Multidisciplinary Approach to Deprescribing Sedative-Hypnotic Medications in Geriatric Primary Care.

INTRODUCTION/OBJECTIVES: Due to the risks associated with sedative hypnotic medications in older adults, our study evaluated the impact of a multidisciplinary approach to deprescribing in geriatric primary care clinics. METHODS: The study was a retrospective review of older adults at 2 academic, geriatric primary care clinics who were prescribed sedative-hypnotic medications. Patients were mailed an education packet of information that included working with the clinical pharmacy team, behavioral health team, or both in order to deprescribe their sedative-hypnotic medication. The study assessed the rate of discontinuation of sedative-hypnotic medications between the different intervention groups. RESULTS: The study included 93 older adults with a mean age of 81.3 years and 39.8% discontinuation rate of their medication. The number of falls decreased in patients who discontinued use compared to when previously using a sedative hypnotic medication. CONCLUSION: Patients are more likely to discontinue their sedative hypnotic medication with a multidisciplinary approach, specifically with primary care provider support.

Disparities in Video and Telephone Visits Among Older Adults During the COVID-19 Pandemic: Cross-Sectional Analysis.

BACKGROUND: Telephone and video telemedicine appointments have been a crucial service delivery method during the COVID-19 pandemic for maintaining access to health care without increasing the risk of exposure. Although studies conducted prior to the pandemic have suggested that telemedicine is an acceptable format for older adults, there is a paucity of data on the practical implementation of telemedicine visits. Due to prior lack of reimbursement for telemedicine visits involving nonrural patients, no studies have compared telephone visits to video visits in geriatric primary care. OBJECTIVE: This study aimed to determine (1) whether video visits had longer durations, more visit diagnoses, and more advance care planning discussions than telephone visits during the rapid implementation of telemedicine in the COVID-19 pandemic, and (2) whether disparities in visit type existed based on patient characteristics. METHODS: We conducted a retrospective, cross-sectional analysis of patients seen at two geriatric clinics from April 23 to May 22, 2020. Approximately 25% of patients who had telephone and video appointments during this time underwent chart review. We analyzed patient characteristics, visit characteristics, duration of visits, number of visit diagnoses, and the presence of advance care planning discussion in clinical documentation. RESULTS: Of the 190 appointments reviewed, 47.4% (n=90) were video visits. Compared to telephone appointments, videoconferencing was, on average, 7 minutes longer (mean 37.3 minutes, SD 10 minutes; P<.001) and had, on average, 1.2 more visit diagnoses (mean 5.7, SD 3; P=.001). Video and telephone visits had similar rates of advance care planning. Furthermore, hearing, vision, and cognitive impairment did not result in different rates of video or telephone appointments. Non-White patients, patients who needed interpreter services, and patients who received Medicaid were less likely to have video visits than White patients, patients who did not need an interpreter, and patients who did not receive Medicaid, respectively (P=.003, P=.01, P<.001, respectively). CONCLUSIONS: Although clinicians spent more time on video visits than telephone visits, more than half of this study's older patients did not use video visits, especially if they were from racial or ethnic minority backgrounds or Medicaid beneficiaries. This potential health care disparity merits greater attention.

Pharmacist-Led Transition of Care Pilot Targeting Older People After Emergency Department Discharge.

OBJECTIVE: To evaluate the impact of a pharmacist-led transitional care intervention targeting high-risk older people after an emergency department (ED) visit.
DESIGN: Retrospective cohort study of older people with ED visits prior to and during a pharmacist-led intervention.
SETTING: Patients receiving primary care from the University of Colorado Health Seniors Clinic.
PARTICIPANTS: The intervention cohort comprised 170 patients with an ED visit between August 18, 2018, and February 19, 2019, and the historical cohort included 166 patients with an ED visit between August 18, 2017, and February 19, 2018. All included patients either had a historical diagnosis of heart failure or chronic obstructive pulmonary disease, or they had an additional ED visit in the previous six months.
INTERVENTIONS: The pilot intervention involved postED discharge telephonic outreach and assessment by a clinical pharmacist, with triaging to other staff if necessary.
MAIN OUTCOME MEASURE: The primary outcome was the proportion of patients with at least one repeat ED visit, hospitalization, or death within 30 days of ED discharge. Outcome rates were also assessed at 90 days postdischarge.
RESULTS: The primary outcome occurred in 21% of the historical cohort and 25% of the intervention cohort (adjusted P-value = 0.48). The incidence of the composite outcome within 90 days of ED discharge was 43% in the historical group compared with 38% in the intervention group (adjusted P-value = 0.29).
CONCLUSION: A pharmacist-led telephonic intervention pilot targeting older people did not appear to have a significant effect on the composite of repeat ED visit, hospitalization, or death within 30 or 90 days of ED discharge. A limited sample size may hinder the ability to make definitive conclusions based on these findings.

