Primary care physician perspectives on screening for axial spondyloarthritis: A qualitative study.

BACKGROUND: Many patients with axial spondylarthritis (axSpA) experience lengthy diagnostic delays upwards of 14 years. (5-14 years). Screening tools for axSpA have been proposed for use in primary care settings, but whether this approach could be implemented into busy primary care settings remains unknown. OBJECTIVE: To solicit feedback from primary care physicians regarding questions from the Inflammatory Back Pain Assessment: the Assessment of Spondyloarthritis International Society (ASAS) Expert Criteria and gain insight about barriers and facilitators for implementing axSpA screening in primary care. METHODS: Guided by Consolidated Criteria for reporting Qualitative Research (COREQ-criteria), we recorded, transcribed, and analyzed in-depth interviews with eight family medicine physicians and ten internists (purposeful sampling) using immersion/crystallization techniques. RESULTS: Few physicians reported awareness of existing classification criteria for axSpA, and many reported a lack of confidence in their ability to distinguish between inflammatory and mechanical back pain. From three domains, 10 subthemes emerged: 1) typical work-up of axSpA patients in primary care, with subthemes including the clues involved in work-up and role of clinical examinations for axSpA; 2) feedback on questions from the Inflammatory Back Pain Assessment: ASAS Expert Criteria, with subthemes to evaluate contents/questions of a potential screening tool for axSpA; and 3) implementation of the screening tool in primary care settings, with subthemes of perceived barriers including awareness, time, other conditions to screen, rare disease, and lack of structured questionnaire for back pain and perceived facilitators including workflow issues and awareness. CONCLUSIONS: Primary care physicians believed that an improved screening instrument and a strong evidence-base to support the need for screening for axSpA are required. The implementation of axSpA screening into a busy primary care practice requires integration into the practice workflow, with use of technology suggested as a possible way to improve efficiency.

Risk Stratification in Patients with Complicated Parapneumonic Effusions and Empyema Using the RAPID Score.

PURPOSE: Complicated parapneumonic effusions and empyema are a leading cause of morbidity in the United States with over 1 million admissions annually and a mortality rate that remains high in spite of recent advances in diagnosis and treatment. The identification of high risk patients is crucial for improved management and the provision of cost-effective care. The RAPID score is a scoring system comprised of the following variables: renal function, age, purulence, infection source, and dietary factors and has been shown to predict outcomes in patients with pleural space infections. METHODS: In a single center retrospective study, we evaluated 98 patients with complicated parapneumonic effusions and empyema who had tube thoracostomy (with or without Intrapleural fibrinolytic therapy) and assessed treatment success rates, mortality, length of hospital stay, and direct hospitalization costs stratified by three RAPID score categories: low-risk (0-2), medium risk (3-4), and high-risk (5-7) groups. RESULTS: Treatment success rate was 71%, and the 90 day mortality rate was 12%. There was a positive-graded association between the low, medium and high RAPID score categories and mortality, (5.3%, 8.3% and 22.6%, respectively), length of hospital stay (10, 21, 19 days, respectively), and direct hospitalization costs ($19,909, $36,317 and $43,384, respectively). CONCLUSION: Our findings suggest that the RAPID score is a robust tool which could be used to identify patients with complicated parapneumonic effusions and empyema who may be at an increased risk of mortality, prolonged hospitalization, and who may incur a higher cost of treatment. Randomized controlled trials identifying the most effective initial treatment modality for medium- and high-risk patients are needed.

Is the BPD epidemic diminishing?

In a previous study of very low birth weight neonates, < or = 1500 g, admitted to the Vanderbilt University Neonatal Intensive Care Unit (NICU) from 1976-1990, improvements in survival were accompanied by a corresponding increase in the incidence of bronchopulmonary dysplasia (BPD). Since then, certain neonatal and perinatal interventions have been introduced and may influence neonatal outcomes. In this study, we have continued the analysis of the incidence of 3 outcomes: 1) Neonatal death (NEOD), 2) BPD, and 3) NEOD or BPD (NEOD/BPD) for an additional 7 years, 1991-1997. A retrospective study was performed of 3,837 patients with birth weight < or = 1500 g and admitted to the Vanderbilt NICU within 24 hours of birth from 1976 through 1997. The outcomes NEOD, BPD, or NEOD/BPD were modeled by using multiple logistic regression with the following risk factors included as covariates: birth weight, gestational age, Apgar scores at 1 and 5 minutes, gender, race, birth location, diagnosis of hyaline membrane disease, maternal age, maternal diabetes, delivery method, multiple births, duration of ruptured membranes, and biologically relevant interactions among these covariates. To assess time trends in the risk factors and outcomes, patients were divided into time periods (1 = 1976-80, 2 = 1981-85, 3 = 1986-90, 4 = 1991-95, and 5 = 1996-97). For each outcome, only covariates or interactions among covariates found to be significant were retained in the final model. Adjusted odds ratios and 95% confidence intervals were calculated to measure the risk associated with a given time period in comparison to the preceding period. There was a progressive decline in NEOD across all time periods. The previously described increase in BPD from period 1 through period 3 is followed by a decrease in periods 4 and 5. The risk of NEOD/BPD remained fairly constant from period 1 to period 3, but then showed a significant decrease over the two most recent periods. Prior to 1991, the cost of improved survival among very low birth weight infants in this large NICU was an increased incidence of BPD. Since 1991, the risk of BPD has been decreasing even though survival continues to improve. If these findings are also representative of other NICUs, they signify an important reduction in the impact of BPD as one of the costly sequelae of prematurity.