Outcomes of the Bethesda system for reporting thyroid cytopathology in community- vs. institution-performed cytology.

OBJECTIVES: Despite the important role of the community in the assessment and risk stratification of patients with thyroid nodules, evidence-based data on the Bethesda System for Reporting Thyroid Cytopathology (BSRTC) performance in community clinics is lacking. We aim to evaluate BSRTC performance of aspirations taken in community clinics compared with primary referral center. METHODS: Patients who underwent thyroid surgery between 2013 and 2018 at our institution were divided according to the fine needle aspirations (FNA) settings: community FNA (cFNA) vs. institutional FNA (iFNA). Demographics, BSRTC results and final pathology were collected. Diagnostic values were calculated for BSRTC categories (sensitivity, specificity, positive predictive value [PPV], and negative predictive value [NPV]), and were compared between the groups. RESULTS: A total of 268 nodules were included in the study; 77% (207) cFNA and 23% (61) iFNA. Patients in the community were younger (51.7 ± 15.1 vs. 56.6 years±14.8, p = 0.03) and with less epidemiology risk factors for thyroid cancer (1.9% vs 13.1%, p < 0.001). cFNA malignancy rate for BSRTC I-VI was 0%, 6.4%, 11.8%, 32.1%, 91.6% and 93.8% respectively. Best sensitivity was found for BSRTC III-VI in both groups (88% and 83%, cFNAs and iFNAs, respectively). Overall best performance was obtained for BSRTC V-VI for both groups (cfNA: 85%, 97%, 93%, 94% and 93%; iFNAs: 81%, 100%, 100%, 87% and 91%, for sensitivity, specificity, PPV, NPV and accuracy, respectively). CONCLUSIONS: Community-performed FNAs demonstrate acceptable BSRTC distribution and malignancy rates, comparable with a primary referral academic hospital. This supports the universality of the BSRTC 2017 and its recommendations also in the community.

Permanence of professionals who work in the Tuberculosis Control Program / Permanencia de profesionales que actúan en el Programa de Control de la Tuberculosis / Permanência de profissionais que atuam no programa de controle da tuberculose

ABSTRACT Objective: To analyze the length of stay of the professionals who work in the Tuberculosis Control Program in Basic Health Units of the city of Rio de Janeiro/RJ. Method: Sectional study, developed in eight Health Units of the Maré Complex/RJ. Physicians, nurses, nursing technicians and Community Health Agents of the Family Health Teams were interviewed. The Kruskal-Wallis test was used to verify the existence of groups with the same distribution, and Dunn's multiple comparison test with Bonferroni correction, to identify which group presented a difference. Results: Among Health Units, a significant difference was observed in the length of work (p-value = 0.0005909) and in the dwell time (p-value = 0.0003598). Conclusion: It was observed low length of stay of the professionals that work in the Basic Health Units. This result points to challenges inherent in the control of tuberculosis at the local level.

RESUMEN Objetivo: Analizar el tiempo de permanencia de los profesionales que actúan en el Programa de Control de la Tuberculosis en Unidades Básicas de Salud del municipio de Río de Janeiro/RJ. Método: Estudio seccional, desarrollado en ocho Unidades de Salud del Complejo de la Maré/RJ. Entrevistaron médicos, enfermeros, técnicos de enfermería y Agentes Comunitarios de Salud de los Equipos de Salud de la Familia. Se optó por la prueba de Kruskal-Wallis para verificar la existencia de grupos con la misma distribución, y prueba de comparaciones múltiples de Dunn, con corrección de Bonferroni, para identificar qué grupo presentaba diferencia. Resultados: Entre las Unidades de Salud, se comprueba diferencia significativa en el tiempo de ejercicio de la función (p-value = 0,0005909) y en el tiempo de permanencia (p-value = 0,0003598). Conclusión: Se constató bajo tiempo de permanencia de los profesionales que actúan en las Unidades Básicas de Salud. Este resultado apunta a desafíos inherentes al control de la tuberculosis a nivel local.