Use of an Ambulatory Patient Portal for Advance Care Planning Engagement.

BACKGROUND: Primary care clinics need sustainable, population-based approaches to engage patients in advance care planning (ACP). Patient portal-based ACP tools may provide an option for patient engagement. OBJECTIVE: To increase ACP outcomes by engaging older adults through portal-based ACP tools, including an electronic Medical Durable Power of Attorney (MDPOA) form. METHODS: Geriatric clinic pilot of a multi-modal population-based outreach strategy for portal-based ACP tools. Outreach was to patients (n = 105) who were 65 years and older with an active portal account, no cognitive impairment, and no MDPOA on file. Patients received a motivational message via the portal and, if not read within 2 weeks, a mailed postcard about the portal-based ACP tools. Primary outcome was composite of any ACP action at 1-year including 1) new advance directive (AD) in the electronic health record, 2) use of portal-based ACP tools, or 3) documented ACP discussion with a provider. RESULTS: Sixty-five older adults read the electronic message at 12 months. Seventeen (16%) engaged in at least 1 ACP action. Fourteen of 17 engaged by adding an AD to their record. More patients completed an AD on article or brought a previously completed AD to clinic, compared with choosing to complete an electronic MDPOA via the portal. CONCLUSIONS: Brief motivational messages about ACP via a patient portal is feasible and may increase ACP outcomes for older adults in primary care. Future studies should evaluate population-based portal outreach strategies in combination with team-based workflows to enhance patient engagement in ACP.

Characteristics and Patterns of Marijuana Use in Community-Dwelling Older Adults.

OBJECTIVES: To understand patterns of marijuana use in community-dwelling older adults in Colorado. DESIGN: Anonymous survey. SETTING: Two academic geriatric primary care clinics. PARTICIPANTS: English-speaking individuals. MEASUREMENTS: We assessed self-reported characteristics and patterns of marijuana use and effect on targeted symptoms. Survey analysis focused on current users, defined as individuals who had used marijuana in the past 3 years. RESULTS: Three hundred forty-five individuals completed the survey (55% response rate); 113 (32%) had used marijuana in the past, of whom 55 (16%) had used since legalization. More than half of current users were aged 75 and older, and one-quarter were aged 85 and older. Most current users were white women. Of current users, 44% used marijuana products at least weekly for common conditions including chronic pain, depression, anxiety, and insomnia, and most found marijuana helpful for these conditions. Most respondents reported obtaining marijuana recreationally (67%) without a prescription. Nine respondents reported negative side effects attributable to marijuana use. CONCLUSION: To our knowledge, this is the first study to characterize marijuana use of older adults in a state in which it is legal for medical and recreational use. Marijuana was used for several common geriatric conditions, and respondents reported few side effects. The small number of survey respondents, the lack of generalizability in states where marijuana sales are illegal, and participation bias were the main study limitations. Further research is needed to better understand useful or harmful effects in this population. J Am Geriatr Soc 66:2167-2171, 2018.

Developing a Quality Measurement Strategy in an Academic Primary Care Setting: An Environmental Scan.

