Differences in Primary Care Follow-up After Acute Care Discharge Within and Across Health Systems: a Retrospective Cohort Study.

BACKGROUND: Timely primary care follow-up after acute care discharge may improve outcomes. OBJECTIVE: To evaluate whether post-discharge follow-up rates differ among patients discharged from hospitals directly affiliated with their primary care clinic (same-site), other hospitals within their health system (same-system), and hospitals outside their health system (outside-system). DESIGN: Retrospective cohort study. PATIENTS: Adult patients of five primary care clinics within a 14-hospital health system who were discharged home after a hospitalization or emergency department (ED) stay. MAIN MEASURES: Primary care visit within 14 days of discharge. A multivariable Poisson regression model was used to estimate adjusted rate ratios (aRRs) and risk differences (aRDs), controlling for sociodemographics, acute visit characteristics, and clinic characteristics. KEY RESULTS: The study included 14,310 discharges (mean age 58.4 [SD 19.0], 59.5% female, 59.5% White, 30.3% Black), of which 57.7% were from the same-site, 14.3% same-system, and 27.9% outside-system. By 14 days, 34.5% of patients discharged from the same-site hospital received primary care follow-up compared to 27.7% of same-system discharges (aRR 0.88, 95% CI 0.79 to 0.98; aRD - 6.5 percentage points (pp), 95% CI - 11.6 to - 1.5) and 20.9% of outside-system discharges (aRR 0.77, 95% CI [0.70 to 0.85]; aRD - 11.9 pp, 95% CI - 16.2 to - 7.7). Differences were greater for hospital discharges than ED discharges (e.g., aRD between same-site and outside-system - 13.5 pp [95% CI, - 20.8 to - 8.3] for hospital discharges and - 10.1 pp [95% CI, - 15.2 to - 5.0] for ED discharges). CONCLUSIONS: Patients discharged from a hospital closely affiliated with their primary care clinic were more likely to receive timely follow-up than those discharged from other hospitals within and outside their health system. Improving care transitions requires coordination across both care settings and health systems.

How Would You Manage This Male Patient With Hypogonadism? : Grand Rounds Discussion From Beth Israel Deaconess Medical Center.

Male hypogonadism is defined as an abnormally low serum testosterone concentration or sperm count. As men age, often in the context of obesity and other comorbid conditions, serum testosterone levels may decrease. Normalizing serum testosterone levels in male adults with hypogonadism may improve symptoms related to androgen deficiency, but controversies exist regarding the long-term benefits and risks of hormone supplementation in this setting. In 2020, the American College of Physicians published a clinical guideline for the use of testosterone supplementation in adult men based on a systematic review of available evidence. Among their recommendations were that clinicians discuss whether to initiate testosterone treatment in men with age-related low testosterone with sexual dysfunction who want to improve sexual function and not initiate testosterone treatment in men with age-related low testosterone to improve energy, vitality, physical function, or cognition. Here, two clinicians with expertise in this area, one a generalist and the other an endocrinologist, debate the management of a patient with sexual symptoms and a low serum testosterone level. They discuss the diagnosis of male hypogonadism, the indications for testosterone therapy, its potential benefits and risks, how it should be monitored, and how long it should be continued.

How Would You Manage Opioid Use in These Three Patients?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center.

The increase in overdose deaths from prescription opioids and heroin in the United States over the past 20 years is believed to have resulted from increases in prescription of opioids for management of acute and chronic pain. Managing chronic pain is challenging for primary care clinicians for many reasons, including the lack of evidence to guide practice. The Centers for Disease Control and Prevention published a comprehensive guideline in 2016 to help clinicians with opioid prescribing for chronic pain. In this Grand Rounds, the guideline is reviewed and an expert discusses its application to 3 patients prescribed opioids to treat chronic pain.

Impact of 30- Versus 60-Second Time Intervals Between Automated Office Blood Pressure Measurements on Measured Blood Pressure.

[Figure: see text].

