Patient and Clinician Decision Support to Increase Genetic Counseling for Hereditary Breast and Ovarian Cancer Syndrome in Primary Care: A Cluster Randomized Clinical Trial.

Importance: To promote the identification of women carrying BRCA1/2 variants, the US Preventive Services Task Force recommends that primary care clinicians screen asymptomatic women for an increased risk of carrying a BRCA1/2 variant risk. Objective: To examine the effects of patient and clinician decision support about BRCA1/2 genetic testing compared with standard education alone. Design, Setting, and Participants: This clustered randomized clinical trial was conducted at an academic medical center including 67 clinicians (unit of randomization) and 187 patients. Patient eligibility criteria included women aged 21 to 75 years with no history of breast or ovarian cancer, no prior genetic counseling or testing for hereditary breast and ovarian cancer syndrome (HBOC), and meeting family history criteria for BRCA1/2 genetic testing. Interventions: RealRisks decision aid for patients and the Breast Cancer Risk Navigation Tool decision support for clinicians. Patients scheduled a visit with their clinician within 6 months of enrollment. Main Outcomes and Measures: The primary end point was genetic counseling uptake at 6 months. Secondary outcomes were genetic testing uptake at 6 and 24 months, decision-making measures (perceived breast cancer risk, breast cancer worry, genetic testing knowledge, decision conflict) based upon patient surveys administered at baseline, 1 month, postclinic visit, and 6 months. Results: From December 2018 to February 2020, 187 evaluable patients (101 in the intervention group, 86 in the control group) were enrolled (mean [SD] age: 40.7 [13.2] years; 88 Hispanic patients [46.6%]; 15 non-Hispanic Black patients [8.1%]; 72 non-Hispanic White patients [38.9%]; 35 patients [18.9%] with high school education or less) and 164 (87.8%) completed the trial. There was no significant difference in genetic counseling uptake at 6 months between the intervention group (20 patients [19.8%]) and control group (10 patients [11.6%]; difference, 8.2 percentage points; OR, 1.88 [95% CI, 0.82-4.30]; P = .14). Genetic testing uptake within 6 months was also statistically nonsignificant (13 patients [12.9%] in the intervention group vs 7 patients [8.1%] in the control group; P = .31). At 24 months, genetic testing uptake was 31 patients (30.7%) in intervention vs 18 patients (20.9%) in control (P = .14). Comparing decision-making measures between groups at baseline to 6 months, there were significant decreases in perceived breast cancer risk and in breast cancer worry (standard mean differences = -0.48 and -0.40, respectively). Conclusions and Relevance: This randomized clinical trial did not find a significant increase in genetic counseling uptake among patients who received patient and clinician decision support vs those who received standard education, although more than one-third of the ethnically diverse women enrolled in the intervention underwent genetic counseling. These findings suggest that the main advantage for these high-risk women is the ability to opt for screening and preventive services to decrease their cancer risk. Trial Registration: ClinicalTrials.gov Identifier: NCT03470402.

Incomplete follow-up of hemoglobinopathy carriers identified by newborn screening despite reporting in electronic medical records.

OBJECTIVE: Has the recent availability of newborn hemoglobinopathy screening results within patient electronic medical records (EMR) of birth hospitals facilitated follow-up by primary care pediatric providers? METHODS: An online survey of all 137 primary care pediatric providers at a New York City academic medical center was conducted in 2008-2009 to assess practices for hemoglobin-apathy trait follow-up. Physicians were resurveyed 1 year later, following educational outreach and a letter of instruction underscoring the availability of screening results in the EMR. All 62 primary care pediatricians were surveyed at a nearby city hospital for comparison. RESULTS: Overall response rate for the initial survey at the teaching hospital was 58% for pediatricians (N = 57) and family physicians (N = 23), and 50% for pediatricians at the city hospital (N = 31). Despite high prevalence of hemoglobinopathies in the population served and screening results in EMRs, only 46.2% of providers surveyed at the academic center reported routinely checking results of their infant patients: 38.6% of pediatricians and 66.7% of family practitioners. Some respondents were unaware that results are available in the EMR. The proportion of providers checking screening results was not significantly affected by educational intervention (N = 40). Provision of recommended follow-up for a positive trait result was modestly improved, especially in referring families for genetic counseling (25% to 50%, p<.01). In contrast, most pediatricians (83%) at the city hospital routinely check and perform follow-up. CONCLUSION: Despite access to results in the EMR and targeted educational outreach, follow-up of hemoglobinopathy screening by primary care varies widely across clinical sites.

Opioid Medications Prescribing and the Pain-Depression Dyad in Primary Care: Analysis of 2014-2015 National Ambulatory Medical Care Survey (NAMCS) Data.

BACKGROUND: Increased drug overdose deaths have become a serious public health problem. Primary care providers prescribe about 50% all opioid medications. This study examined opioids prescribing during primary visits to patients with a pain-depression dyad and patient demographic characteristics associated with opioids prescribing. METHOD: This study analyzed data from the 2014 to 2015 National Ambulatory Medical Care Survey and included primary care visits by adult patients (aged 18 years or older) with noncancer pain. RESULTS: An opioid medication was prescribed in 26.4% (95% CI, 22.6% to 30.6%) of the primary care visits by patients with noncancer pain. Opioid medications were more likely to be prescribed during visits by patients with a pain and depression dyad (adjusted odds ratios [AOR] = 1.8; 95% CI, 1.4 to 2.4). Narcotic analgesics were more likely to be prescribed during visits by patients aged 46 to 64 years; by male patients or non-Hispanic white patients. DISCUSSION/CONCLUSIONS: Pain-depression dyad is associated with higher odds of opioids prescribing during primary care visits. Future studies are needed to understand the complexity of these factors and identify effective strategies to prevent opioids addiction and overdose among patients with pain and depression.

