Improving Ambulatory Health Care Proxy Completion Rates: Implementing an Interdisciplinary Clinic-Based Process

2020 ◽  
Vol 35 (6) ◽  
pp. 491-499
Author(s):  
Lauge Sokol-Hessner ◽  
Griffen Allen ◽  
Jennifer Cluett
Keyword(s):  
Primary Care ◽  
Health Care ◽  
Care Practice ◽  
Fisher Exact Test ◽  
Health Care Proxy ◽  
Exact Test ◽  
The North ◽  
Increased Risk ◽  
Physician Leaders ◽  
Interdisciplinary Process

All adults should complete a health care proxy (HCP), especially those who are seriously ill or otherwise at increased risk of losing capacity. This study describes the implementation of an interdisciplinary process for helping patients complete HCPs during nonurgent visits at a large urban academic primary care practice between July 2014 and May 2017. The process was mapped using direct observations. Pre- and post-implementation measurement of the percent of patients who completed HCPs during their visit revealed significant improvement (1.4% vs 26.1% in the North Suite, special cause variation). Over the study period, the percentage of patients with HCP information rose significantly across the entire clinic (eg, 37% to 80% in the North Suite, Fisher exact test P < .0001; similar findings in other suites). Key facilitators and barriers to implementation were identified by physician leaders. An interdisciplinary process can sustainably improve the percentage of primary care patients with a completed HCP.

Electronic cigarettes: How confident and effective are allergists, pulmonologists, and primary care physicians in their practice behavior?

2020 ◽  
Vol 41 (3) ◽  
pp. 192-197
Author(s):  
Sherry S. Zhou ◽  
Alan P. Baptist
Keyword(s):  
Primary Care ◽  
Primary Care Physicians ◽  
Electronic Cigarettes ◽  
The United States ◽  
Fisher Exact Test ◽  
Exact Test ◽  
Knowledge And Beliefs ◽  
Tobacco Cigarette ◽  
Number Of Patients ◽  
Personal Use

Background: There has been a striking increase in electronic cigarette (EC) use in the United States. The beliefs and practices toward ECs among physicians are unknown. Objective: The purpose of this study was to investigate EC practice patterns among allergists, pulmonologists, and primary care physicians. Methods: An anonymous survey was sent to physicians. The survey contained 32 questions and addressed issues related to demographics, cessation counseling behaviors, personal use, and knowledge and beliefs about ECs. Statistical analysis was performed by using analysis of variance, the Pearson χ2 test, Fisher exact test, and logistic regression. Results: A total of 291 physicians completed the survey (222 primary care physicians, 33 pulmonologists, and 36 allergists) for a response rate of 46%. The allergists asked about tobacco cigarette use as frequently as did the pulmonologists and more than the primary care physicians (p < 0.001), but they rarely asked about EC use. The pulmonologists scored highest on self-reported knowledge on ECs, although all the groups answered <40% of the questions correctly. The allergists did not feel as comfortable about providing EC cessation counseling as did the pulmonologists and primary care physicians (p < 0.001). All three groups were equally unlikely to recommend ECs as a cessation tool for tobacco cigarette users. Conclusion: Allergists lacked knowledge and confidence in providing education and cessation counseling for EC users. As the number of patients who use these products continues to increase, there is an urgent need for all physicians to be comfortable and knowledgeable with counseling about ECs.

scholarly journals Relation of severe COVID-19 to polypharmacy and prescribing of psychotropic drugs: the REACT-SCOT case-control study

BMC Medicine ◽  
2021 ◽  
Vol 19 (1) ◽  
Author(s):  
Paul M. McKeigue ◽  
◽  
Sharon Kennedy ◽  
Amanda Weir ◽  
Jen Bishop ◽  
...  
Keyword(s):  
Primary Care ◽  
Rate Ratio ◽  
Case Control Study ◽  
Fatal Outcome ◽  
Case Control ◽  
Care Practice ◽  
Drug Classes ◽  
Increased Risk ◽  
Co Morbidity ◽  
Control Study

