scholarly journals Impact of a “Chart Closure” Hard Stop Alert on Prescribing for Elevated Blood Pressures Among Patients With Diabetes: Quasi-Experimental Study (Preprint)

2019 ◽  
Author(s):  
Magaly Ramirez ◽  
Kimberly Chen ◽  
Robert W Follett ◽  
Carol M Mangione ◽  
Gerardo Moreno ◽  
...  
Keyword(s):  
Primary Care ◽  
Los Angeles ◽  
Subgroup Analysis ◽  
Primary Care Providers ◽  
Multivariate Logistic Regression Model ◽  
Diabetes Diagnosis ◽  
Elevated Blood ◽  
Care Providers ◽  
Predicted Probability ◽  
Patients With Diabetes

BACKGROUND University of California at Los Angeles Health implemented a Best Practice Advisory (BPA) alert for the initiation of an angiotensin-converting enzyme inhibitor (ACEI) or angiotensin-receptor blocker (ARB) for individuals with diabetes. The BPA alert was configured with a “chart closure” hard stop, which demanded a response before closing the chart. OBJECTIVE The aim of the study was to evaluate whether the implementation of the BPA was associated with changes in ACEI and ARB prescribing during primary care encounters for patients with diabetes. METHODS We defined ACEI and ARB prescribing opportunities as primary care encounters in which the patient had a diabetes diagnosis, elevated blood pressure in recent encounters, no active ACEI or ARB prescription, and no contraindications. We used a multivariate logistic regression model to compare the change in the probability of an ACEI or ARB prescription during opportunity encounters before and after BPA implementation in primary care sites that did (n=30) and did not (n=31) implement the BPA. In an additional subgroup analysis, we compared ACEI and ARB prescribing in BPA implementation sites that had also implemented a pharmacist-led medication management program. RESULTS We identified a total of 2438 opportunity encounters across 61 primary care sites. The predicted probability of an ACEI or ARB prescription increased significantly from 11.46% to 22.17% during opportunity encounters in BPA implementation sites after BPA implementation. However, in the subgroup analysis, we only observed a significant improvement in ACEI and ARB prescribing in BPA implementation sites that had also implemented the pharmacist-led program. Overall, the change in the predicted probability of an ACEI or ARB prescription from before to after BPA implementation was significantly greater in BPA implementation sites compared with nonimplementation sites (difference-in-differences of 11.82; <i>P</i>&lt;.001). CONCLUSIONS A BPA with a “chart closure” hard stop is a promising tool for the treatment of patients with comorbid diabetes and hypertension with an ACEI or ARB, especially when implemented within the context of team-based care, wherein clinical pharmacists support the work of primary care providers.

scholarly journals Impact of a “Chart Closure” Hard Stop Alert on Prescribing for Elevated Blood Pressures Among Patients With Diabetes: Quasi-Experimental Study

10.2196/16421 ◽  
2020 ◽  
Vol 8 (4) ◽  
pp. e16421
Author(s):  
Magaly Ramirez ◽  
Kimberly Chen ◽  
Robert W Follett ◽  
Carol M Mangione ◽  
Gerardo Moreno ◽  
...  
Keyword(s):  
Primary Care ◽  
Los Angeles ◽  
Subgroup Analysis ◽  
Primary Care Providers ◽  
Multivariate Logistic Regression Model ◽  
Diabetes Diagnosis ◽  
Elevated Blood ◽  
Care Providers ◽  
Predicted Probability ◽  
Patients With Diabetes

Background University of California at Los Angeles Health implemented a Best Practice Advisory (BPA) alert for the initiation of an angiotensin-converting enzyme inhibitor (ACEI) or angiotensin-receptor blocker (ARB) for individuals with diabetes. The BPA alert was configured with a “chart closure” hard stop, which demanded a response before closing the chart. Objective The aim of the study was to evaluate whether the implementation of the BPA was associated with changes in ACEI and ARB prescribing during primary care encounters for patients with diabetes. Methods We defined ACEI and ARB prescribing opportunities as primary care encounters in which the patient had a diabetes diagnosis, elevated blood pressure in recent encounters, no active ACEI or ARB prescription, and no contraindications. We used a multivariate logistic regression model to compare the change in the probability of an ACEI or ARB prescription during opportunity encounters before and after BPA implementation in primary care sites that did (n=30) and did not (n=31) implement the BPA. In an additional subgroup analysis, we compared ACEI and ARB prescribing in BPA implementation sites that had also implemented a pharmacist-led medication management program. Results We identified a total of 2438 opportunity encounters across 61 primary care sites. The predicted probability of an ACEI or ARB prescription increased significantly from 11.46% to 22.17% during opportunity encounters in BPA implementation sites after BPA implementation. However, in the subgroup analysis, we only observed a significant improvement in ACEI and ARB prescribing in BPA implementation sites that had also implemented the pharmacist-led program. Overall, the change in the predicted probability of an ACEI or ARB prescription from before to after BPA implementation was significantly greater in BPA implementation sites compared with nonimplementation sites (difference-in-differences of 11.82; P<.001). Conclusions A BPA with a “chart closure” hard stop is a promising tool for the treatment of patients with comorbid diabetes and hypertension with an ACEI or ARB, especially when implemented within the context of team-based care, wherein clinical pharmacists support the work of primary care providers.