RESUMO Objetivo: Analisar o tempo de permanência dos profissionais que atuam no Programa de Controle da Tuberculose em Unidades Básicas de Saúde do município do Rio de Janeiro/RJ. Método: Estudo seccional, desenvolvido em oito Unidades de Saúde do Complexo da Maré/RJ. Entrevistaram-se médicos, enfermeiros, técnicos de enfermagem e Agentes Comunitários de Saúde das Equipes de Saúde da Família. Optou-se pelo teste de Kruskal-Wallis para verificar a existência de grupos com a mesma distribuição, e teste de comparações múltiplas de Dunn, com correção de Bonferroni, para identificar qual grupo apresentava diferença. Resultados: Entre as Unidades de Saúde, comprova-se diferença significativa no tempo de exercício da função (p-value = 0,0005909) e no tempo de permanência (p-value = 0,0003598). Conclusão: Constatou-se baixo tempo de permanência dos profissionais que atuam nas Unidades Básicas de Saúde. Esse resultado aponta para desafios inerentes ao controle da tuberculose em nível local.

Patterns of care for anal cancer in the United States - a comparison between academic and community cancer centers.

BACKGROUND: Management of squamous cell carcinoma of the anus (SCCA) is becoming more relevant, as its incidence increases. The purpose of this study was to investigate possible differences in patient population and care delivery for SCCA between academic and community cancer programs in the United States. METHODS: A review of available data from the American College of Surgeons Committee on Cancer National Cancer DataBase focused on gender, age, race, type of health insurance, comorbidity score, distance traveled for care, stage at diagnosis, and therapy utilization (surgery, chemotherapy, and radiation therapy) as first course of treatment (FCT). The analysis included 38,766 patients treated for SCCA. Of them, 14,422 patients received treatment at Academic Cancer Programs (ACPs), while 24,344 were treated at Community Cancer Programs (CCPs) between the years 2003 and 2013. RESULTS: Over the 11-year study period, ACPs had significantly more male patients, of younger age, a greater non-white race population, with more Medicaid or no insurance coverage, who traveled farther for cancer center care (p < 0.001). There was no difference between ACPs and CCPs with respect to Charlson co-morbidity score and stage of SCCA at diagnosis. For stage 0 patients, use of chemotherapy was 8% for ACPs, 9% for CCPs, and use of radiotherapy was 10% for ACPs and 14% for CCPs. The incidence of stage unknown was identical at both ACPs and CCPs (11.5%). CCPs had a greater overall utilization of radiation therapy as FCT for stage 0, I, II and IV patients (p < 0.001). CONCLUSIONS: Our study indicates that gender, demographic and socio-economic differences exist in the patient population with SCCA accessing different cancer programs in the US. The high incidence of stage unknown patients reflects ongoing challenges in the pre-treatment phase. A significant percentage of stage 0 patients received systemic chemotherapy and/or radiotherapy, rather than surgery alone. Despite comparable stage at diagnosis and comorbidity scores between ACPs and CCPs, there appear to be variations in treatment choices, especially with the use of radiotherapy, with associated cost and toxicity risks. Further analysis and monitoring of SCCA management in the US may lead to improved compliance with NCCN guidelines.

Do cystic fibrosis centres with the lowest FEV1 still use the least amount of intravenous antibiotics? A registry-based comparison of intravenous antibiotic use among adult CF centres in the UK.

BACKGROUND: The Epidemiologic Study of Cystic Fibrosis using 1995-1996 and 2003-2005 data found that CF centres with lowest FEV1 tended to use fewer intravenous antibiotics. We repeated the analyses using 2013-2014 UK CF registry data to determine if this was still the case. METHODS: Analysing data for 2013 and 2014 separately, 28 adult CF centres were ranked according to median % age-adjusted FEV1. The top 7 centres were placed in the 'upper quarter' (best FEV1), the bottom 7 centres in 'lower quarter' (lowest FEV1), and the rest in 'middle half'. IV use was stratified according to %FEV1, then compared between the three groups. RESULTS: Centres in the 'upper quarter' and 'middle half' used significantly more IV antibiotics compared to centres in the 'lower quarter' (van Elteren test P-value<0.001). Regression analyses showed that people with CF attending centres in the 'upper quarter' or 'middle half' are 30-50% more likely to receive at least one IV course per year compared to people attending centres in the 'lower quarter'. CONCLUSIONS: CF centres with lowest FEV1 are still distinguished by lower use of intravenous antibiotics.

