Not Perfect, but Better: Primary Care Providers’ Experiences with Electronic Referrals in a Safety Net Health System

Abstract Background Colorectal cancer (CRC) is a major public health issue in the Arab region. In Kuwait, CRC is the second most frequent cancer, with an age-standardized (world) incidence rate of 13.2 cases/100,000 in 2018. Despite the national efforts to promote CRC screening the current participation rate is very low (5 to 17%). Primary Care Providers (PCPs) are considered as the gatekeepers of cancer screening globally. This is one of the first studies in Kuwait that examined the current beliefs/practices of PCPs on CRC screening. Methods This cross-sectional study was conducted at governmental primary care centers in Kuwait from 2015-2017. Of 564 PCPs invited to participate from all centers, 255 completed the self-administered questionnaires. The 14-page survey contained 75 questions on PCPs’ beliefs and practices of CRC screening. Data were analyzed by using descriptive statistics. Results The study sample consisted primarily of females (52.0%) and non-Kuwaiti (79%) physicians, with mean age =43.3 (SD: 11.2) years. Most respondents (92%) believed that colonoscopy is the most effective screening tool. The majority (78%) reported that they recommend CRC screening to their patients, with colonoscopy as the most frequent modality (87%) followed by the Faecal Occult Blood Test (FOBT) (52%). Around 40% of the respondents stated that they did not have time to discuss CRC screening with their patients. The majority (72%) believed that their patients did not complete their CRC screening tests. Health system related barriers included difficulties in obtaining test results from the gastroenterologist (61.4%), ordering follow-up test after a positive screening test (50.6%) and shortage of trained staff to conduct the screening test (44.2%). Conclusions A majority of PCPs in Kuwait recommend CRC screening to their patients, but not all patients follow through their recommendation. More research is needed to find out how to further enhance patient uptake of CRC screening. Key messages Colonoscopy is the most frequent screening CRC modality used in Kuwait. Health system related factors can be important future intervention targets to promote CRC screening.

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Primary Care Providers' Views on Chronic Pain Management Among High-Risk Patients in Safety Net Settings

Pain Medicine ◽

10.1111/j.1526-4637.2012.01443.x ◽

2012 ◽

Vol 13 (9) ◽

pp. 1141-1148 ◽

Cited By ~ 15

Author(s):

Maya Vijayaraghavan ◽

Joanne Penko ◽

David Guzman ◽

Christine Miaskowski ◽

Margot B. Kushel

Keyword(s):

Primary Care ◽

Chronic Pain ◽

Pain Management ◽

High Risk ◽

Primary Care Providers ◽

Safety Net ◽

Chronic Pain Management ◽

Care Providers ◽

High Risk Patients ◽

Risk Patients

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Identification of barriers to safe opioid prescribing in primary care: a qualitative analysis of field notes collected through academic detailing

British Journal of General Practice ◽

10.3399/bjgp20x711737 ◽

2020 ◽

Vol 70 (697) ◽

pp. e589-e597 ◽

Cited By ~ 2

Author(s):

Christopher D Saffore ◽

Sarette T Tilton ◽

Stephanie Y Crawford ◽

Michael A Fischer ◽

Todd A Lee ◽

...

Keyword(s):

Primary Care ◽

Pain Management ◽

Qualitative Analysis ◽

Health System ◽

Primary Care Providers ◽

Academic Detailing ◽

Care Providers ◽

Opioid Prescribing ◽

Field Notes ◽

Safe Opioid Prescribing

Background Understanding barriers to safe opioid prescribing in primary care is critical amid the epidemic of prescription opioid abuse, misuse, and overdose in the US. Educational outreach strategies, such as academic detailing (AD), provide a forum for identification of barriers to, and strategies to facilitate, safe opioid prescribing in primary care.AimTo identify barriers to safe opioid prescribing among primary care providers (PCPs) through AD.Design and settingQualitative analysis of data was collected through an existing AD intervention to improve safe opioid prescribing in primary care. The AD intervention was delivered from June 2018 to August 2018 to licensed PCPs with prescriptive authority within a large independent health system in the metropolitan Chicagoland area.MethodThe AD intervention involved visits by trained detailers to PCPs who contemporaneously documented details from each visit via field notes. Using qualitative analysis, field notes were analysed to identify recurring themes related to opioid prescribing barriers.ResultsDetailer-entered field notes from 186 AD visits with PCPs were analysed. Barriers to safe opioid prescribing were organised into six themes: 1) gaps in knowledge; 2) lack of prescription monitoring programme (PMP) utilisation; 3) patient pressures to prescribe opioids; 4) insurance coverage policies; 5) provider beliefs; and 6) health system pain management practices.ConclusionBarriers to safe opioid prescribing in primary care, identified through AD visits among this large group of PCPs, support the need for continued efforts to enhance pain-management education, maximise PMP utilisation, and increase access to, and affordability of, non-opioid treatments.

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Inter-clinician eConsults without programmatic incentives or requirements: a qualitative study of primary care provider perspectives

Family Practice ◽

10.1093/fampra/cmaa016 ◽

2020 ◽

Vol 37 (4) ◽

pp. 525-529 ◽

Cited By ~ 1

Author(s):

Leah Zallman ◽

Carolyn F Fisher ◽

Sofia Ladner ◽

Kira Mengistu ◽

Alison B Rapaport ◽

...

