Use of eConsult to enhance genetics service delivery in primary care: A multimethod study.

PURPOSE: Electronic consultation (eConsult) is a freely-available secure online platform connecting primary care providers (PCPs) to geneticists. Our purpose was to determine whether eConsult is effective in improving genetics service delivery in primary care. METHODS: PCP questionnaires regarding eConsult's utility, geneticists' tracking form assessments of eConsult type and appropriateness, and geneticists' interviews on implementing eConsult were carried out. RESULTS: In 2 regions of Ontario, Canada, from January 2019 to June 2020, there were 305 genetics eConsults. For 169 (55%), PCPs indicated receiving good advice for a new course of action; for 110 (36%), referral was now avoided; and for 261 (86%), eConsult was perceived valuable for patient management. Of the 131 geneticist-completed tracking forms, cancer questions were most common (68, 52%). For 63 (48%), geneticists disagreed/strongly disagreed PCPs should know the answer to the referral question. From the interview data, it was observed that geneticists described eConsult positively and suggested how it might improve access and efficiencies if integrated into genetic service delivery. Dealing with eConsults virtually could reduce waitlists, and suggesting appropriate investigations for PCPs could improve efficiencies. CONCLUSION: eConsult offers a potential solution for receiving timely genetics advice and avoiding unnecessary patient referrals, however, greater effect on access and wait times will need systematic integration into PCP and geneticist practice.

The prevalence and clinical correlates of adverse childhood experiences in a cross-sectional study of primary care patients with cardiometabolic disease or risk factors.

BACKGROUND: Adverse childhood experiences (ACEs) are associated with risk of poor adult health, including cardiometabolic diseases. Little is known about the correlates of ACEs for adults who have already developed cardiometabolic diseases, or who are at elevated risk. METHODS: Adult primary care patients with cardiometabolic disease (hypertension, diabetes, stroke, angina, myocardial infarction, coronary artery bypass graft, angioplasty) or with a risk factor (obesity, smoking, high cholesterol, family history) were surveyed regarding ACEs, psychological distress, attachment insecurity, quality of life, behavior change goals, stages of change, and attitudes toward potential prevention strategies. RESULTS: Of 387 eligible patients, 74% completed the ACEs survey. Exposure to ACEs was reported by 174 participants (61%). Controlling for age, gender, relationship status and income, number of ACEs was associated with psychological distress (F = 3.7, p = .01), quality of life (F = 8.9, p = .001), attachment anxiety (F = 3.4, p = .02), drinking alcohol most days (F = 4.0, p = .008) and smoking (F = 2.7, p = .04). Greater ACE exposure was associated with less likelihood of selecting diet or physical activity as a behavior change goal (linear-by-linear association p = .009). Stage of change was not associated with ACEs. ACEs exposure was not related to preferred resources for behavior change. CONCLUSIONS: ACEs are common among patients at cardiometabolic risk and are related to quality of life, psychological factors that influence cardiometabolic outcomes and behavior change goals. ACEs should be taken into account when managing cardiometabolic risk in family medicine.

Enhanced skills training in family medicine maternity care: Cross-sectional study of graduates' experiences.

OBJECTIVE: To describe the experiences of participants in Canadian family medicine maternity care enhanced skills programs: their current practice situation with respect to maternity care; the reasons they pursued enhanced maternity care training; and their perceptions of competencies attained during the program. DESIGN: Cross-sectional questionnaire. SETTING: Canada. PARTICIPANTS: Graduates of family medicine enhanced skills programs in maternity care in Canada between 2004 and 2014. MAIN OUTCOME MEASURES: Participants' current engagement in intrapartum care; reasons for participating in the enhanced skills programs; interest in obstetrics at different points in training; and development of maternity care competencies during both core residency and the enhanced skills program. RESULTS: Eighty-seven graduates (response rate of 44%) participated. At an average of 5 years in practice, 77% of enhanced skills graduates were providing intrapartum care. Sixty-nine percent of respondents took the enhanced skills program because they did not feel ready to practise obstetrics without supervision. More than half (55%) of respondents had intended to include obstetrics in their future practices when they were in medical school. By the end of residency, 99% intended to practise obstetrics; however, this percentage decreased to 87% by the end of fellowship. There was a statistically significant increase in graduates' perceptions of various maternity care competencies (eg, vacuum-assisted birth, perineal repair) following enhanced skills training. Eighty-two percent of respondents indicated that the ability to access enhanced skills training supported their decision to provide obstetrics care. CONCLUSION: This is the first evaluation of graduates of enhanced skills programs in maternity care in Canada. Enhanced skills programs appear to support the education of family medicine maternity care providers; however, these programs might be compensating for residents' lack of confidence in providing maternity care independently rather than providing truly enhanced skills. This study also confirms that some medical students and family medicine residents change their minds in the direction of wanting to provide full-scope maternity care during the course of their education.