Abstract Background The objective of this study was to investigate the relation of severe COVID-19 to prior drug prescribing. Methods Severe cases were defined by entry to critical care or fatal outcome. For this matched case-control study (REACT-SCOT), all 4251 cases of severe COVID-19 in Scotland since the start of the epidemic were matched for age, sex and primary care practice to 36,738 controls from the population register. Records were linked to hospital discharges since June 2015 and dispensed prescriptions issued in primary care during the last 240 days. Results Severe COVID-19 was strongly associated with the number of non-cardiovascular drug classes dispensed. This association was strongest in those not resident in a care home, in whom the rate ratio (95% CI) associated with dispensing of 12 or more drug classes versus none was 10.8 (8.8, 13.3), and in those without any of the conditions designated as conferring increased risk of COVID-19. Of 17 drug classes postulated at the start of the epidemic to be “medications compromising COVID”, all were associated with increased risk of severe COVID-19 and these associations were present in those without any of the designated risk conditions. The fraction of cases in the population attributable to exposure to these drug classes was 38%. The largest effect was for antipsychotic agents: rate ratio 4.18 (3.42, 5.11). Other drug classes with large effects included proton pump inhibitors (rate ratio 2.20 (1.72, 2.83) for = 2 defined daily doses/day), opioids (3.66 (2.68, 5.01) for = 50 mg morphine equivalent/day) and gabapentinoids. These associations persisted after adjusting for covariates and were stronger with recent than with non-recent exposure. Conclusions Severe COVID-19 is associated with polypharmacy and with drugs that cause sedation, respiratory depression, or dyskinesia; have anticholinergic effects; or affect the gastrointestinal system. These associations are not easily explained by co-morbidity. Measures to reduce the burden of mortality and morbidity from COVID-19 should include reinforcing existing guidance on reducing overprescribing of these drug classes and limiting inappropriate polypharmacy. Registration ENCEPP number https://EUPAS35558

Mental Health Care of Children and Adolescents: A Guide for Primary Care Clinicians

2018 ◽  
Keyword(s):  
Mental Health ◽  
Primary Care ◽  
Health Care ◽  
Mental Health Care ◽  
Children And Adolescents ◽  
Primary Care Practice ◽  
Care Practice ◽  
Primary Care Clinicians

This indispensable resource provides vital guidance for integrating mental health care into your everyday primary care practice. https://shop.aap.org/mental-health-care-of-children-and-adolescents-a-guide-for-primary-care-clinicians-paperback/

scholarly journals Patient Views of Behavioral Health Providers in Primary Care: A Qualitative Study of 2 Southeastern Clinics

2019 ◽  
Vol 7 (4) ◽  
pp. 527-533
Author(s):  
Aubry N Koehler ◽  
Grisel Trejo ◽  
Joanne C Sandberg ◽  
Brittany H Swain ◽  
Gail S Marion ◽  
...  
Keyword(s):  
Primary Care ◽  
Health Care ◽  
Behavioral Health ◽  
Care Delivery ◽  
Behavioral Health Care ◽  
Patient Care Team ◽  
Care Team ◽  
Care Practice ◽  
Health Providers ◽  
Integrated Behavioral Health

Background: Limited research is available around patient experience of integrated behavioral health care in primary care settings. Objective: We sought to identify the major themes through which patients described their integrated behavioral health care experiences as a means of informing and improving clinic processes of integrated health care delivery. Methods: We captured viewpoints from 16 patients who experienced an integrated behavioral health care model from 2 primary care clinics and completed at least 3 visits with a behavioral health provider (BHP). Using grounded theory analyses, we coded and analyzed transcriptions for emergent themes. Analysis: The interview process yielded 3 major themes related to the BHP including (a) the BHPs’ clinic presence made behavioral health care more convenient and accessible, (b) BHPs worked within time and program limitations, and (c) BHPs helped with coping, wellness, and patient-care team communication. Conclusion: The BHPs serving in a large primary care practice and a Federally Qualified Health Center played an important role in connecting patients with behavioral health care and improving care team collaboration, both in terms of communication within the team and between the team and the patient/family.