PURPOSE: The purpose of this project was to: (1) develop a strategy for primary care quality measurement using an environmental scan and interviews to identify best practices and candidate measures; (2) present recommendations to facilitate successful measurement. METHODS: Following stakeholder interviews and review of existing measures, we created a three-tiered recommendation system for selecting and implementing measures. We also developed a framework for reviewing and prioritizing measures and prepared a detailed project report. RESULTS: Interviews provided a broader perspective on measuring quality, including implementing measures, measuring value, and identifying measurement gaps. Our recommendations fall into three tiers: Tier 1 measures can be implemented quickly and include clinical processes and outcomes for preventive care and disease states. Tier 2 measures require modifications to electronic health record, workflows, and/or staff preparation. Tier 3 (Strategic Vision) addresses topics that should be incorporated in the future to ensure high-quality primary care (adherence, patient activation, patient experience, teamness, staff satisfaction, and value), and infrastructure development to support ongoing quality measurement. CONCLUSIONS: Implementing a quality measurement strategy is challenging and labor-intensive but is necessary to improve healthcare quality. Our work demonstrates the effort and investment required to progress quality measurement and offers recommendations for successfully undertaking this type of endeavor.

Development and economic evaluation of a pharmacist-provided chronic care management service in an ambulatory care geriatrics clinic.

PURPOSE: The implementation and delivery of a pharmacist-led chronic care management (CCM) service in a geriatric primary care clinic are described. METHODS: A CCM service was provided March 1 through December 31, 2016, at the University of Colorado Hospital Seniors Clinic ("Seniors Clinic"). The electronic health record (EHR) team for the University of Colorado Health system developed a patient registry through EPIC Healthy Planet (Epic Systems Corp., Verona, WI) to identify patients at the Seniors Clinic eligible for CCM services. The EHR team constructed a note type and documentation template within the EHR to ensure documentation of all necessary components for billing and to allow individual clinical staff to document the time spent providing CCM care. RESULTS: Overall, 36 elderly patients enrolled in the pharmacist-provided CCM service over the 10 months. Clinical pharmacists spent a total of 156-849 minutes per month providing CCM services, with a mean outreach time of 45.4 minutes per patient. The clinical pharmacists submitted 95 claims, and all but 5 were paid. The total amount reimbursed from the health plans during the 10 months was $2,775.02. CONCLUSION: Medicare patients were successfully enrolled in a CCM service in a geriatrics primary care clinic led by clinical pharmacists and medical providers. The CCM services were more time-consuming than the allotted 20 minutes per patient per month with the CCM Current Procedural Terminology code used during this study.

Outcomes and provider perspectives on geriatric care by a nurse practitioner-led community paramedicine program.

This study explores the use of a nurse practitioner-led paramedicine program for acute, home-based care of geriatric patients. This case series describes patients, outcomes, and geriatric primary care provider perspectives related to use of this independent paramedicine program. There were 40 patient visits from August 2016-May 2017. We reviewed patient demographics, medical conditions, healthcare utilization, and communication processes and used semi-structured interviews and content analysis to explore staff perspectives. The most commonly treated diagnoses were respiratory conditions, urinary tract infections, and gastrointestinal concerns. Two patients required an immediate transfer to a higher level of care. Six patients had emergency department visits and five patients were hospitalized within two weeks. Geriatric providers identified three themes including: potential benefits to geriatric patients, importance of enhanced care coordination and communication, and considerations for the specific role of nurse practitioner-led community paramedicine programs for geriatric patient care.

Success in the Achieving CARdiovascular Excellence in Colorado (A CARE) Home Blood Pressure Monitoring Program: A Report from the Shared Networks of Colorado Ambulatory Practices and Partners (SNOCAP).