Accuracy of Modified Checklist for Autism in Toddlers (M-CHAT) in Detecting Autism and Other Developmental Disorders in Community Clinics.

This study determined the accuracy of Modified Checklist for Autism in Toddlers (M-CHAT) in detecting toddlers with autism spectrum disorder (ASD) and other developmental disorders (DD) in community mother and child health clinics. We analysed 19,297 eligible toddlers (15-36 months) who had M-CHAT performed in 2006-2011. Overall sensitivities for detecting ASD and all DD were poor but better in the 21 to <27 months and 27-36-month age cohorts (54.5-64.3%). Although positive predictive value (PPV) was poor for ASD, especially the younger cohort, positive M-CHAT helped in detecting all DD (PPV = 81.6%). This suggested M-CHAT for screening ASD was accurate for older cohorts (>21 months) and a useful screening tool for all DD.

Design of the Indian NCA study (Indian national collaboration on AIDS): a cluster randomized trial to evaluate the effectiveness of integrated care centers to improve HIV outcomes among men who have sex with men and persons who inject drugs in India.

BACKGROUND: Globally, men who have sex with men and people who inject drugs remain disproportionately affected by HIV, but they have not been the focus of prevention and treatment interventions in many resource-limited settings. METHODS/DESIGN: This cluster-randomized trial (conducted from June 2012 to June 2017), evaluates whether single-venue, integrated delivery of core HIV services to vulnerable high-risk populations improves service utilization and consequently, HIV testing and other outcomes along the HIV care continuum. Core services include: HIV counseling and testing, information, education and communication, condom distribution, needle and syringe exchange programs, opioid agonist therapy, management of sexually transmitted infections, tuberculosis screening, diagnosis, and treatment, and antiretroviral therapy. Stratified restricted randomization was used to allocate 22 Indian cities (10 men who have sex with men and 12 people who inject drugs sites) at a 1:1 ratio to either the intervention or control condition. Integrated care centers were scaled-up and implemented in the 11 intervention cities and outcomes will be assessed by pre- and post-intervention surveys at intervention and control sites. As men who have sex with men and people who inject drugs are hidden populations, with no sampling frame, respondent-driven sampling will be used to accrue samples for the two independent cross-sectional surveys. DISCUSSION: For an AIDS-free generation to be realized, prevention, care and treatment services need to reach all populations at risk for HIV infection. There is a clear gap in access to services among men who have sex with men and people who inject drugs. Trials need to be designed to optimize utilization of services in these populations. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01686750 Date of Registration: September 13, 2012.

Ações de prevenção do hiv e de promoção à saúde no contexto da aids pela estratégia saúde da família em joão pessoa-pb / Acciones de prevención del vih y promoción de la salud en el contexto del sida por la estrategia salud de la familia en joão pessoa-pb / Actions of prevention of hiv and health promotion in the context of aids by strategy health of the family in joão pessoa-pb

RESUMO O estudo objetivou analisar as ações de prevenção do HIV e promoção à saúde no contexto da Aids desenvolvidas pela Estratégia Saúde da Família (ESF), em João Pessoa-PB. Trata-se de um estudo descritivo, com abordagem qualitativa, realizado com 16 enfermeiros atuantes na ESF. Para a obtenção dos dados, utilizouse um roteiro de entrevista semiestruturado e seguiu-se as etapas de análise de conteúdo temática. Os enfermeiros atuam no contexto da Aids com ações em educação em saúde e contextos do cuidar, além de vivenciar facilidades e dificuldades para que essas ações sejam implementadas com êxito. Concluiu-se que as ações voltadas para a prevenção do HIV e promoção à saúde no contexto da Aids estão presentes nas atividades dos profissionais enfermeiros atuantes na ESF, no entanto, não se constituem ações cotidianas e préestabelecidas, acontecendo, em sua maioria, em momentos pontuais e nas demandas durante as consultas de enfermagem.