Impact of Clinic-Based Blood Pressure Approaches on Blood Pressure Measurement.

BACKGROUND: Clinic-based blood pressure (BP) is a closely-tracked metric of health care quality, but is prone to inaccuracy and measurement imprecision. Recent guidelines have advocated for automated office blood pressure (AOBP) devices to improve clinic-based BP assessments. METHODS: Patients from a single hypertension clinic underwent a 3-day evaluation that included a 24-hour ambulatory blood pressure monitoring (ABPM), 2 manual clinic-based BP measurements (over 2 visits), and an unattended AOBP measurement (single visit). All measurements were compared to the average wake-time systolic BP (SBP) and diastolic BP (DBP) from ABPM. RESULTS: Among 103 patients (mean age 57.3 ± 14.8 years, 51% women, 29% black) the average wake-time SBP was 131.3 ± 12.3 mm Hg and DBP was 78.3 ± 9.2 mm Hg. The average of 2 manual BPs was significantly higher than wake-time ABPM with mean differences of 5.5 mm Hg (P < 0.001) for SBP and 2.7 mm Hg (P = 0.002) for DBP. In contrast, the averages of the last 2 AOBP measurements did not significantly differ from ABPM with mean differences of 1.6 mm Hg (P = 0.21) for SBP and -0.5 mm Hg (P = 0.62) for DBP. The estimated prevalence of SBP ≥ 140 or DBP ≥ 90 mm Hg based on wake-time ABPM was 27.2% vs. 49.5% based on the average of 2 manual measurements (difference 22.3%; P < 0.001) and 31.1% based on the average of the last 2 AOBP measurements (difference 3.9%; P = 0.57). CONCLUSIONS: A single visit, unattended AOBP more precisely estimated BP and the prevalence of stage 2 and uncontrolled hypertension than even the average of 2 manual clinic visits, supporting guideline recommendations to use AOBP for clinic-based BP measurements.

A Pre-Test-Post-Test Trial of a Breast Cancer Risk Report for Women in Their 40s.

INTRODUCTION: Guidelines recommend individualized breast cancer screening and prevention interventions for women in their 40s. Yet, few primary care clinicians assess breast cancer risk. STUDY DESIGN: Pretest-Posttest trial. SETTING/PARTICIPANTS: Women aged 40-49 years were recruited from one large Boston-based academic primary care practice between July 2017 and April 2019. INTERVENTION: Participants completed a pretest, received a personalized breast cancer risk report, saw their primary care clinician, and completed a posttest. MAIN OUTCOME MEASURES: Using mixed effects models, changes in screening intentions (0-100 scale [0=will not screen to 100=will screen]), mammography knowledge, decisional conflict, and receipt of screening were examined. Analyses were conducted from June 2019 to February 2020. RESULTS: Patient (n=337) mean age was 44.1 (SD=2.9) years, 61.4% were non-Hispanic white, and 76.6% were college graduates; 306 (90.5%) completed follow-up (203 with 5-year breast cancer risk <1.1%). Screening intentions declined from pre- to post-visit (79.3 to 68.0, p<0.0001), especially for women with 5-year risk <1.1% (77.2 to 63.3, p<0.0001), but still favored screening. In the 2 years prior, 37.6% had screening mammography compared with 41.8% over a mean 16 months follow-up (p=0.17). Mammography knowledge increased and decisional conflict declined. Eleven (3.3%) women met criteria for breast cancer prevention medications (ten discussed medications with their clinicians), 22 (6.5%) for MRI (19 discussed MRI with their clinician), and 67 (19.8%) for genetic counseling (47 discussed with the clinician). CONCLUSIONS: Receipt of a personalized breast cancer report was associated with women in their 40s making more-informed and less-conflicted mammography screening decisions and with high-risk women discussing breast cancer prevention interventions with clinicians. TRIAL REGISTRATION: This study is registered at www.clinicaltrials.govNCT03180086.

Psychological status and weight-related distress in overweight or at-risk-for-overweight children.