scholarly journals Diabetes in Appalachia: providers’ perspectives

2020 ◽  
Vol 21 ◽  
Author(s):  
Elizabeth A. Beverly ◽  
Marilyn D. Ritholz ◽  
Karie Cook ◽  
Lesli K. Johnson ◽  
Anirudh Ruhil ◽  
...  
Keyword(s):  
Primary Care ◽  
Diabetes Care ◽  
Healthcare Providers ◽  
Primary Care Providers ◽  
Cultural Humility ◽  
Care Providers ◽  
Post Traumatic Stress ◽  
Appalachian Culture ◽  
Patients With Diabetes ◽  
Appalachian Ohio

Abstract Background: Southeastern Appalachian Ohio has more than double the national average of diabetes and a critical shortage of healthcare providers. Paradoxically, there is limited research focused on primary care providers’ experiences treating people with diabetes in this region. This study explored providers’ perceived barriers to and facilitators for treating patients with diabetes in southeastern Appalachian Ohio. Methods: We conducted in-depth interviews with healthcare providers who treat people with diabetes in rural southeastern Ohio. Interviews were transcribed, coded, and analyzed via content and thematic analyses using NVivo 12 software (QSR International, Chadstone, VIC, Australia). Results: Qualitative analysis revealed four themes: (1) patients’ diabetes fatalism and helplessness: providers recounted story after story of patients believing that their diabetes was inevitable and that they were helpless to prevent or delay diabetes complications. (2) Comorbid psychosocial issues: providers described high rates of depression, anxiety, incest, abuse, and post-traumatic stress disorder among people with diabetes in this region. (3) Inter-connected social determinants interfering with diabetes care: providers identified major barriers including lack of access to providers, lack of access to transportation, food insecurity, housing insecurity, and financial insecurity. (4) Providers’ cultural understanding and recommendations: providers emphasized the importance of understanding of the values central to Appalachian culture and gave culturally attuned clinical suggestions for how to use these values when working with this population. Conclusions: Evidence-based interventions tailored to Appalachian culture and training designed to increase the cultural competency and cultural humility of primary care providers may be effective approaches to reduce barriers to diabetes care in Appalachian Ohio.

scholarly journals DEFINING PEDIATRIC DIABETES USING EMR RECORDS AND VALIDATION FROM LINKABLE MANITOBA COHORT DATA

2018 ◽  
Vol 23 (suppl_1) ◽  
pp. e10-e11
Author(s):  
Alexander Singer ◽  
Leanne Kosowan ◽  
John Queenan ◽  
Roseanne Yeung ◽  
Shazhan Amed ◽  
...  
Keyword(s):  
Primary Care ◽  
Diabetes Education ◽  
Primary Care Providers ◽  
Case Definition ◽  
Research Network ◽  
Diabetes Diagnosis ◽  
Care Providers ◽  
Paediatric Diabetes ◽  
Number Of Patients ◽  
Paediatric Endocrinologist

Abstract BACKGROUND The prevalence of paediatric diabetes is increasing. Identifying and describing populations with paediatric diabetes using Primary Care Electronic Medication Records (EMR) can improve surveillance and management. OBJECTIVES To describe the population of children diagnosed with paediatric diabetes in Manitoba using Electronic Medical Record data from Community Paediatricians and Family Physcians in Manitoba. DESIGN/METHODS We applied a previously validated case definition for type 1 and type 2 diabetes to patients aged 1–18 seen by one of the 221 primary care providers participating in the Manitoba Primary Care Research Network (MaPCReN) between 1998–2015. We compared the agreement between the MaPCReN definition and Manitoba’s Diabetes Education Resource for Children and Adolescents (DERCA) clinical database of confirmed cases. Cases were described, including prevalence, patient characteristics, and health system use. RESULTS Our definition identified 166 children (0.4%, 95% CI 0.36% - 0.49%) of whom 53.0% lived in a rural location and 53.6% were female. The mean age at diagnosis was 11.4 years (SD 5.4). There were 90 patients identified by the definition also cared for by a paediatric endocrinologist at DERCA [sensitivity (54.2%), specificity (98.7%), and kappa (0.61, CI 0.54-.069)]. An additional 286 patients had at least one documented HbA1C of 6.5% or higher but did not have a corresponding diabetes diagnosis within the EMR. Of those, 45% had an HbA1c between 6.5 -7.5 and 25.9% had an HbA1c over 8.5%. Most of these patients also had an abnormal fasting glucose in the EMR (76.9%). There were 280 patients with an elevated HbA1c that had no evidence of attending an appointment with a paediatric endocrinologist at DERCA, 70.8% have a rural address. CONCLUSION The inclusion of HbA1c values in identifying paediatric diabetes suggested a large number of patients without a corresponding diabetes diagnosis or record of care from DERCA. Therefore, the DERCA database might be underestimating the true prevalence of diabetes in Manitoba. Understanding further characteristics of this population, is an essential step to inform the development of enhanced services and strategies.