The Effect of Changes in Cervical Cancer Screening Guidelines on Chlamydia Testing.

PURPOSE: Many chlamydia infections are identified through screening, which is frequently offered to females concomitantly with cervical cancer screening. Recent cervical cancer screening guidelines recommend screening less frequently and starting later. We sought to evaluate the impact of the May 2012 Ontario, Canada, cervical cancer screening guideline change on Papanicolaou (Pap) and chlamydia trachomatis (chlamydia) testing and incidence. METHODS: We extracted population-based physician billing claims data to identify Pap and chlamydia tests and public health surveillance data to identify chlamydia cases. We used interrupted time series analysis of quarterly data spanning 2 years before and after the guideline change and fitted segmented linear regression or rational functions to the outcomes using autoregressive integrated moving average models. Outcomes were stratified by sex and age group. RESULTS: Two years after the guideline change, we observed reduced chlamydia testing in females, with the greatest relative reduction (25.5%) among those aged 15 to 19 years. We also observed decreases in reported chlamydia incidence for females aged 15 to 19 years and 20 to 24 years (relative reductions of 16.8% and 14.4%, respectively). Chlamydia incidence remained the same for males, despite increased chlamydia testing. CONCLUSIONS: Recent cervical cancer screening guideline changes in Ontario were associated with reduced chlamydia testing and reported new cases of chlamydia in females. Females aged 15 to 19 years, who are at high risk for chlamydia if sexually active, and who no longer warrant cervical cancer screening, were disproportionately affected. Females should be tested for chlamydia based on risk, regardless of need for Pap testing.

Assessing family history of chronic disease in primary care: Prevalence, documentation, and appropriate screening.

OBJECTIVE: To assess the proportion of primary care patients who report a family history (FH) of type 2 diabetes, coronary artery disease, breast cancer, or colorectal cancer (CRC); assess concordance of FH information derived from the electronic medical record (EMR) compared with patient-completed health questionnaires; and assess whether appropriate screening was informed by risk based solely on FH. DESIGN: Data from the BETTER (Building on Existing Tools to Improve Chronic Disease Prevention and Screening in Primary Care) trial were used. Patients were mailed questionnaires. Baseline FH and screening data were obtained for enrolled patients from the EMR and health questionnaires. SETTING: Ontario and Alberta. PARTICIPANTS: Randomly selected patients from 8 family practices. MAIN OUTCOME MEASURES: Agreement on FH between the EMR and questionnaire was determined; logistic regression was used to assess significant predictors of screening. RESULTS: In total, 775 of 789 (98%) patients completed the health questionnaire. The mean age of participants was 52.5 years and 72% were female. A minimum of 12% of patients (range 12% to 36%) had a reported FH of 1 of 4 chronic diseases. Among patients with positive FH, the following proportions of patients had that FH recorded in the EMR compared with the questionnaire: diabetes, 24% in the EMR versus 36% on the questionnaire, κ = 0.466; coronary artery disease, 35% in the EMR versus 22% on the questionnaire, κ = 0.225; breast cancer, 21% in the EMR versus 22% on the questionnaire, κ = 0.241; and CRC, 12% in the EMR versus 14% on the questionnaire, κ = 0.510. There was moderate agreement for diabetes and CRC. The presence of FH was a significant predictor of CRC screening (odds ratio 1.9, 95% CI 1.1 to 3.1). CONCLUSION: A moderate prevalence of FH was found for 4 conditions for which screening recommendations vary with risk based on FH. Having patients self-complete an FH was thought to be feasible; however, questions about FH accuracy and completeness from both self-report and EMR remain. Work is needed to determine how to facilitate the adoption of FH tools into practice as well as strategies linking familial risk to appropriate screening.Trial registration number ISRCTN07170460 (ISRCTN Registry).