OBJECTIVE: To associate psychological status, weight-related distress, and weight status during childhood in overweight or at-risk-for-overweight children. RESEARCH METHODS AND PROCEDURES: We associated self-report of depression, trait anxiety, and weight-related distress (body size dissatisfaction and weight-related peer teasing after controlling for the effects of weight) in 164 children (black 35%; age 11.9 +/- 2.5 years; girls 51%) who were overweight or at-high-risk-for-overweight and were not seeking weight loss. RESULTS: Overall, heavier children reported more psychological and weight-related distress. Black children reported more anxiety and body size dissatisfaction than white children, despite equivalent weights. However, psychological distress was not significantly associated with weight in white children. Girls reported more weight-related distress than boys. Depression was associated with weight-related teasing in all predictive models, except in the model using only black subjects. Trait anxiety was associated with report of peer teasing when using all subjects. Depression was also significantly associated with children's report of body size dissatisfaction in models using all subjects, only girls, or white subjects, but not in analyses using only boys or black subjects. For boys peer teasing was associated with body size dissatisfaction. In models including only black children, depression and trait anxiety were not significantly associated with either report of peer teasing or body size dissatisfaction. DISCUSSION: Regardless of race or sex, increasing weight is associated with emotional and weight-related distress in children. However, associations of psychological status, weight, and weight-related distress differ for girls and boys, and for black and white children.

A prospective study of psychological predictors of body fat gain among children at high risk for adult obesity.

OBJECTIVE: Limited data suggest that psychological factors, including binge eating, dieting, and depressive symptoms, may predispose children to excessive weight gain. We investigated the relationship between baseline psychological measures and changes in body fat (measured with dual-energy x-ray absorptiometry) over time among children thought to be at high risk for adult obesity. METHODS: A cohort study of a convenience sample of children (age: 6-12 years) recruited from Washington, DC, and its suburbs was performed. Subjects were selected to be at increased risk for adult obesity, either because they were overweight when first examined or because their parents were overweight. Children completed questionnaires at baseline that assessed dieting, binge eating, disordered eating attitudes, and depressive symptoms; they underwent measurements of body fat mass at baseline and annually for an average of 4.2 years (SD: 1.8 years). RESULTS: Five hundred sixty-eight measurements were obtained between July 1996 and December 2004, for 146 children. Both binge eating and dieting predicted increases in body fat. Neither depressive symptoms nor disturbed eating attitudes served as significant predictors. Children who reported binge eating gained, on average, 15% more fat mass, compared with children who did not report binge eating. CONCLUSIONS: Children's reports of binge eating and dieting were salient predictors of gains in fat mass during middle childhood among children at high risk for adult obesity. Interventions targeting disordered eating behaviors may be useful in preventing excessive fat gain in this high-risk group.

Weight and its relationship to adolescent perceptions of their providers (WRAP): a qualitative and quantitative assessment of teen weight-related preferences and concerns.

PURPOSE: To examine the relationship of body weight to satisfaction with care in adolescents, and to obtain qualitative data on preferences for general and weight-related medical care in normal weight and overweight adolescents. METHODS: The Weight and its Relationship to Adolescent Perceptions of their Providers survey, a 4-page questionnaire containing previously validated satisfaction scales and open-ended qualitative questions regarding health care preferences, was administered to 62 severely overweight (body mass index [BMI] 38.9 +/- 8.4 kg/m2) and 29 normal weight (BMI 22.5 +/- 4.0 kg/m2) adolescents (age 13.9 +/- 1.7 years; 57% female; 50% Caucasian, 47% African-American, 3% Hispanic). RESULTS: The affective subscale of the medical satisfaction scale was negatively correlated with BMI standard deviation score (r = -.22, p < .05). Multiple regression models predicting affective satisfaction with medical care included BMI standard deviation score; however, continuity with provider appeared to be the strongest independent predictor of affective satisfaction. Fifty-five percent of participants identified their mother as the person they felt most comfortable talking with about weight, although 68% believed their provider knew the most about healthy eating. "Overweight" was identified by 47% of participants as the preferred term for heavy teens. Seventy-nine percent of overweight adolescents stated their health care provider discussed their weight with them; however, only 41% of overweight adolescents desired to discuss their weight. Compared to normal-weight adolescents, overweight teens were more likely to report that their provider raised topics of weight (p < .001), diet (p < .01), and exercise (p < .01) at their last physical, and were more likely to report that they would have liked their provider to discuss diet and exercise (both p < .05). Ten percent of overweight teens expressed concerns regarding the public location of their provider's office scale. CONCLUSIONS: Satisfaction with affective aspects of the provider-patient relationship is negatively correlated with BMI standard deviation score. Length of experience with one's provider is also a strong predictor of teen satisfaction with their medical care. Teens prefer the term "overweight" for those with high body weight. Sensitivity to confidentiality, privacy, and embarrassment regarding physical examination and weight are important for teen satisfaction.