scholarly journals Development of a Telehealth-Coordinated Intervention to Improve Access to Community-Based Mental Health

2018 ◽  
Vol 28 (Supp) ◽  
pp. 457-466 ◽  
Author(s):  
Sandra Contreras ◽  
Lorena Porras-Javier ◽  
Bonnie T. Zima ◽  
Neelkamal Soares ◽  
Christine Park ◽  
...  
Keyword(s):  
Mental Health ◽  
Primary Care ◽  
Los Angeles ◽  
Qualitative Interviews ◽  
Medication Management ◽  
Primary Care Providers ◽  
Care Process ◽  
Care Providers ◽  
Community Mental Health Clinics ◽  
Transition Points

Objective: To develop an intervention to improve the mental health referral and care process for children referred by primary care providers (PCPs) to community mental health clinics (MHCs) using a community partnered approach.Design: A Project Working Group (PWG) with representatives from each partner orga­nization met monthly for 6 months.Setting: Multi-site federally qualified health center (FQHC) and two community MHCs in Los Angeles county.Participants: 26 stakeholders (14 FQHC clinic providers/staff, 8 MHC providers/staff, 4 parents) comprised the PWG.Data Sources: Qualitative interviews, PWG meeting notes, intervention processes and workflow reports.Intervention: The PWG reviewed qualita­tive data from stakeholders (interviews of 7 parents and 13 providers/staff). The PWG met monthly to identify key transition points where access to and coordination of care were likely compromised and to develop solutions.Results: Three critical transition points and system solutions were identified: 1) Parents refuse initial referral to the MHC due to stigma regarding mental health services. Solution: During initial referral, parents watch a video introducing them to the MHC. 2) Parents don’t complete the MHC’s screening after referral. Solution: A live videoconference session connecting parents at the FQHC with MHC staff ensures completion of the screening and eligibility process. 3) PCPs reject transfer of patients back to primary care for ongoing psycho­tropic medication management. Solution: Regularly scheduled live videoconferences connect PCPs and MHC providers.Conclusions: A community partnered ap­proach to care design utilizing telehealth for care coordination between clinics can potentially be used to address key chal­lenges in MHC access for children.Ethn Dis. 2018;28(Suppl 2):457-466; doi:10.18865/ed.28.S2.457.

Primary care provider engagement about breast cancer care during treatment: Results from the iCanCare Study.

2016 ◽  
Vol 34 (3_suppl) ◽  
pp. 101-101
Author(s):  
Lauren P. Wallner ◽  
Paul Abrahamse ◽  
Christopher Ryan Friese ◽  
Steven J. Katz ◽  
Sarah T. Hawley
Keyword(s):  
Breast Cancer ◽  
Primary Care ◽  
Los Angeles ◽  
Collaborative Care ◽  
Cancer Care ◽  
Primary Care Providers ◽  
Current Response ◽  
Care Providers ◽  
Breast Cancer Patients ◽  
High Quality