BACKGROUND: Blood pressure (BP) control among primary care patients with hypertension is suboptimal. Home BP monitoring (HBPM) has been shown to be effective but is underused. METHODS: This study was a quasi-experimental evaluation of the impact of the A CARE HBPM program on hypertension control. Nonpregnant adults with hypertension or cardiovascular disease risk factors were given validated home BP monitors and reported monthly average home BP readings by Internet or phone. Patients and providers received feedback. Change in average home and office BP and the percentage of patients achieving target BP were assessed based on patient HBPM reports and a chart audit of office BPs. RESULTS: A total of 3578 patients were enrolled at 26 urban and rural primary care practices. Of these, 36% of participants submitted ≥2 HBPM reports. These active participants submitted a mean of 13.5 average HBPM reports, with a mean of 19.3 BP readings per report. The mean difference in home BP between initial and final HBPM reports for active participants was -6.5/-4.4 mmHg (P < .001) and -6.7/-4.7 mmHg (P < .001) for those with diabetes. The percentage of active participants at or below target BP increased from 34.5% to 53.3% (P < .001) and increased 24.6% to 40.0% (P < .001) for those with diabetes. The mean difference in office BP over 1 year between participants and nonparticipants was -5.4/-2.7 mmHg (P < .001 for systolic BP, P = .01 for diastolic BP) for all participants and -8.5/-1.5 mmHg (P = .014 for systolic BP, P = .405 for diastolic BP) for those with diabetes. CONCLUSIONS: An HBPM program with patient and provider feedback can be successfully implemented in a range of primary care practices and can play a significant role in BP control and decreased cardiovascular disease risk in patients with hypertension.

Effects of pioglitazone or exercise in older adults with mild cognitive impairment and insulin resistance: a pilot study.

AIMS: To examine the effects of pioglitazone or endurance exercise training on cognitive function in older adults with mild cognitive impairment (MCI) and insulin resistance. METHODS: Seventy-eight adults (mean age ± SD: 65 ± 7 years) with central obesity and MCI were randomized to 6 months of endurance exercise, pioglitazone or control. RESULTS: Sixty-six participants completed the study. Exercise training did not significantly increase peak oxygen uptake compared to control (p = 0.12). Compared to control, insulin resistance improved in the pioglitazone group (p = 0.002) but not in the exercise group (p = 0.25). There was no measureable effect of pioglitazone or exercise on cognitive performance compared to control. CONCLUSION: In this pilot study, pioglitazone improved insulin resistance but not cognitive performance in older adults with MCI and insulin resistance.

Sociopsychological tailoring to address colorectal cancer screening disparities: a randomized controlled trial.

PURPOSE: Interventions tailored to sociopsychological factors associated with health behaviors have promise for reducing colorectal cancer screening disparities, but limited research has assessed their impact in multiethnic populations. We examined whether an interactive multimedia computer program (IMCP) tailored to expanded health belief model sociopsychological factors could promote colorectal cancer screening in a multiethnic sample. METHODS: We undertook a randomized controlled trial, comparing an IMCP tailored to colorectal cancer screening self-efficacy, knowledge, barriers, readiness, test preference, and experiences with a nontailored informational program, both delivered before office visits. The primary outcome was record-documented colorectal cancer screening during a 12-month follow-up period. Secondary outcomes included postvisit sociopsychological factor status and discussion, as well as clinician recommendation of screening during office visits. We enrolled 1,164 patients stratified by ethnicity and language (49.3% non-Hispanic, 27.2% Hispanic/English, 23.4% Hispanic/Spanish) from 26 offices around 5 centers (Sacramento, California; Rochester and the Bronx, New York; Denver, Colorado; and San Antonio, Texas). RESULTS: Adjusting for ethnicity/language, study center, and the previsit value of the dependent variable, compared with control patients, the IMCP led to significantly greater colorectal cancer screening knowledge, self-efficacy, readiness, test preference specificity, discussion, and recommendation. During the followup period, 132 (23%) IMCP and 123 (22%) control patients received screening (adjusted difference = 0.5 percentage points, 95% CI -4.3 to 5.3). IMCP effects did not differ significantly by ethnicity/language. CONCLUSIONS: Sociopsychological factor tailoring was no more effective than nontailored information in encouraging colorectal cancer screening in a multiethnic sample, despite enhancing sociopsychological factors and visit behaviors associated with screening. The utility of sociopsychological tailoring in addressing screening disparities remains uncertain.

Effects of tailored knowledge enhancement on colorectal cancer screening preference across ethnic and language groups.