Primary care providers' experiences with and perceptions of personalized genomic medicine.

OBJECTIVE: To assess primary care providers' (PCPs') experiences with, perceptions of, and desired role in personalized medicine, with a focus on cancer. DESIGN: Qualitative study involving focus groups. SETTING: Urban and rural interprofessional primary care team practices in Alberta and Ontario. PARTICIPANTS: Fifty-one PCPs. METHODS: Semistructured focus groups were conducted and audiorecorded. Recordings were transcribed and analyzed using techniques informed by grounded theory including coding, interpretations of patterns in the data, and constant comparison. MAIN FINDINGS: Five focus groups with the 51 participants were conducted; 2 took place in Alberta and 3 in Ontario. Primary care providers described limited experience with personalized medicine, citing breast cancer and prenatal care as main areas of involvement. They expressed concern over their lack of knowledge, in some circumstances relying on personal experiences to inform their attitudes and practice. Participants anticipated an inevitable role in personalized medicine primarily because patients seek and trust their advice; however, there was underlying concern about the magnitude of information and pace of discovery in this area, particularly in direct-to-consumer personal genomic testing. Increased knowledge, closer ties to genetics specialists, and relevant, reliable personalized medicine resources accessible at the point of care were reported as important for successful implementation of personalized medicine. CONCLUSION: Primary care providers are prepared to discuss personalized medicine, but they require better resources. Models of care that support a more meaningful relationship between PCPs and genetics specialists should be pursued. Continuing education strategies need to address knowledge gaps including direct-to-consumer genetic testing, a relatively new area provoking PCP concern. Primary care providers should be mindful of using personal experiences to guide care.

Specialist wait time reporting using family physicians' electronic medical record data: a mixed method study of feasibility and clinical utility.

BACKGROUND: More than 50% of Canadian adult patients wait longer than four weeks to see a specialist after referral from primary care. Access to accurate wait time information may help primary care physicians choose the timeliest specialist to address a patient's specific needs. We conducted a mixed-methods study to assess if primary to specialist care wait times can be extracted from electronic medical records (EMR), analyzed the wait time information, and used focus groups and interviews to assess the potential clinical utility of the wait time information. METHODS: Two family practices were recruited to examine primary care physician to specialist wait times between January 2016 and December 2017, using EMR data. The primary outcome was the median wait time from physician referral to specialist appointment for each specialty service. Secondary outcomes included the physician and patient characteristics associated with wait times as well as qualitative analyses of physician interviews about the resulting wait time reports. RESULTS: Wait time data can be extracted from the primary care EMR and converted to a report format for family physicians and specialists to review. After data cleaning, there were 7141 referrals included from 4967 unique patients. The 5 most common specialties referred to were Dermatology, Gastroenterology, Ear Nose and Throat, Obstetrics and Gynecology and Urology. Half of the patients were seen by a specialist within 42 days, 75% seen within 80 days and all patients within 760 days. There were significant differences in wait times by specialty, for younger patients, and those with urgently labelled medical situations. Overall, wait time reports were perceived by clinicians to be important since they could help family physicians decide how to triage referrals and might lead to system improvements. CONCLUSIONS: Wait time information from primary to specialist care can aid in decision-making around specialist referrals, identify bottlenecks, and help with system planning. This mixed method study is a starting point to review the importance of providing wait time data for both family physicians, specialists and local health systems. Future work can be directed towards developing wait time reporting functionality and evaluating if wait time information will help increase system efficiency and/or improve provider and patient satisfaction.

GenetiKit: a randomized controlled trial to enhance delivery of genetics services by family physicians.