RESUMEN El estudio tuvo como objetivo analizar las acciones de prevención del VIH y promoción de la salud en el contexto del SIDA desarrolladas por la Estrategia Salud de la Familia (ESF) en João Pessoa-PB. Se trata de un estudio descriptivo, con enfoque cualitativo, realizado con 16 enfermeros que trabajan en la ESF. Para la recogida de datos, se utilizó un guión de entrevista semiestructurado y fueron seguidos los pasos del análisis de contenido temático. Los enfermeros actúan en el contexto del SIDA con acciones en educación para la salud y contextos de la atención, además de vivir facilidades y dificultades para que esas acciones sean implementadas con éxito. Se concluyó que las acciones dirigidas a la prevención del VIH y promoción de la salud en el contexto del SIDA están presentes en las actividades de los profesionales de enfermería que trabajan en la ESF, sin embargo no se constituyen acciones cotidianas y preestablecidas, ocurriendo, sobre todo, en momentos puntuales y en las demandas durante las consultas de enfermería.

ABSTRACT The study aimed to analyze the prevention of the actions of HIV and health promotion in the context of AIDS developed by the Strategy Family Health (ESF) in João Pessoa-PB. This search is a descriptive study with qualitative approach, performed with 16 nurses working in the ESF, using a semi-structured interview guide and followed the steps of content analysis. Nurses work in the context of AIDS with actions in health education and care contexts, additionally ease and difficulties in these experiences for these actions are implemented successfully. It was concluded that the actions aimed at prevention of HIV and health promotion in the context of AIDS are present in the activities of professional nurses who are working in the ESF, however not constitute everyday actions and pre-established, happening mostly in special moments and the demands during nursing visits.

[The experience of functioning of diabetic retinopathy room of municipal medical institution].

The diabetic retinopathy rooms are relatively new interdisciplinary structure in the medical care system. The evaluation of sufficiency of the number of this type of medical service for all patients with diabetes mellitus is lacking. The article presents calculation of required number of diabetic retinopathy rooms based on analysis of actual normative base, epidemiological data and experience of functioning of such rooms kind of rooms in municipal medical institution. It is established that for the room assisting particular population of patients with diabetes mellitus workload in average makes up to 1.87 visits per patient annually. The structure and authorized number of diabetic retinopathy rooms specified by actual normative documents, can be considered as sufficient only under condition that primary screening of diabetic retinopathy will be implemented at least to certain percentage of patients by ophthalmologists outside diabetic retinopathy rooms. This condition is to be considered during development of routing of referral of patients with diabetes mellitus to diabetic retinopathy rooms and other ophthalmologists of polyclinic network for full coverage of patients with screening for retinopathy and other affections of organ of vision under diabetes mellitus.

Nivel de satisfacción del paciente respecto a la asistencia kinésica en Centros de Atención Primaria de la Salud de la Capital de la Provincia de Corrientes