OBJECTIVE: Tailoring to psychological constructs (e.g. self-efficacy, readiness) motivates behavior change, but whether knowledge tailoring alone changes healthcare preferences--a precursor of behavior change in some studies--is unknown. We examined this issue in secondary analyses from a randomized controlled trial of a tailored colorectal cancer (CRC) screening intervention, stratified by ethnicity/language subgroups (Hispanic/Spanish, Hispanic/English, non-Hispanic/English). METHODS: Logistic regressions compared effects of a CRC screening knowledge-tailored intervention versus a non-tailored control on preferences for specific test options (fecal occult blood or colonoscopy), in the entire sample (N=1164) and the three ethnicity/language subgroups. RESULTS: Pre-intervention, preferences for specific tests did not differ significantly between study groups (experimental, 64.5%; control 62.6%). Post-intervention, more experimental participants (78.6%) than control participants (67.7%) preferred specific tests (P<0.001). Adjusting for pre-intervention preferences, more experimental group participants than control group participants preferred specific tests post-intervention [average marginal effect (AME)=9.5%, 95% CI 5.3-13.6; P<0.001]. AMEs were similar across ethnicity/language subgroups. CONCLUSION: Knowledge tailoring increased preferences for specific CRC screening tests across ethnic and language groups. PRACTICE IMPLICATIONS: If the observed preference changes are found to translate into behavior changes, then knowledge tailoring alone may enhance healthy behaviors.

An assessment of the Hawthorne Effect in practice-based research.

BACKGROUND: Practical studies in real-world settings may be particularly vulnerable to unintended effects on intervention outcomes, including what is commonly known as the Hawthorne Effect. This phenomenon suggests that study subjects' behavior or study results are altered by the subjects' awareness that they are being studied or that they received additional attention. This is especially a concern when subjects are not blinded to randomization or when they participate in studies with observational components. As part of a larger practical intervention designed to improve the clinical management of skin and soft tissue infections (SSTIs), we specifically examined the potential for a Hawthorne Effect from the extra attention some clinicians received when completing follow-up case reviews. METHODS: De-identified, electronic data from a larger practical intervention allowed for the comparison of the clinical management of SSTIs among 14 randomly selected clinicians who participated in follow-up case reviews versus 77 clinicians who did not. RESULTS: There were no differences in the management of SSTIs between the 2 groups of clinicians. No evidence of a Hawthorne Effect was observed in this quality-improvement intervention. CONCLUSION: More extensive contact with the research team did not seem to have unintended effects on the outcomes of interest for the management of SSTIs. Further study in practice-based research settings could help to establish whether different types of studies and outcomes are more or less susceptible to the Hawthorne Effect.

Chronic non-cancer pain: a siren for primary care--a report from the PRImary Care MultiEthnic Network (PRIME Net).

INTRODUCTION: Patients with chronic non-cancer pain (CNCP) are common and have a high degree of morbidity. Previous studies document clinician frustration and variability in CNCP management. We conducted this study to gather in-depth clinicians' views about factors that affect management of CNCP. METHODS: We conducted a survey in the Primary Care MultiEthnic Network, a consortium of PBRNs of primary care clinicians practicing in low-income, medically underserved communities, and in a network of private primary care offices. RESULTS: Of 792 clinicians surveyed, 497 (63%) participated. Responses and accompanying narrative comments clustered around 5 themes: (1) barriers to and uncertainties in optimal management; (2) the complex biopsychosocial nature of CNCP; (3) seriousness of prescription opioid abuse; (4) effort and burden required to properly manage CNCP; and (5) clinician commitment to provide care for CNCP patients and benefits of expanded care model for CNCP. One-third reported a severe outcome (death or life-threatening event) in a CNCP patient for whom they had prescribed opioids. Roughly one-third do not initiate prescribing of opioids. CONCLUSIONS: Guidelines and increased continuing medical education alone are unlikely to be the solutions to the challenges of CNCP management. Increased evidence for recommendations and resources for more comprehensive care management are needed.

Improving the management of skin and soft tissue infections in primary care: a report from State Networks of Colorado Ambulatory Practices and Partners (SNOCAP-USA) and the Distributed Ambulatory Research in Therapeutics Network (DARTNet).