BACKGROUND: Patients look to their family physicians (FPs) for credible information and guidance in making informed choices about genetic testing. FPs are challenged by lack of knowledge and the rapid pace of genetic discovery. There is an urgent need for effective interventions to facilitate integration of genetics into family medicine. OBJECTIVE: To determine if a multi-faceted knowledge translation intervention would improve skills, including referral decisions, confidence in core genetics competencies and knowledge. METHODS: Randomized controlled trial involving FPs in four communities in Ontario, Canada (two urban and two rural). The intervention consisted of an interactive educational workshop, portfolio of practical clinical genetics tools and knowledge service called Gene Messenger. Outcome measures included appropriate genetics referral decisions in response to 10 breast cancer scenarios, decisional difficulty, self-reported confidence in 11 genetics core competencies, 3 knowledge questions and evaluation of intervention components 6 months afterwards. RESULTS: Among the one hundred and twenty-five FPs randomized, 80 (64%) completed the study (33 control, 47 intervention). Intervention FPs had significantly higher appropriate referral decision scores [6.4/10 [95% confidence interval (CI) 5.8-6.9] control, 7.8/10 (95% CI 7.4-8.2) intervention] and overall self-reported confidence on core genetics competencies [37.9/55 (95% CI 35.1-40.7) control, 47.0/55 (95% CI 44.9-49.2) intervention]. Over 90% of FPs wanted to continue receiving Gene Messengers and would recommend them to colleagues. No significant differences were found in decisional difficulty or knowledge. CONCLUSIONS: This study demonstrated that a complex educational intervention was able to significantly improve practice intent for clinical genetics scenarios found in primary care, as well as confidence in genetics skills.

Anticipating the primary care role in genomic medicine: expectations of genetics health professionals.

Our purpose was to explore genetics health professionals' (GHPs) expectations of primary care providers' (PCPs) role in genomic medicine now and in the future. Focus groups/interviews were conducted with GHPs in Ontario, Canada. Recordings were transcribed and analysed using qualitative descriptive analysis. Five focus groups (6 clinical geneticists, 24 genetic counselors, 1 nurse, 4 laboratory staff, 3 genetics program administrators) and 3 interviews (nurses) were conducted. GHPs described a key role for PCPs in genomic medicine that could be enhanced if GHPs and PCPs worked together more effectively, making better use of GHPs as a scarce specialist resource, improving PCP knowledge and awareness of genomics, and increasing GHPs' understanding of primary care practice and how to provide PCPs meaningful education and support. Health system change is needed to facilitate the GHP/PCP relationship and improve care. This might include: PCPs ordering more genetic tests independently or with GHP guidance prior to GHP consultations, genomic expertise in primary care clinics or GHPs being accessible through buddy systems or virtually through telemedicine or electronic consultation, and developing educational materials and electronic decision support for PCPs. Our findings highlight need for change in delivering genomic medicine, which requires building the relationship between GHPs and PCPs, and creating new service delivery models to meet future needs.

Hereditary colorectal cancer screening: A 10-year longitudinal cohort study following an educational intervention.

Family history (FH) of a first-degree relative with colorectal cancer (CRC) is associated with two to fourfold increased risk, yet screening uptake is suboptimal despite proven mortality reduction. We developed a FH-based CRC Risk Triage/Management tool for family physicians (FPs), and educational booklet for patients with CRC FH. This report describes physician referral and patient screening behavior 5 and 10 years post-educational intervention, and factors associated with screening. Longitudinal cohort study. FPs/patients in Ontario and Newfoundland, Canada were sent questionnaires at baseline (2005), 5 and 10 years (2015) following tool/booklet receipt. FPs were asked about CRC screening, patients about FH, screening type and timing. "Correct" screening was concordance with tool recommendations. Results reported for 29/121 (24%) FPs and 98/297 (33%) patients who completed all 3 questionnaires. Over 10 years 2/3 patients received the correct CRC screening test at appropriate timing (baseline 75%, 5-year 62%, 10-year 65%). About half reported their FP recommended CRC screening (5-year 51%, 10-year 63%). Fewer than half the patients correctly assessed their CRC risk (44%, 40%, 41%). Patients were less likely to have correct screening timing if female (RR 0.78; 95% CI 0.61, 0.99; p = 0.045). Patients were less likely to have both correct test and timing if moderate/high CRC risk (RR 0.66; 95% CI 0.47, 0.93; p = 0.017) and more likely if their physician recommended screening (RR1.69; 95% CI 1.15, 2.49; p = 0.007). Physician discussion of CRC risk and screening can positively impact patient screening behavior. Efforts are particularly needed for women and patients at moderate/high CRC risk.