En la Atención Primaria de Salud (APS), conocer el nivel de satisfacción del paciente es sustancial para mejorar la calidad de asistencia. El objetivo del presente trabajo fue explorar el NS de los pacientes con tratamientos kinésicos en los Centros de Atención Primaria de la Salud (CAPS) de Corrientes. Metodología: Diseño descriptivo transversal, multicéntrico comparativo, con modalidad de encuestas realizadas a 180 pacientes en los CAPS Nº 1, 3, 8, 9, 10 y 14 durante 6 meses, en las dos primeras semanas de cada mes. Se estudiaron variables demográficas, la información brindada por el kinesiólogo y personal auxiliar, la accesibilidad al servicio y la valoración del equipo de salud, del entorno físico y del servicio. Los datos categóricos fueron analizados en tabla de contingencia para comparación de porcentajes y confrontados entre sí aplicando Chi-Cuadrado – T. de Pearson, considerando nivel de significación: p < 0.05. Resultados: Existió asociación entre las respuestas y el CAPS de donde provinieron (P<0.0001) respecto a: la información, atención, trato por parte del kinesiólogo y personal administrativo, accesibilidad a los centros y la comodidad e higiene del gabinete. Por el contrario, no existió asociación entre las respuestas y el CAPS de donde provinieron respecto a: la accesibilidad estructural, el interés que demostró el kinesiólogo en resolver el problema de salud y la opción de volver al mismo lugar de rehabilitación. El NS de los pacientes en los CAPS Nº 1, 3 y 8 en la mayoría de los aspectos analizados fue mayor que en los CAPS Nº 9, 10 y 14. Conclusión: La percepción de satisfacción del paciente kinésico, en general fue buena en todos los centros; existiendo puntos diferentes dependiendo de cada CAPS. El desarrollo de programas de mejoramiento en la APS conociendo el problema y necesidades del usuario, mejoraría el nivel de satisfacción del paciente

SUMMARY: In Primary Health Care (PHC), knowing the patient’s level of satisfaction is crucial for improving care quality. The aim of this study was to explore the LS of patients with physiotherapy treatments at Primary Health Care Centers (PHCC) in Corrientes. Methodology: Descriptive, cross-sectional, multicenter comparative design, with surveys of 180 patients at the PHCCs No. 1, 3, 8, 9, 10 and 14 over 6 months, in the first two weeks of each month. We studied demographic variables, information provided by the physiotherapist and support staff, the accessibility of the service, the assessment of the healthcare team, the physical and the service environment. Categorical data were analyzed in a contingency table to compare percentages and compared with each other by applying Chi-square - Pearson's T-tests, with significance level: p < 0.05. Results: There was an association between the responses and the PHCC from which they came (P<0.0001) in terms of: information, care, relationship with the physiotherapist and administrative staff, center accessibility, and office comfort and hygiene. On the other hand, there was no association between the responses and the PHCC from which they came regarding: the structural accessibility, the interest the physiotherapist showed in resolving the health problem and the option of returning to the same place for rehabilitation. The LS of the patients at PHCCs No. 1, 3 and 8 in most of the aspects studied was greater than at PHCCs No. 9, 10 and 14. Conclusion: The perception of satisfaction of the physiotherapy patient was generally good at all the centers. There are different points depending on each PHCC. The development of PHC improvement programs taking into account the problems and needs of the user, would enhance the level of patient satisfaction

Implementing tobacco use treatment guidelines in community health centers in Vietnam.

BACKGROUND: Vietnam has a smoking prevalence that is the second highest among Southeast Asian countries (SEACs). According to the World Health Organization (WHO), most reductions in mortality from tobacco use in the near future will be achieved through helping current users quit. Yet, largely due to a lack of research on strategies for implementing WHO-endorsed treatment guidelines in primary care settings, services to treat tobacco dependence are not readily available to smokers in low middle-income countries (LMICs) like Vietnam. The objective of this study is to conduct a cluster randomized controlled trial that compares the effectiveness of two system-level strategies for implementing evidence-based guidelines for the treatment of tobacco use in 26 public community health centers (CHCs) in Vietnam. METHODS/DESIGN: The current study will use a cluster-randomized design and multiple data sources (patient exit interviews, provider and village health worker (VHW) surveys, and semi-structured provider/VHW interviews) to study the process of adapting and implementing clinical practice guidelines in Vietnam and theory-driven mechanisms hypothesized to explain the comparative effectiveness of the two strategies for implementation. CHCs will be randomly assigned to either of the following: (1) training plus clinical reminder system (TC) or (2) TC + referral to a VHW (TCR) for three in person counseling sessions. The primary outcome is provider adherence to tobacco use treatment guidelines. The secondary outcome is 6-month biochemically verified smoking abstinence. DISCUSSION: The proposed implementation strategies draw on evidence-based approaches and a growing literature that supports the effectiveness of integrating community health workers as members of the health care team to improve access to preventive services. We hypothesize that the value of these implementation strategies is additive and that incorporating a referral resource that allows providers to delegate the task of offering counseling (TCR) will be superior to TC alone in improving delivery of cessation assistance to smokers. The findings of this research have potential to guide large-scale adoption of promising strategies for implementing and disseminating tobacco use treatment guidelines throughout the public health system in Vietnam and will serve as a model for similar action in other LMICs. TRIAL REGISTRATION: NCT01967654.