BACKGROUND: Purulent skin and soft tissue infections (SSTIs) requiring medical attention are often managed in primary care. The prevalence of SSTIs caused by community-acquired Methicillin-resistant Staphylococcus aureus (CA-MRSA) has been increasing rapidly, including in otherwise healthy individuals. The Centers for Disease Control and Prevention (CDC) issued guidelines to improve the management of SSTIs in primary care. PURPOSE: In primary care settings, to assess the prevalence of CA-MRSA using an electronic chart audit and then evaluate SSTI management strategies consistent with CDC guidelines. METHODS: A practical intervention that compared a historical cohort to an intervention cohort of patients seen for SSTI in 16 primary care practices in two health care systems. The intervention included a ready-made kit for I & D procedures, MRSA information for clinicians, a patient information handout, provider education, and patient follow-up. RESULTS: A total of 3112 SSTI cases (cellulitis or purulent) were observed during the preintervention period and 1406 cases during the intervention. For purulent infections in the intervention period (n = 148), univariate and multivariate analyses showed no significant improvement in the rate of I & D procedures or cultures obtained but showed increased use of antibiotics overall and agents that typically cover MRSA strains (OR, 2.183; 95% CI, 1.443 to 3.303 and 2.624; 95% CI, 1.500 to 4.604, respectively). For infections that were cellulitis with or without purulence (n = 1258), overall rates in the use of antibiotics and those that cover MRSA increased significantly, but secular trends could not be ruled out as an explanation for this increase. CONCLUSION: In SSTIs, this intervention resulted in increased use of antibiotics, including antibiotics that typically cover MRSA strains, but did not demonstrate increased rates of recommended drainage procedures. It is replicable and portable, and may improve antibiotic selection in other settings.

What keeps patients from adhering to a home blood pressure program?

BACKGROUND: Home blood pressure monitoring (HBPM) predicts cardiovascular risk and increases hypertension control. Non-participation in HBPM is prevalent and decreases the potential benefit. METHODS: Telephone surveys were conducted with a random quota sample of non-participants in a HBPM program, which supplied a complimentary automated blood pressure cuff and utilized a centralized reporting system. Questioning assessed use of monitors, perceived benefit, communication with providers, and barriers. RESULTS: There were 320 completed surveys (response rate 53%). Of non-participants, 70.2% still used HBPM cuffs and 58% communicated values to providers. Spanish-speakers were 4.4 times more likely to not use cuffs (95% CI, 2.22-8.885). Barriers to participation were largely personal (forgetting, not having time, or self-described laziness). Reasons for not communicating readings with providers were largely clinic factors (no doctor visit, doctor didn't ask, thinking doctor wouldn't care). Lack of knowledge of HBPM and program design also contributed. After being surveyed, patients were over three times more likely to use the central reporting system. DISCUSSION: Most non-participants still used HBPM and communicated values to providers, suggesting many "drop-outs" may still receive clinical benefit. However, much valuable information is not utilized. Future programs should focus on reminder systems, patient motivation, education, and minimizing time involvement.

Card studies for observational research in practice.

PURPOSE: Observational studies that collect patient-level survey data at the point-of-care are often called card studies. Card studies have been used to describe clinical problems, management, and outcomes in primary care for more than 30 years. In this article we describe 2 types of card studies and the methods for conducting them. METHODS: We undertook a descriptive review of card studies conducted in 3 Colorado practice-based research networks and several other networks throughout the United States. We summarized experiences of the State Networks of Colorado Ambulatory Practices and Partners (SNOCAP). RESULTS: Card studies can be designed to study specific conditions or care (clinicians complete a card when they encounter patients who meet inclusion criteria) and to determine trends and prevalence of conditions (clinicians complete a card on all patients seen during a period). Data can be collected from clinicians and patients and can be linked. CONCLUSIONS: Card studies provide cross-sectional descriptive data about clinical care, knowledge and behavior, perception of care, and prevalence of conditions. Card studies remain a robust method for describing primary care.

Acanthosis Nigricans: high prevalence and association with diabetes in a practice-based research network consortium--a PRImary care Multi-Ethnic network (PRIME Net) study.

