Documenting Pharmacogenomic Test Results in Electronic Health Records: Practical Considerations for Primary Care Teams

With increasing patient interest in and access to pharmacogenomic testing, clinicians practicing in primary care are more likely than ever to encounter a patient seeking or presenting with pharmacogenomic test results. Gene-based prescribing recommendations are available to healthcare providers through Food and Drug Administration-approved drug labeling and Clinical Pharmacogenetics Implementation Consortium guidelines. Given the lifelong utility of pharmacogenomic test results to optimize pharmacotherapy for commonly prescribed medications, appropriate documentation of these results in a patient’s electronic health record (EHR) is essential. The current “gold standard” for pharmacogenomics implementation includes entering pharmacogenomic test results into EHRs as discrete results with associated clinical decision support (CDS) alerts that will fire at the point of prescribing, similar to drug allergy alerts. However, such infrastructure is limited to the few institutions that have invested in the resources and personnel to develop and maintain it. For the majority of clinicians who do not practice at an institution with a dedicated clinical pharmacogenomics team and integrated pharmacogenomics CDS in the EHR, this report provides practical tips for documenting pharmacogenomic test results in the problem list and allergy field to maximize the visibility and utility of results over time, especially when such results could prevent the occurrence of serious adverse drug reactions or predict therapeutic failure.

Social Workers in Primary Care Increase Access to Palliative Care

Clinical trials show that palliative care improves patient experiences and reduces costs, and use of palliative care and hospice care have been increasing over the past three decades. In the Veterans Administration health care system (VA), Veterans may receive palliative care concurrently with other treatments. However, many barriers exist to the use of palliative care, such as patients’ misperceptions. Social workers in primary care teams may increase use of this valuable service by establishing trust between patient and care team, educating patients and caregivers, and coordinating services. Leveraging a national social-work-staffing program as a natural experiment, we evaluated the effect of hiring one or more social workers to the primary-care team on use of palliative or hospice care among Veterans with a recent hospital stay. Our data included 91,675 episodes of care between 2016 and 2018. 1.45 percent of episodes were followed by use of palliative care or hospice within 30 days. The addition of one or more social workers through the staffing program was associated with an increase of 0.53 percentage points (p<0.001) in the probability of any palliative or hospice care, i.e., a more than 30% increase relative to the mean. Policy makers and health system leaders who seek to improve patient experience and reduce costs through increased access to palliative and hospice care could consider social work staffing as a policy tool to achieve those aims.

Providing community intravenous therapy during the COVID-19 pandemic

Community intravenous therapy is well-established in most regions of the UK. Although there are national good practice recommendations detailing the service provision of outpatient parenteral antibiotic therapy (OPAT), examples of extended service delivery of other therapies are limited. This article describes the development of a community IV therapy service through integration with acute and primary care teams. IV therapies delivered in addition to antimicrobials safely outside of the hospital setting are also discussed with scope for future areas of development explored. The benefits of care closer to home for patients during the global COVID-19 pandemic are examined, as well as the potential for widening the whole gamut of practice for already established NHS community services through the development of integrated working in a local care organisation.

Prevalence and Incidence of Patients with Fibromyalgia in Catalonia between 2010 and 2017. A Descriptive Observational Study

Background: To measure the prevalence and cumulative incidence of individuals diagnosed with fibromyalgia (FM) in Catalonia between 2010 and 2017. Methods: A retrospective observational study of the population of Catalonia between 2010 and 2017, both included, was designed to describe the incidence, prevalence and sociodemographic characteristics of individuals diagnosed with fibromyalgia. A total of 56,098 patients were included in the study. The scope of the study were the 283 Primary Care Teams (PCT), all managed by the Instituto Catalán de la Salud [Catalan Institute of Health] (ICS). Results: The diagnosis of FM is higher in females (95.4%) than males (4.55%), with a mean age of 53.0 [45.0-61.0] years. The prevalence of FM in the total population was 0.4% in 2010 and 1.4% in 2017. The highest prevalence was found in the 55-65 age group (1.05% in 2010, and 2.46% in 2017). A relationship was found between the prevalence of FM and the degree of socioeconomic deprivation in urban areas: the greater the deprivation, the greater the prevalence of FM. The cumulative incidence of FM in the population remained constant over time (0.11% in 2010 and 0.10% in 2017), being more prevalent in women than men (0.18% women, 0.01% men in 2017).Conclusions: Our study confirms that FM is a prevalent disease in Catalonia, with an upward trend in recent years and it is more prevalent in women.