Health-related quality of life in overweight and nonoverweight black and white adolescents.

OBJECTIVES: To assess the impact of obesity on quality of life (QOL) in black and white adolescents. STUDY DESIGN: One hundred ten overweight (body mass index [BMI], 41.7 +/- 8.9 kg/m2) and 34 nonoverweight adolescents (BMI, 20.6 +/- 2.9 kg/m2) and their parents completed measures of QOL. RESULTS: Overweight was associated with poorer adolescent-reported QOL and parent reports of their children's QOL. Examining groups by weight status and race, overweight whites reported the greatest impairment on Social/Interpersonal, Self-Esteem, and Physical Appearance QOL (all P < .01), whereas parents of overweight blacks reported the poorest General Health Perceptions scores regarding their children. Interactions between BMI z-score and race were detected for Social/Interpersonal, Self-esteem, Daily Living, Self-Efficacy, Self-regard, and Physical Appearance QOL (all P < .05): Higher BMI in whites was associated with greater impairments in QOL than in blacks. Parents reported similar relations for their children. CONCLUSIONS: According to adolescent and parent reports, overweight is associated with poorer QOL in adolescence, regardless of race; however, compared with overweight white adolescents, blacks report less impairment in QOL. Future research is required to determine whether differences in QOL are predictive of treatment success.

Comparison of the child and parent forms of the Questionnaire on Eating and Weight Patterns in the assessment of children's eating-disordered behaviors.

OBJECTIVE: The assessment of eating-disordered behaviors in middle childhood is challenging. Frequently, both child and parents are queried about the child's eating behavior. However, no direct comparisons between parent and child reports of child eating disturbance have been published. We compared results from the adolescent and parent versions of the Questionnaire on Eating and Weight Patterns (QEWP-A and QEWP-P, respectively) in a nontreatment sample of overweight and normal weight children. METHOD: The QEWP-A and QEWP-P were administered to 142 overweight (body mass index [BMI] > or = 85th percentile) and 121 normal weight (BMI 15th-84th percentile) children, age 9.7 +/- 1.9 years, recruited from the community. RESULTS: The QEWP-A and QEWP-P showed good agreement for the absence of eating-disordered behavior but were not concordant in terms of the number or type of binge eating, overeating episodes, or compensatory weight control behaviors in the past 6 months. Children categorized by their own reports (QEWP-A) as engaging in no overeating, simple overeating, or binge eating behaviors did not differ significantly in body composition or in eating and general psychopathology. Children categorized according to their parents' reports (QEWP-P) as engaging in binge eating had significantly greater body adiposity, eating-disordered cognitions, body dissatisfaction, and parent-reported problems (all ps <.001) than children engaging in no overeating or simple overeating according to the QEWP-P. DISCUSSION: Child and parent reports of eating behaviors are not concordant regarding the presence of binge eating or compensatory behaviors. Further investigation of the utility of these questionnaires is needed before either can serve as a surrogate for a clinical interview.