BACKGROUND: Previous work has established a surprisingly high prevalence of acanthosis nigricans (AN) and its association with increased risk of type 2 diabetes in a Southwestern practice-based research network (PBRN). Our objective was to establish whether this high prevalence of AN would be present in other areas. METHODS: We examined the prevalence of type 2 diabetes and its risk factors and the prevalence of AN among patients aged 7 to 65 years who had been seen by one of 86 participating clinicians in a national PBRN consortium during a 1-week data collection period. In a subsample of nondiabetic matched pairs who had or did not have AN, we compared fasting glucose, insulin, and lipid levels. RESULTS: AN was present in 19.4% of 1730 patients from among all age ranges studied. AN was most prevalent among persons with more risk factors for diabetes. Patients with AN were twice as likely as those without AN to have type 2 diabetes (35.4% vs 17.6%; P < .001). In multivariable analysis, the prevalence ratio for diabetes was 2.1 (95% CI, 1.3-3.5) among non-Hispanic whites with AN and 1.4 (95% CI, 1.1-1.7) among minority patients with AN. In a subsample of 11 matched pairs, those with AN had higher levels of insulin and insulin resistance. CONCLUSIONS: We found high rates of AN among patients in primary care practices across the country. Patients with AN likely have multiple diabetes risk factors and are more likely to have diabetes.

Context of clinical care: the case of hepatitis C in underserved communities--a report from the Primary Care Multiethnic Network (PRIME Net) Consortium.

BACKGROUND: The importance of Hepatitis C (HCV) as a public and individual health concern is well established. However, national groups differ in their recommendations to primary care clinicians about screening people at high risk for HCV. The purpose of this study was to explore the context of care within which primary care clinicians decide to detect and initially manage HCV. METHODS: The Primary Care Multiethnic Network conducted a web- and paper-based survey of primary care clinicians who largely practice in low-income, medically underserved communities in 3 regions across the country. RESULTS: A total of 494 clinicians participated, for a response rate of 61%. Most (68%) clinicians view HCV as an important problem; more than half (59%) consider screening for HCV to be important when compared with other conditions they screen for in practice. With regard to reported screening habits for risk factors, 54% of clinicians routinely ask new patients whether they have used intravenous drugs and 28% inquire about blood transfusions before 1992. Sixty-one percent order an alanine aminotransferase test when patients present with other risk factors for HCV. The majority of clinicians (54%) refer 75% or fewer of their patients with HCV for treatment; nearly one-fifth (18%) provide antiviral treatment themselves. Key factors influencing clinician HCV decision making are patient comorbidities (74% reported this as a factor), access to treatment (55% reported this as a factor), and tolerance (44% reported this as a factor) of treatment. CONCLUSIONS: In the face of conflicting national guideline recommendations about screening people at high risk for HCV, clinicians have varied views and practice habits influenced by multiple patient, access, and treatment issues.

Lack of impact of direct-to-consumer advertising on the physician-patient encounter in primary care: a SNOCAP report.

PURPOSE: Direct-to-consumer advertising (DTCA) has increased tremendously during the past decade. Recent changes in the DTCA environment may have affected its impact on clinical encounters. Our objective was to determine the rate of patient medication inquiries and their influence on clinical encounters in primary care. METHODS: Our methods consisted of a cross-sectional survey in the State Networks of Colorado Ambulatory Practices and Partners, a collaboration of 3 practice-based research networks. Clinicians completed a short patient encounter form after consecutive patient encounter for one-half or 1 full day. The main outcomes were the rate of inquiries, independent predictors of inquiries, and overall impact on clinical encounters. RESULTS: One hundred sixty-eight clinicians in 22 practices completed forms after 1,647 patient encounters. In 58 encounters (3.5%), the patient inquired about a specific new prescription medication. Community health center patients made fewer inquiries than private practice patients (1.7% vs 7.2%, P<.001). Predictors of inquiries included taking 3 or more chronic medications and the clinician being female. Most clinicians reported the requested medication was not their first choice for treatment (62%), but it was prescribed in 53% of the cases. Physicians interpreted the overall impact on the visit as positive in 24% of visits, neutral in 66%, and negative in 10%. CONCLUSIONS: Patient requests for prescription medication were uncommon overall, and even more so among patients in lower income groups. These requests were rarely perceived by clinicians as having a negative impact on the encounter. Future mixed methods studies should explore specific socioeconomic groups and reasons for clinicians' willingness to prescribe these medications.