Assessment of primary care facilities for cardiovascular disease preparedness in Madhya Pradesh, India.

BACKGROUND: Government of India has launched National Program for Prevention & Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) to address high prevalence of non-communicable diseases (NCDs) in India. Cardiovascular diseases (CVDs) constitute a significant portion of NCD burden. While this program is yet to be launched in all districts of Madhya Pradesh state of India, we performed this study to understand facility-level gaps that need to be addressed to improve CVD services in primary care provided by the public sector. METHODS: This is a cross-sectional questionnaire based study. A standardized questionnaire was self-administered to 85 medical officers from as many primary care facilities from 24 districts of the state. These medical officers were working in two types of primary care facilities - primary health center (PHC) and community health centers (CHC). Facilities were assessed for 36 items in 5 domains (human-resource, equipment, drug supplies, point-of-care tests and laboratory services) with a focus on management of hypertension and diabetes mellitus in primary-care. Each item was to be answered as either present or absent at the facility where medical officer was working. We compared availability of an item across two levels of primary care facilities. All statistical analysis were done using Microsoft Excel. RESULTS: Availability of facilities was least in laboratory services, and human resource domains followed by drugs, and better in equipment and point-of-care supply domains. Across these domains, availability of items in CHCs was (37.1, 49.0, 56.1, 67.9 and 80.9 % respectively) and in PHCs (11.8, 18.2, 44.2, 55.1, and 55.3 % respectively). DISCUSSION: Current facility assessment study shows critical gaps in key items required for management of NCDs at primary care level. Human resource and laboratory services need to be strengthened the most, followed by sustained availability of all required drug classes, equipment and related supplies, and upgrading point-of-care testing. There are larger gaps in PHCs, which are level 1 facilities, as compared to CHCs, which are level 2 facilities in primary-care. CONCLUSIONS: Increasing burden of NCDs like hypertension and diabetes mellitus necessitates public health response through health systems. Therefore health system preparedness in form of trained human resources, functional laboratories and well stocked pharmacies are essential in primary care facilities.

Community partnered projects: residents engaging with community health centers to improve care.

BACKGROUND: Important residency curricular elements, including scholarship, quality improvement (QI), and community health, often exist as independent components. We developed a curriculum to train residents to become community-responsive physicians that included longitudinal care at a community health center (CHC) with a unique community-partnered project (CPP). We evaluated outcomes of one CPP and delineated challenges in implementing the curriculum. METHODS: After performing a needs assessment, the resident-CHC team designed a QI intervention to improve documentation of smoking status and cessation counseling. A chart review of 100 random patients assessed pre- and post-intervention documentation. Patient focus groups were held to guide the development of the final intervention, which included medical assistant (MA) education, appropriate patient education materials, and a visual communication system for MAs and providers. Curriculum evaluation via interviews with residency and community partners was done periodically throughout the 2-year process. RESULTS: Focus group participants saw clinicians as a resource for quitting but did not want to talk about quitting at every visit. We reviewed 317 patient visits pre-QI intervention and 191 post-QI intervention. There were no significant changes in the percent of visits where smoking status was documented (82% versus 79%); however, smoking cessation counseling during office visits increased significantly (19% to 54%). Key challenges included academic-community communication and resident scheduling and availability. CONCLUSIONS: In this CPP curriculum, residents made a difference in practice outcomes, and ongoing attention to challenges assisted with the project's success, possibly enhancing residents' likelihood of incorporating QI and principles of community health into their future careers.