Informing Integration of Genomic Medicine Into Primary Care: An Assessment of Current Practice, Attitudes, and Desired Resources.

Introduction: Preparing primary care providers for genomic medicine (GM) first requires assessment of their educational needs in order to provide clear, purposeful direction and justify educational activities. More understanding is needed about primary care providers' perspectives on their role in newer areas of GM and what resources would be helpful in practice. Our objective was to determine family physicians' (FP) current involvement and confidence in GM, attitudes regarding its clinical value, suggestions for integration of GM into practice, and resources and education required. Methods: A self-complete anonymous questionnaire was mailed to a random sample of 2,000 FPs in Ontario, Canada in September 2012. Results: Adjusted response rate was 26% (361/1,365), mean age was 51, and 53% were male. FPs reported many aspects of traditional GM as part of current practice (eliciting family history: 93%; deciding who to refer to genetics: 94%; but few reported confidence (44%, 32% respectively). Newer areas of GM were not part of most FPs' current practice and confidence was low (pharmacogenetics: 28% part of practice, 5% confident; direct-to-consumer genetic testing: 14%/2%; whole genome sequencing: 8%/2%). Attitudes were mixed with 59% agreeing that GM would improve patient health outcomes, 41% seeing benefits to genetic testing, but only 36% agreeing it was their responsibility to incorporate GM into practice. Few could identify useful sources of genetic information (22%) or find information about genetic tests (21%). Educational resources participants anticipated would be useful included contact information for local genetics clinics (89%), summaries of genetic disorders (86%), and genetic referral (85%) and testing (86%) criteria. About 58% were interested in learning about new genetic technologies. Most (76%) wanted to learn through in-person teaching (lectures, seminars etc.), 66% wanted contact with a local genetic counselor to answer questions, and 59% were interested in a genetics education website. Conclusion: FPs lack confidence in GM skills needed for practice, particularly in emerging areas of GM. They see their role as making appropriate referrals, are somewhat optimistic about the contribution GM may make to patient care, but express caution about its current clinical benefits. There is a need for evidence-based educational resources integrated into primary care and improved communication with genetic specialists.

The use of the Antenatal Psychosocial Health Assessment (ALPHA) tool in the detection of psychosocial risk factors for postpartum depression: a randomized controlled trial.

OBJECTIVE: Eliciting known risk factors for postpartum depression (PPD) during pregnancy may enable primary health care providers to identify women at increased risk of becoming depressed. The purpose of this study was to examine how well the Antenatal Psychosocial Health Assessment (ALPHA) form identified antenatal risk factors for PPD, compared with routine care, in a sample of pregnant women. METHODS: A randomized controlled trial was conducted to assess the effectiveness of the ALPHA form in detecting antenatal risk factors associated with the adverse postpartum outcomes of postpartum depression, intimate partner violence, child abuse, and couple dysfunction. The participants were primary antenatal care providers--family physicians, obstetricians, and midwives--from four diverse communities in Ontario. These providers were matched and then randomly allocated into the intervention group, who used the ALPHA form, or into the control group, who administered usual care. In total, 227 pregnant women were recruited: 98 in the ALPHA group and 129 in the control group. The data presented in this paper are from a secondary analysis focusing on PPD as the outcome. RESULTS: Providers randomized to the ALPHA group identified a statistically significantly higher proportion of women with antenatal psychosocial risk factors for PPD (36% vs. 26%) and a significantly higher number of risk factors per woman compared with the control group (mean 2.1 vs.1.8) (z = -1.96, P = 0.05). Providers in the ALPHA group also identified significantly more women having a "previous history of depression" (16% vs. 6%) (chi2 = 5.243, df = 1, P = 0.03) and "[having] witnessed or experienced abuse as a child" (17% vs. 3%) (chi2 = 12.488, df = 1, P = 0.0005), which are both established risk factors for PPD. CONCLUSION: The ALPHA provides a systematic means of eliciting antenatal psychosocial risk factors for PPD for primary care providers, and it may be particularly useful for raising and discussing sensitive issues. The detection of depressive symptomatology during pregnancy remains problematic, however, and detection may be improved by administering a simple standardized measure of depressive symptomatology during routine antenatal care.

