmacotherapy initiation and clinician referrals for non-pharmacologic pain treatment, complementary and integrative pain therapies, and specialty mental health and substance use disorder treatment between patients discontinued from opioid therapy due to aberrant behaviors versus other reasons.

Design

The design included retrospective manual electronic health record review and administrative data abstraction.

Participants

Patients were sampled from a national cohort of US Department of Veterans Affairs patients prescribed continuous opioid therapy in 2011 who subsequently discontinued opioid therapy in 2012. The study sample comprised 509 patients discontinued from LTOT by opioid-prescribing clinicians.

Main Measures

The primary independent variable was reason for discontinuation of LTOT (aberrant behaviors versus other reasons). Pain care dichotomous outcomes included clinician use of an opioid taper; initiating new non-opioid analgesic pharmacotherapy; and referrals for non-pharmacologic pain treatment, complementary and integrative pain therapies, and specialty mental health and substance use disorder treatment.

Key Results

We observed low rates of opioid taper (15% of patients), initiations of new or modifications of existing non-opioid analgesic pharmacotherapy (45% of patients), and clinician referrals for non-pharmacologic pain treatment (58% of patients) and complementary and integrative therapies (25% of patients). Patients discontinued due to aberrant behaviors, relative to patients discontinued for other reasons, were more likely to receive opioid tapers (adjusted OR?=?5.60, 95% CI?=?2.10–14.93), receive new non-opioid analgesic medications or dose changes to an existing non-opioid analgesic medications (adjusted OR?=?2.61, 95% CI?=?1.59–4.29), or be referred for specialty substance use disorder treatment (adjusted OR?=?7.39, 95% CI?=?3.76–14.53).

Conclusions

These findings highlight the variability in referral rates for different types of non-opioid pain treatments and challenges accessing specific types of pain care.

     

Health-related quality of life predicts unplanned rehospitalization following coronary revascularization

Background

Health-related quality of life (HRQL) is an increasingly well-recognized measure of health outcome in cardiology. We examined HRQL as a predictor of unplanned rehospitalization for cardiac reasons in patients after coronary revascularization over a period of 3 years.

Patients and methods

Out of 791 patients enrolled in the study, 743 completed the MacNew HRQL questionnaire after coronary revascularization. MacNew HRQL scores were used as predictors of unplanned rehospitalization.

Results

Within the 3-year follow-up period, 125 patients (16.8?%) were rehospitalized. After adjustment for age, gender, and myocardial infarction as the initiating event, there were significant differences in unplanned rehospitalization rates between patients with low or moderate vs. high MacNew HRQL global scores (HR: 1.8, 95?% CI: 1.2–2.7) and both physical (HR: 2.2, 95?% CI: 1.4–3.5) and social (HR: 1.8, 95?% CI: 1.2–2.7) subscale scores.

Conclusion

Poor HRQL assessed after coronary revascularization appears to be a powerful predictor of rehospitalization over a 3-year period.