Improving psychosocial assessment in a community-based cancer center.

Numerous articles have demonstrated that patients undergoing treatment for cancer experience distress. Research has also shown that patients whose distress is effectively identified and treated may tolerate their chemotherapy better and have improved quality of life. Oncology nurses at the Lowell General Hospital Cancer Center, through their participation in the Breast Cancer Care Measures portion of the ONS Foundation-supported Breast Cancer Quality Measures Set pilot and the Oncology Quality Collaborative, identified that the distress assessment used at their institution was ineffective. The assessment tool did not identify the reason for the patient's distress and therefore was ineffective at triggering appropriate interventions needed for resolution of the patient's distress. The following article highlights the process by which the Lowell General Hospital Cancer Center implemented a new distress assessment tool and uses a patient case study to illustrate its effectiveness.

The longitudinal impact of patient navigation on equity in colorectal cancer screening in a large primary care network.

BACKGROUND: The long-term effects of interventions to improve colorectal (CRC) screening in vulnerable populations are uncertain. The authors evaluated the impact of patient navigation (PN) on the equity of CRC prevention over a 5-year period. METHODS: A culturally tailored CRC screening PN program was implemented in 1 community health center (CHC) in 2007. In a primary care network, CRC screening rates from 2006 to 2010 among eligible patients from the CHC with PN were compared with the rates from other practices without PN. Multivariable logistic regression models for repeated measures were used to assess differences over time. RESULTS: Differences in CRC screening rates diminished among patients at the CHC with PN and at other practices between 2006 (49.2% vs 62.5%, respectively; P < .001) and 2010 (69.2% vs 73.6%, respectively; P < .001). The adjusted rate of increase over time was higher at the CHC versus other practices (5% vs 3.4% per year; P < .001). Among Latino patients at the CHC compared with other practices, lower CRC screening rates in 2006 (47.5% vs 52.1%, respectively; P = .02) were higher by 2010 (73.5% vs 67.3%, respectively; P < .001). Similar CRC screening rates among non-English speakers at the CHC and at other practices in 2006 (44.3% vs 44.7%, respectively; P = .79) were higher at the CHC by 2010 (70.6% vs 58.6%, respectively; P < .001). Adjusted screening rates increased more over time for Latino and non-English speakers at the CHC compared with other practices (both P < .001). CONCLUSIONS: A PN program increased CRC screening rates in a CHC and improved equity in vulnerable patients. Long-term funding of PN programs has the potential to reduce cancer screening disparities.

Trainees' experiences of a four-year programme for specialty training in general practice.

In 2012 the first Scottish cohort of trainees completed a four-year training programme in general practice. In the same year, the Royal College of General Practitioners (RCGP) successfully made the educational case for lengthening training from three to four years in the rest of the UK. This project sought to evaluate the experiences of the initial four-year cohorts (2012 and 2013) to gain the Certificate of Completion of Training (CCT). We aimed to capture trainees' experiences of the training programme and how well it prepared them for independent general practice. We also investigated whether perceived levels of clinical confidence in key areas of the curriculum improved over time. To achieve this we undertook a cross-sectional online questionnaire survey. Open-ended questions were included to elicit more in-depth responses by participants on all issues. A total of 20/49 trainees in 2012 (40%) and 46/50 trainees in 2013 (92%) completed the survey. Perceived mean levels of clinical confidence in the key curriculum domains surveyed in 2012/13 were generally high, particularly in clinical domains or topics such as cancer management (94%) and paediatrics (94%). It was lowest in non-clinical domains such as GP partnership (57%), practice management (68%) and leadership (65%), but also in some skills specific to general practice that are of importance where healthcare delivery is increasingly community-based such as public health (63%) and caring for the long-term unemployed (33%). This small study will inform the implementation of an integrated, community-based model of training to enable GP trainees to achieve the clinical and generalist skills required in the immediate future.