The Gene Messenger Impact Project: An Innovative Genetics Continuing Education Strategy for Primary Care Providers.

INTRODUCTION: Primary care providers (PCP) will need to be integrally involved in the delivery of genomic medicine. The GenetiKit trial demonstrated effectiveness of a knowledge translation intervention on family physicians' (FP) genetics referral decision-making. Most wanted to continue receiving Gene Messengers (GM), evidence-based summaries of new genetic tests with primary care recommendations. Our objective was to determine the value of GMs as a continuing education (CE) strategy in genomic medicine for FPs. METHODS: Using a "push" model, we invited 19,060 members of the College of Family Physicians of Canada to participate. Participants read GMs online, receiving 12 emailed topics over 6 months. Participants completed an online Information Assessment Method questionnaire evaluating GMs on four constructs: cognitive impact, relevance, intended use of information for a patient, and expected health benefits. RESULTS: One thousand four hundred two FPs participated, 55% rated at least one GM. Most (73%) indicated their practice would be improved after reading GMs, with referral to genetics ranked highly. Of those who rated a GM relevant, 94% would apply it to at least one patient and 79% would expect health benefits. This method of CE was found useful for genetics by 88% and 94% wanted to continue receiving GMs. DISCUSSION: FPs found this novel CE strategy, brief individual reflective e-learning, to be valuable for learning about genetics. This method of information delivery may be an especially effective method for CE in genomic medicine where discoveries occur at a rapid pace and lack of knowledge is a barrier to integration of genetic services.

Supporting genetics in primary care: investigating how theory can inform professional education.

Evidence indicates that many barriers exist to the integration of genetic case finding into primary care. We conducted an exploratory study of the determinants of three specific behaviours related to using breast cancer genetics referral guidelines effectively: 'taking a family history', 'making a risk assessment', and 'making a referral decision'. We developed vignettes of primary care consultations with hypothetical patients, representing a wide range of genetic risk for which different referral decisions would be appropriate. We used the Theory of Planned Behavior to develop a survey instrument to capture data on behavioural intention and its predictors (attitude, subjective norm, and perceived behavioural control) for each of the three behaviours and mailed it to a sample of Canadian family physicians. We used correlation and regression analyses to explore the relationships between predictor and dependent variables. The response rate was 96/125 (77%). The predictor variables explained 38-83% of the variance in intention across the three behaviours. Family physicians' intentions were lower for 'making a risk assessment' (perceived as the most difficult) than for the other two behaviours. We illustrate how understanding psychological factors salient to behaviour can be used to tailor professional educational interventions; for example, considering the approach of behavioural rehearsal to improve confidence in skills (perceived behavioural control), or vicarious reinforcement as where participants are sceptical that genetics is consistent with their role (subjective norm).

Effectiveness of the Antenatal Psychosocial Health Assessment (ALPHA) form in detecting psychosocial concerns: a randomized controlled trial.

BACKGROUND: A pregnant woman's psychological health is a significant predictor of postpartum outcomes. The Antenatal Psychosocial Health Assessment (ALPHA) form incorporates 15 risk factors associated with poor postpartum outcomes of woman abuse, child abuse, postpartum depression and couple dysfunction. We sought to determine whether health care providers using the ALPHA form detected more antenatal psychosocial concerns among pregnant women than providers practising usual prenatal care. METHODS: A randomized controlled trial was conducted in 4 communities in Ontario. Family physicians, obstetricians and midwives who see at least 10 prenatal patients a year enrolled 5 eligible women each. Providers in the intervention group attended an educational workshop on using the ALPHA form and completed the form with enrolled women. The control group provided usual care. After the women delivered, both groups of providers identified concerns related to the 15 risk factors on the ALPHA form for each patient and rated the level of concern. The primary outcome was the number of psychosocial concerns identified. Results were controlled for clustering. RESULTS: There were 21 (44%) providers randomly assigned to the ALPHA group and 27 (56%) to the control group. A total of 227 patients participated: 98 (43%) in the ALPHA group and 129 (57%) in the control group. ALPHA group providers were more likely than control group providers to identify psychosocial concerns (odds ratio [OR] 1.8, 95% confidence interval [CI] 1.1-3.0; p = 0.02) and to rate the level of concern as "high" (OR 4.8, 95% CI 1.1-20.2; p = 0.03). ALPHA group providers were also more likely to detect concerns related to family violence (OR 4.8, 95% CI 1.9-12.3; p = 0.001). INTERPRETATION: Using the ALPHA form helped health care providers detect more psychosocial risk factors for poor postpartum outcomes, especially those related to family violence. It is a useful prenatal tool, identifying women who would benefit from additional support and interventions.