Telephone care management to improve cancer screening among low-income women: a randomized, controlled trial.

BACKGROUND: Minority and low-income women receive fewer cancer screenings than other women. OBJECTIVE: To evaluate the effect of a telephone support intervention to increase rates of breast, cervical, and colorectal cancer screening among minority and low-income women. DESIGN: Randomized, controlled trial conducted between November 2001 and April 2004. SETTING: 11 community and migrant health centers in New York City. PATIENTS: 1413 women who were overdue for cancer screening. INTERVENTION: Over 18 months, women assigned to the intervention group received an average of 4 calls from prevention care managers and women assigned to the control group received usual care. Follow-up data were available for 99% of women, and 91% of the intervention group received at least 1 call. MEASUREMENTS: Medical record documentation of mammography, Papanicolaou testing, and colorectal cancer screening according to U.S. Preventive Services Task Force recommendations. RESULTS: The proportion of women who had mammography increased from 0.58 to 0.68 with the intervention and decreased from 0.60 to 0.58 with usual care; the proportion who had Papanicolaou testing increased from 0.71 to 0.78 with the intervention and was unchanged with usual care; and the proportion who had colorectal screening increased from 0.39 to 0.63 with the intervention and from 0.39 to 0.50 with usual care. The difference in the change in screening rates between groups was 0.12 for mammography (95% CI, 0.06 to 0.19), 0.07 for Papanicolaou testing (CI, 0.01 to 0.12), and 0.13 for colorectal screening (CI, 0.07 to 0.19). The proportion of women who were up to date for 3 tests increased from 0.21 to 0.43 with the intervention. LIMITATIONS: Participants were from 1 city and had access to a regular source of care. Medical records may not have captured all cancer screenings. CONCLUSIONS: Telephone support can improve cancer screening rates among women who visit community and migrant health centers. The intervention seems to be well suited to health plans, large medical groups, and other organizations that seek to increase cancer screening rates and to address disparities in care.

Does receiving care in a medical home reduce racial/ethnic disparities in ED visits among children with asthma in the United States?

Evidence has shown the implementation of medical home model improves care quality and outcomes. However, it is not clear whether receiving care from a medical home has any impact on racial/ethnic disparities in emergency department (ED) use by children with asthma. This study using the US National Survey of Children with Special Health Care Needs, 2009-2010, estimated racial/ethnic disparities in ED use. Generalized liner models were used to examine factors associated with ED use. Racial/ethnic differences in ED use were attenuated after adjusting for socio-economic variables. Ratios of prevalence ratios were calculated to examine the effect modification of medical home on ED use associated with race/ethnicity. The adjusted prevalence ratio of ED use of the Black to non-Hispanic White was 1.51 (95% confidence interval (CI): 1.36-1.67) with medical home and 1.35 (95% CI: 1.24-1.47) without medical home. Among those with care from a medical home Latino children had higher ED use compared with White children. There is no evidence that the self-reported care from a medical home narrows the gaps in ED use between non-Hispanic White and Black or Latino children with asthma.

Depressed parents' treatment needs and children's problems in an urban family medicine practice.

OBJECTIVE: The study examined interest in treatment and treatment preferences and obstacles of low-income depressed parents. METHODS: A total of 273 primarily low-income, Hispanic parents of children aged seven to 17 attending an urban family medicine practice agreed to complete a survey by interview or self-report, including screening diagnoses and treatment history. Three groups were compared: major, subthreshold, and no depression. RESULTS: Nearly one-third had major (9%) or subthreshold depression (23%), and many in the depressed groups reported recent treatment (50% and 31%, respectively). Parents with any depression were significantly more likely than nondepressed parents to report interest in receiving help, endorse treatment obstacles, and report children's problems. CONCLUSIONS: High rates of personal and child problems, interest in treatment, and treatment obstacles among low-income, depressed parents highlight the need to develop acceptable mental health services for them and their children, even when parents do not meet full diagnostic criteria for depression.

The New York City eClinician Project: using Personal Digital Assistants and wireless internet access to support emergency preparedness and enhance clinical care in community health centers.

The New York City Department of Health and Mental Hygiene, The Community Health Care Association of New York State and Clinical Directors Network are collaborating on the "eClinician Project," which has distributed seven hundred public health-friendly, wireless (WiFi) enabled Personal Digital Assistants (PDAs) to primary care clinicians working in New York City, federally funded, Community Health Centers (CHC) which serve minority underserved communities that suffer a disproportionate burden of chronic disease and lack access to health promotion disease prevention services. Each participating health center also received a wireless router to create an onsite internet hot spot to enable clinicians to have internet access. The goals of the eClinician Project are to: 1) To encourage adoption of information technology among providers in Community Health Centers in New York City by providing PDAs as a first line strategy towards achieving this goal, 2) enhance access to information on emergency preparedness, 3) improve patient outcomes by providing PDA-based clinical decision-support tools that support evidence-based care, 4) encourage chronic care management and health promotion/disease prevention activities, and 5) increase productivity and efficiency. CHC clinicians have received a hands-on, on-site orientation to PDAs. Ongoing training has continued via online CME-accredited webcasts (see www.CDNetwork.org). Clinical decision-support tools are available for download via the eClinician project web portal (see www.eClinician.org ). Public health alerts can be delivered to the PDAs or to the clinicians' desktop computers. Pre and post training surveys, in addition to a case study, have been used to evaluate the population demographics, PDA adoption by the clinicians, clinician attitudes towards using PDAs, PDA influence on clinical-decision making and barriers to adoption of PDAs and information technology in general.