Diabetes care quality is highly correlated with patient panel characteristics.

INTRODUCTION: Health care reimbursement is increasingly based on quality. Little is known about how clinic-level patient characteristics affect quality, particularly in community health centers (CHCs). METHODS: Using data from electronic health records for 4019 diabetic patients from 23 primary care CHCs in the OCHIN practice-based research network, we calculated correlations between a clinic's patient panel characteristics and rates of delivery of diabetes preventive services in 2007. Using regression models, we estimated the proportion of variability in clinics' preventive services rates associated with the variability in the clinics' patient panel characteristics. We also explored whether clinics' performance rates were affected by how patient panel denominators were defined. RESULTS: Clinic rates of hemoglobin testing, influenza immunizations, and lipid screening were positively associated with the percentage of patients with continuous health insurance coverage and negatively associated with the percentage of uninsured patients. Microalbumin screening rates were positively associated with the percentage of racial minorities in a clinic's panel. Associations remained consistent with different panel denominators. CONCLUSIONS: Clinic variability in delivery rates of preventive services correlates with differences in clinics' patient panel characteristics, particularly the percentage of patients with continuous insurance coverage. Quality scores that do not account for these differences could create disincentives to clinics providing diabetes care for vulnerable patients.

Pediatric provider processes for behavioral health screening, decision making, and referral in sites with colocated mental health services.

OBJECTIVE: Validated behavioral health (BH) screens are recommended for use at well-child visits. This study aimed to explore how pediatricians experience and use these screens for subsequent care decisions in primary care. METHODS: The study took place at 4 safety net health centers. Fourteen interviews were conducted with pediatricians who were mandated to use validated BH screens at well-child visits. Interview questions focused on key domains, including clinic BH context, screening processes, assessment of screening scores, and decision making about referral to mental health services. Qualitative analysis used the Framework Approach. RESULTS: A variety of themes emerged: BH screens were well accepted and valued for the way they facilitated discussion of mental health issues. However, screening results were not always used in the way that instrument designers intended. Providers' beliefs about the face validity of the instruments, and their observations about performance of instruments, led to discounting scored results. As a result, clinical decisions were made based on a variety of evidence, including individual item responses, parent or patient concerns, and perceived readiness for treatment. Additionally, providers, although interested in expanding their mental health discussions, perceived a lack of time and of their own skills to be major obstacles in this pursuit. CONCLUSIONS: Screens act as important prompts to stimulate discussion of BH problems, but their actual scored results play a variable role in problem identification and treatment decisions. Modifications to scheduling policies, additional provider training, and enhanced collaboration with mental health professionals could support better BH integration in pediatric primary care.

BCN Checkpoint, a community-based centre for men who have sex with men in Barcelona, Catalonia, Spain, shows high efficiency in HIV detection and linkage to care.

OBJECTIVES: We assessed the efficiency of BCN Checkpoint in detecting new cases of HIV infection and efficiently linking newly diagnosed individuals to care. METHODS: This study analysed during 2007-2012 the number of tests performed and the number of persons tested in BCN Checkpoint, the HIV prevalence, global and in first visits, the capacity of HIV detection compared to the reported cases in MSM in Catalonia, and the linkage to care rate. RESULTS: During the six years a total of 17.319 tests were performed and 618 HIV-positive cases were detected. Median prevalence of clients who visited the centre for the first time was 5.4% (4.1-5.8). BCN Checkpoint detected 36.3% (35.0-40.4) of all reported cases in MSM during 2009-2011. Linkage to care was achieved directly in 90.5% of the cases and only 2.4% of cases were lost to follow-up. CONCLUSIONS: A community-based centre, addressed to a key population at risk, can be less effort consuming (time and funding) and show high efficiency in HIV detection and linkage to care.