The Experience of Working With a Faith Community Nurse Liaison of Care in a Primary Care Practice Among Older Adult Clients and Their Informal Caregiver

2020 ◽  
pp. 089801012097732
Author(s):  
Loralee Sessanna ◽  
Sherry H. Pomeroy ◽  
Yvonne Askew ◽  
Kathleen McDonald-Shanahan ◽  
Maureen Couche
Keyword(s):  
Primary Care ◽  
Health Care ◽  
Older Adult ◽  
Primary Care Practice ◽  
Informal Caregiver ◽  
Informal Caregivers ◽  
Essential Element ◽  
Faith Community ◽  
Care Practice ◽  
Community Nurse

Informal caregivers of older adults aging in place are at risk for adverse health and financial consequences. This descriptive qualitative study explored the experience of working with a faith community nurse (FCN) liaison of care in a Catholic health care system affiliated primary care practice among older adult clients and their informal caregiver. Semistructured face-to-face interviews were conducted with nine older adult client–informal caregiver dyads, three clients, and one caregiver ( n = 22). Interviews were audio recorded, transcribed, and analyzed using Braun and Clarke’s reflexive thematic analysis method. The analysis generated one overarching theme, I’m Sorry the Study and FCN Visits Are Coming to an End, and two key themes, The FCN Was Always There to Help Us (older adult clients) and The FCN Took the Pressure Off of Caregiving for Awhile (informal caregivers). Participants viewed the FCN as an instrumental member of their health care team and considered prayer and spiritual support offered by the FCN an essential element of care.

scholarly journals Determination of Clopidogrel Resistance by Whole Blood Platelet Aggregometry and Inhibitors of the P2Y12 Receptor

2006 ◽  
Vol 52 (3) ◽  
pp. 383-388 ◽  
Author(s):  
Boris T Ivandic ◽  
Philipp Schlick ◽  
Peter Staritz ◽  
Kerstin Kurz ◽  
Hugo A Katus ◽  
...  
Keyword(s):  
Whole Blood ◽  
Adenosine Monophosphate ◽  
Blood Platelet ◽  
P2y12 Receptor ◽  
Fisher Exact Test ◽  
Exact Test ◽  
Clopidogrel Resistance ◽  
Impedance Aggregometry ◽  
Platelet Aggregometry ◽  
Increased Risk

Abstract Background: Inhibition of platelet aggregation by clopidogrel may be insufficient in up to 30% of users. These nonresponders carry an increased risk of cardiovascular events. We reported here a simple assay to study clopidogrel responsiveness. Methods: Electrical impedance aggregometry was performed in diluted whole blood in the presence of 5 and 20 μmol/L ADP. Some samples were incubated with 0.1 mmol/L methyl-S-adenosine monophosphate (MeSAMP), a P2Y12 receptor blocker, to maximize inhibition of aggregation before aggregometry. To validate the assay, we analyzed 6-min impedance in 21 healthy probands and 244 patients with coronary artery disease (CAD). Results: At 5 μmol/L ADP, the imprecision of the assay was 11%. Mean (SD) impedance of the healthy cohort was 12.2 (2.2) Ω. The mean − 3 SD was used to define the cutoff for clopidogrel responsiveness: responders and nonresponders exhibited a 6-min impedance ≤5 Ω and &gt;5 Ω, respectively. Samples from nonresponders were incubated with MeSAMP and analyzed again to distinguish pharmacokinetic and pharmacodynamic types of resistance. Sixteen percent of CAD patients were classified as nonresponders (38 and 2 cases of pharmacokinetic and pharmacodynamic resistance, respectively). Female sex was strongly associated with clopidogrel resistance (P = 0.0002, Fisher exact test). A higher clopidogrel loading dose (P = 0.0353, Mann–Whitney U-test) was given to responders (median, 450 mg) than nonresponders (median, 300 mg). Age and cardiovascular diagnosis showed no significant associations. Conclusions: Impedance aggregometry using 5 μmol/L ADP is a useful tool for studying clopidogrel responsiveness. MeSAMP allows characterization of responsiveness “on treatment” and may be useful for optimizing clopidogrel dosing.