101 Background: Collaborative care between cancer specialists and primary care providers (PCP) ensures high quality cancer care. Yet, little is known about patient’s perspectives about the level of PCP engagement in and communication about breast cancer (BC) care during treatment. Methods: A weighted random sample of newly diagnosed breast cancer patients in the Georgia and Los Angeles SEER registries were surveyed approximately 6 months after diagnosis (expected final N = 2600, 70% current response rate). PCP BC engagement and communication were defined using 2 outcome measures (categorized as less (never/rarely) vs. more (sometimes/often/always)): how informed the respondent’s PCP was about BC treatment and how often respondents talked with their PCP about their BC care visits. Overall PCP quality was assessed by averaging patient responses (5 categories, never to always) to 5 questions: ease of access to PCP (3 questions) and PCP’s awareness of patient values (2 questions) and categorized as high ( ≥ 4), moderate (3) and low ( < 3). The associations between patient factors and PCP quality with BC engagement and communication were evaluated using multivariable logistic regression. Results: In a preliminary sample (N = 2054), the majority of women reported high PCP quality (63%), high PCP BC engagement (65%) and communication (68%). (Table) Women who reported less PCP BC engagement were more likely to report low PCP quality (OR: 15.7, 95%CI: 9.5, 25.9;) and chemotherapy use (OR: 1.3, 95%CI: 1.1, 1.6), adjusting for age, race, insurance, comorbidities and PCP continuity. The results were similar for PCP communication. Conclusions: Patient perceptions of PCP quality, engagement and communication during BC treatment are high for most women with BC. However, there remains opportunity for improvement in both, as many women report poor engagement and communication despite perceiving high quality primary care. Targeting these patients and their clinicians may be particularly effective in interventions to improve collaborative care in cancer. [Table: see text]

scholarly journals Evaluation of provider response to positive depression screenings and physician attitudes on integrating psychiatric pharmacist services in primary care settings

2018 ◽  
Vol 8 (1) ◽  
pp. 28-32 ◽  
Author(s):  
Brittany H. Denson ◽  
Rory E. Kim
Keyword(s):  
Primary Care ◽  
Los Angeles ◽  
Suicide Ideation ◽  
Retrospective Chart Review ◽  
Primary Care Providers ◽  
Physician Attitudes ◽  
Care Providers ◽  
Primary Care Clinics ◽  
Primary Care Settings ◽  
Provider Survey

Abstract Introduction: The aim of this study was to identify potential gaps in the management of depression and assess the perceptions of primary care providers (PCPs) toward integrating psychiatric pharmacists into primary care settings. Method: This was a retrospective chart review of patients ≥18 years of age seen in primary care clinics in Los Angeles County with a documented annual health screening (AHS) between January 1, 2015, through December 31, 2015. Primary outcomes were number and percentage of patients screened for depression with patient health questionnaire (PHQ) assessments, positive depression screenings, and interventions made for positive depression screenings. Secondary outcomes were PCPs' perceptions on management of depression, use of AHS, and roles for psychiatric pharmacists through evaluation of provider survey. Results: Of the patients who received an AHS (n = 6797), 63% received PHQ assessments. Of 145 individuals with a positive PHQ-2, 69% had a positive PHQ-9. Greater than 50% of individuals with a positive PHQ-9 had no preexisting depression diagnosis. Seventy-six percent of individuals with a positive PHQ-9 and 78% with reported suicide ideation had no documented intervention. The majority of providers reported there is a role for psychiatric pharmacists in primary care. Discussion: Gaps in the management of depression were identified. Although depression screenings were performed for the majority of individuals receiving an AHS, no documented interventions were made for most of those individuals who screened positive for depression. Primary care clinics could benefit from psychiatric pharmacist involvement in depression screening and follow-up processes.

The Perspective of Older Men With Depression on Suicide and Its Prevention in Primary Care

Crisis ◽  
2018 ◽  
Vol 39 (5) ◽  
pp. 397-405 ◽  
Author(s):  
Steven Vannoy ◽  
Mijung Park ◽  
Meredith R. Maroney ◽  
Jürgen Unützer ◽  
Ester Carolina Apesoa-Varano ◽  
...  
Keyword(s):  
Primary Care ◽  
Low Socioeconomic Status ◽  
Thematic Analysis ◽  
Older Men ◽  
Primary Care Providers ◽  
Depression Treatment ◽  
Care Providers ◽  
Low Socioeconomic ◽  
Self Image ◽  
The Impact

Abstract. Background: Suicide rates in older men are higher than in the general population, yet their utilization of mental health services is lower. Aims: This study aimed to describe: (a) what primary care providers (PCPs) can do to prevent late-life suicide, and (b) older men's attitudes toward discussing suicide with a PCP. Method: Thematic analysis of interviews focused on depression and suicide with 77 depressed, low-socioeconomic status, older men of Mexican origin, or US-born non-Hispanic whites recruited from primary care. Results: Several themes inhibiting suicide emerged: it is a problematic solution, due to religious prohibition, conflicts with self-image, the impact on others; and, lack of means/capacity. Three approaches to preventing suicide emerged: talking with them about depression, talking about the impact of their suicide on others, and encouraging them to be active. The vast majority, 98%, were open to such conversations. An unexpected theme spontaneously arose: "What prevents men from acting on suicidal thoughts?" Conclusion: Suicide is rarely discussed in primary care encounters in the context of depression treatment. Our study suggests that older men are likely to be open to discussing suicide with their PCP. We have identified several pragmatic approaches to assist clinicians in reducing older men's distress and preventing suicide.

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