Keyword(s):

Primary Care ◽

Health Care ◽

Focus Groups ◽

Health Care Systems ◽

Primary Care Providers ◽

Safety Net ◽

Care Providers ◽

Provider Perspectives ◽

Care Systems ◽

The Usa

Abstract Background Inter-clinician electronic consultation (eConsult) programmes are becoming more widespread in the USA as health care systems seek innovative ways of improving specialty access. Existing studies examine models with programmatic incentives or requirements for primary care providers (PCPs) to participate. Objective We aimed to examine PCP perspectives on eConsults in a system with no programmatic incentive or requirement for PCPs to use eConsults. Methods We conducted seven focus groups with 41 PCPs at a safety-net community teaching health care system in Eastern Massachusetts, USA. Results Focus groups revealed that eConsults improved PCP experience by enabling patient-centred care and enhanced PCP education. However, increased workload and variations in communication patterns added challenges for PCPs. Patients were perceived as receiving timelier and more convenient care. Timelier care combined with direct documentation in the patient record was perceived as improving patient safety. Although cost implications were less clear, PCPs perceived costs as being lowered through fewer unnecessary visits and laboratories. Conclusions Our findings suggest that eConsult systems with no programmatic incentives or requirements for PCPs have the potential to improve care.

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Reasons for Opioid Discontinuation and Unintended Consequences Following Opioid Discontinuation Within the TOPCARE Trial

Pain Medicine ◽

10.1093/pm/pny124 ◽

2018 ◽

Vol 20 (7) ◽

pp. 1330-1337 ◽

Cited By ~ 1

Author(s):

Jawad M Husain ◽

Marc LaRochelle ◽

Julia Keosaian ◽

Ziming Xuan ◽

Karen E Lasser ◽

...

Keyword(s):

Primary Care ◽

Primary Care Providers ◽

Safety Net ◽

Opioid Therapy ◽

Unintended Consequences ◽

Care Providers ◽

Opioid Use ◽

Opioid Prescribing ◽

Ed Visits

Abstract Objective To identify reasons for opioid discontinuation and post-discontinuation outcomes among patients in the Transforming Opioid Prescribing in Primary Care (TOPCARE) study. Design In TOPCARE, an intervention to improve adherence to opioid prescribing guidelines, randomized intervention primary care providers (PCPs) received nurse care manager support, an electronic registry, academic detailing, and electronic tools, and control PCPs received electronic tools only. Setting Four Boston safety net primary care practices. Subjects Patients in both TOPCARE study arms who discontinued opioid therapy during the trial. Methods Through chart review, we examined the reason for discontinuation and post-discontinuation outcomes: one or more PCP visits, one or more pain-related emergency department (ED) visits, evidence of opioid use disorder (OUD), and referral for OUD treatment. Results Opioid discontinuations occurred in 83/586 (14.2%) intervention and 42/399 (10.5%) control patients (P = 0.09). Among patients who discontinued opioids, 81 (65%) discontinued for misuse, with no difference by group (P = 0.38). Aberrancy in monitoring (e.g., discordant urine drug test results) was the most common type of misuse prompting discontinuation (occurring in (51/83 [61%] of intervention patients vs 19/42 [45%, P = 0.08] of control patients). Intervention patients who discontinued opioids had less PCP follow-up (65% vs 88%, P < 0.01) compared with control patients. We found no differences between groups for pain-related ED visits, evidence of OUD, or OUD treatment referral following discontinuation. Conclusions The decreased follow-up among TOPCARE intervention patients who discontinued opioids highlights the need to understand unintended consequences of involuntary opioid discontinuations resulting from interventions to reduce opioid risk.

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Shared Decision Making in Primary Care Based Depression Treatment: Communication and Decision-Making Preferences Among an Underserved Patient Population

Frontiers in Psychiatry ◽

10.3389/fpsyt.2021.681165 ◽

2021 ◽

Vol 12 ◽

Author(s):

Elizabeth B. Matthews ◽

Margot Savoy ◽

Anuradha Paranjape ◽

Diana Washington ◽

Treanna Hackney ◽

...

Keyword(s):

Primary Care ◽

Decision Making ◽

Shared Decision Making ◽

Patient Population ◽

Primary Care Providers ◽

Safety Net ◽

Depression Treatment ◽

Shared Decision ◽

Care Providers ◽

Depression Care

Objectives: Although depression is a significant public health issue, many individuals experiencing depressive symptoms are not effectively linked to treatment by their primary care provider, with underserved populations have disproportionately lower rates of engagement in depression care. Shared decision making (SDM) is an evidence-based health communication framework that can improve collaboration and optimize treatment for patients, but there is much unknown about how to translate SDM into primary care depression treatment among underserved communities. This study seeks to explore patients' experiences of SDM, and articulate communication and decision-making preferences among an underserved patient population receiving depression treatment in an urban, safety net primary care clinic.Methods: Twenty-seven patients with a depressive disorder completed a brief, quantitative survey and an in-depth semi-structured interview. Surveys measured patient demographics and their subjective experience of SDM. Qualitative interview probed for patients' communication preferences, including ideal decision-making processes around depression care. Interviews were transcribed verbatim and analyzed using thematic analysis. Univariate statistics report quantitative findings.Results: Overall qualitative and quantitative findings indicate high levels of SDM. Stigma related to depression negatively affected patients' initial attitude toward seeking treatment, and underscored the importance of patient-provider rapport. In terms of communication and decision-making preferences, patients preferred collaboration with doctors during the information sharing process, but desired control over the final, decisional outcome. Trust between patients and providers emerged as a critical precondition to effective SDM. Respondents highlighted several provider behaviors that helped facilitated such an optimal environment for SDM to occur.Conclusion: Underserved patients with depression preferred taking an active role in their depression care, but looked for providers as partner in this process. Due to the stigma of depression, effective SDM first requires primary care providers to ensure that they have created a safe and trusting environment where patients are able to discuss their depression openly.

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