Assessment of the Impact of Clinical Pharmacology Consultations Provided to Hospital Clinicians From the Drug Information Center—An Outcome Research in a Developing Country

2019 ◽  
pp. 089719001988525
Author(s):  
CVN Harish ◽  
Devaraj Belavigi ◽  
Amol N. Patil ◽  
Smita Pattanaik ◽  
Ashish Kakkar ◽  
...  
Keyword(s):  
Health Care ◽  
Evidence Based Medicine ◽  
Drug Information ◽  
Care Practice ◽  
Fisher Exact Test ◽  
Evidence Based ◽  
Care Hospital ◽  
Information Center ◽  
Based Medicine ◽  
The Impact

Background: Drug Information Center (DIC) with on-call evidence-based medicine service can revolutionize health-care practice and also can play a major role in health-care delivery in both developed and developing countries. Objective: To assess the feedback received from hospital clinicians for the newly initiated DIC services in a tertiary care hospital of North India. Methods: This is a retrospective cohort study conducted between January 1, 2016, to December 31, 2018. The clinicians approached DIC for specific pharmacotherapeutic questions for managing an index patient. After providing consultation, DIC followed up with them for the action taken and feedback on the consultation. The results of the data analyzed using Fisher Exact test and descriptive statistics. Results: Of 264 encounters, more than 98% of clinicians found the service satisfactory. There was a statistically significant association between the timely answer provided to treating physicians and their level of satisfaction with the service ( P < .05). There was no significant association between academic experiences and the satisfaction or dissatisfaction among the clinical fraternity colleagues. The interpretation ability of on-call pharmacology postgraduate students was a significantly associated factor with clinician’s satisfaction level ( P < .05). More than 96% of clinicians followed the pharmacotherapy advice recommended by DIC in their patient management. Conclusion: Thorough evaluation of published research needs to be taught to budding pharmacologists, pharmacists in their curriculum for an effective DIC service. DIC service has the potential to minimize the barrier of evidence-based medicine practice in developing as well as developed countries.

scholarly journals A qualitative study of urban hospital transitional care

2018 ◽  
Vol 2 (2) ◽  
Author(s):  
Joe Feinglass ◽  
Samuel Wein ◽  
Caroline Teter ◽  
Christine Schaeffer ◽  
Angela Rogers
Keyword(s):  
Mental Health ◽  
Primary Care ◽  
Health Care ◽  
Quality Improvement ◽  
Transitional Care ◽  
Behavioral Health Care ◽  
Care Quality ◽  
Care Staff ◽  
Internal Quality ◽  
Care Practice

This study is part of a mixed methods evaluation of a large urban medical center transitional care practice (NMG-TC). The NMG-TC provides integrated physical and behavioral health care for high need patients referred from the hospital emergency department or inpatient units and who lack a usual source of primary care. The study was designed for internal quality improvement and sought to evaluate staff perceptions of successful transitions for their medically and socially complex patients, and alternatively, the obstacles most likely to negatively impact patient outcomes. All 16 NMG-TC patient care staff were interviewed in a collaborative effort to produce empowered testimony that might go beyond expected clinical narratives. The interview schedule included questions on risk stratification, integrated mental health care, provider to provider handoffs, and how staff deal with key social determinates of patients’ health. The constant comparative method was used to deductively derive themes reflecting key domains of transitional care practice. Seven themes emerged: i) the need to quickly assess patient complexity; ii) emphasizing caring for major mental health and substance use issues; iii) obstacles to care for uninsured, often undocumented patients; iv) the intractability of homelessness; v) expertise in advancing patients’ health literacy, engagement and activation; vi) fragmented handoffs from hospital care and vii) to primary care in the community. Respondent stories emphasized methods of nurturing patients’ self-efficacy in a very challenging urban health environment. Findings will be used to conceptualize pragmatic, potentially high-impact transitional care quality improvement initiatives capable of better addressing frequent hospital use.

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