Comparing primary care Interprofessional and non-interprofessional teams on access to care and health services utilization in Ontario, Canada: a retrospective cohort study

Background Many countries, including Canada, have introduced primary care reforms to improve health system functioning and value. The purpose of this study was to examine the association between receiving care from interprofessional primary care teams and after-hours access to care, patient-reported walk-in clinic visits and emergency department use. Methods We conducted a retrospective cohort study linking population-based administrative databases to Ontario’s Health Care Experience Survey (HCES) between 2012 and 2018. We adjusted for physician group characteristics as well as individual physician and patient characteristics while assessing the relationship between receiving care from interprofessional teams and the outcomes of interest. Results As of March 31st, 2015, there were 465 physician groups with HCES respondents of which 177 (38.0%) were interprofessional teams and 288 (62.0%) were non-interprofessional teams in the same blended capitation reimbursement model. In this period, there were 4518 physicians with HCES respondents, of whom 2131 (47.2%) were in interprofessional teams and 2387 (52.8%) were in non-interprofessional teams. There were 10,102 HCES respondents included in this study, of whom 42.4% were in interprofessional teams and 42.3% were in non-interprofessional teams. After adjustment, we found that being in an interprofessional team was associated with an increase in the odds of patients reporting same/next day access to care by 12.0% (OR = 1.12 CI = 1.00 to 1.24 p-value 0.0436) and a decrease in the odds of patients reporting walk-in clinic use by 16% (OR = 0.84 CI = 0.75 to 0.94 p-value 0.0019). After adjustment, there were no significant differences in patient-reported after-hours access to care and emergency department use. Conclusions Ontario has invested heavily in interprofessional primary care teams. As compared to patients in non-interprofessional teams, patients in interprofessional teams self-reported more timely access to care and less walk-in clinic use but no significant difference in self-reported access to after-hours care or in emergency department use. For jurisdictions aiming to expand physician voluntary participation in interprofessional teams, our study results inform expectations around access to care and health services utilization.

Development and Preliminary Evaluation of an Education Program for Primary Care Teams on Discussing Firearms Storage Safety with Veterans

Background Reducing access to lethal means is one of the few empirically supported approaches for lowering suicide rates, and safe firearms storage practices have been associated with reduced risk of death by suicide. Although there is substantial opportunity for primary care to assist in addressing lethal means with veterans, approaches to intervention and educating staff are not well documented. We sought to 1) describe development of an education program for primary care teams to help them discuss firearms storage safety (FSS) with veterans during primary care visits; and 2) conduct a preliminary evaluation of the pilot education program. Methods We used an iterative process involving veterans and primary care staff stakeholders to develop program content, format, and supplemental materials. A grounded theory approach was used to analyze data from focus groups and individual interviews. Following piloting of the program with 71 staff members in two primary care clinics, we analyzed pre- and post-training participant surveys of program satisfaction and attitudes and behaviors related to firearms safety. Results During the development phase, 68 veterans and 107 staff members participated in four veteran focus groups and four primary care focus groups, respectively, and/or individual interviews. The program that was developed, “’Just in Case’: Discussing means safety with veterans at elevated risk for suicide,” addresses knowledge and skills learning objectives, and includes video demonstrations and skills practice. Survey data obtained just prior to the two pilot training sessions showed low self-reported rates of discussing firearms safety with veterans who may be at elevated risk for suicide. Immediate post-training data showed generally high satisfaction with the program and significant improvements in participant self-reported ratings of the importance of, and comfort with FSS. Conclusions The program shows promise as a means for educating primary care staff to deliver messaging about firearms safety to veterans. Additional research is needed to refine and evaluate impacts of this or similar training programs on clinician and veteran behaviors over time.

Interprofessional advanced access – a quality improvement protocol for expanding access to primary care services

Background The Advanced Access (AA) Model has shown considerable success in improving timely access for patients in primary care settings. As a result, a majority of family physicians have implemented AA in their organizations over the last decade. However, despite its widespread use, few professionals other than physicians and nurse practitioners have implemented the model. Among those who have integrated it to their practice, a wide variation in the level of implementation is observed, suggesting a need to support primary care teams in continuous improvement with AA implementation. This quality improvement research project aims to document and measure the processes and effects of practice facilitation, to implement and improve AA within interprofessional teams. Methods Five primary care teams at various levels of organizational AA implementation will take part in a quality improvement process. These teams will be followed independently over PDSA (Plan-Do-Study-Act) cycles for 18 months. Each team is responsible for setting their own objectives for improvement with respect to AA. The evaluation process consists of a mixed-methods plan, including semi-structured interviews with key members of the clinical and management teams, patient experience survey and AA-related metrics monitored from Electronic Medical Records over time. Discussion Most theories on organizational change indicate that practice facilitation should enable involvement of stakeholders in the process of change and enable improved interprofessional collaboration through a team-based approach. Improving access to primary care services is one of the top priorities of the Quebec’s ministry of health and social services. This study will identify key barriers to quality improvement initiatives within primary care and help to develop successful strategies to help teams improve and broaden implementation of AA to other primary care professionals.