Screening for asymptomatic bacteriuria in pregnancy.

OBJECTIVE: To compare the following 4 screening strategies for detecting asymptomatic bacteriuria (ABU) in pregnancy: urine testing with leukocyte-esterase-nitrite (LEN) strips at each prenatal visit followed by a urine culture if positive; a single urine culture at fewer than 20 weeks' gestation; 2 urine cultures, at fewer than 20 weeks' gestation and at 28 weeks' gestation; or 3 urine cultures, at fewer than 20 weeks', at 28 weeks', and at 36 weeks' gestation. METHODS: Participants were pregnant women presenting to 2 obstetricians and 6 family physicians at outpatient family medicine and obstetrical clinics in a large Canadian urban teaching hospital. LEN dipstick urine testing was conducted at each prenatal visit. A midstream urine culture was obtained from all women before 20 weeks' gestation and at 28 weeks' and 36 weeks' gestation, as well as for positive LEN tests. Any positive urine culture in an asymptomatic woman was designated a case of ABU. The total number of ABU cases that would be detected by each of the 4 strategies (LEN dipstick testing only, a single urine culture, 2 cultures, and 3 cultures) was determined and compared. RESULTS: There were 49 cases of ABU among 1050 women (4.7%). LEN testing at each prenatal visit identified 7 cases (14.3%), compared with 20 cases (40.8%) with 1 urine culture, 31 (63.3%) with 2 urine cultures, and 43 (87.8%) with 3 urine cultures. CONCLUSION: A single urine culture before 20 weeks' gestation missed more than one-half the ABU cases. A culture in each trimester identified most ABU cases.

Effect on antibiotic prescribing of repeated clinical prompts to use a sore throat score: lessons from a failed community intervention study.

OBJECTIVES: Infections with group A streptococcus (GAS) occur in 10% to 20% of patients with sore throats, whereas antibiotics are prescribed 50% of the time. Clinical scoring rules can more accurately predict the likelihood of GAS infection, but whether family physicians will adopt such approaches is unclear. This study sought to determine whether repeated clinical prompts to use a scoring approach could help family physicians lower antibiotic use in patients with a sore throat. STUDY DESIGN: Randomized trial in which physicians were assigned to use either (1) chart stickers that prompted them to calculate a score based on clinical findings and provided management recommendations linked to score totals or (2) a clinical checklist. POPULATION: Ninety-seven family physicians in Ontario, Canada, assessed 621 children and adults with sore throat and obtained a throat swab for culture. OUTCOMES MEASURED: (1) Unnecessary antibiotic prescriptions given to patients with a negative throat culture and (2) overall antibiotic use. RESULTS: There were no differences between the control and intervention group in unnecessary antibiotic prescriptions (16.1% vs 20.4%, respectively, P =.29) or overall antibiotic use (27.9% vs 28.1%, P =.97). However, a number of physicians dropped out of the study; as a result, the characteristics of the physicians in the 2 groups were dissimilar in factors related to prescribing. After adjusting for these differences and patient clustering by physician, the odds ratio for the effect of the intervention on unnecessary antibiotic prescriptions was 0.76 (95% confidence interval [CI] = 0.42, 1.40) and 0.57 for overall antibiotic use (95% CI = 0.27, 1.17). CONCLUSIONS: Chart prompts during clinical encounters to use a clinical score in the assessment of patients with a sore throat did not reduce unnecessary antibiotic prescribing by family physicians. The problems encountered in conducting this community-based intervention trial are discussed in relation to the negative result.