Abordaje contextual en la práctica del médico de familia / Contextual approach in the practice of the family physician

El contexto representa un conjunto de circunstancias que rodean una situación y, sin las cuales, esta no puede comprenderse en forma correcta. La relación médico paciente está enmarcada en un vínculo contextual. En la práctica cotidiana del médico de familia la atención del paciente se realiza de manera integral, sin disociar el cuerpo del contexto. En este artículo los autores desarrollan el abordaje contextual como herramienta diagnóstica y se describen con detalle dos instrumentos útiles para ponerla en práctica: la evaluación contextual y la entrevista de FOCO (Familia, Orientación y Contexto). (AU)

The context represents a set of circumstances that surround a situation without which it can not be properly understood.The patient-physician relationship is framed in a contextual link. In the daily practice of the family physician, patient careis carried out in an integral manner, without dissociating the body from the context. In this article the authors develop the contextual approach as a diagnostic tool and describe in detail two useful instruments to put it into practice: the contextual assessment and the FOCO interview (Family, Orientation and Context). (AU)

Thyroid cancer under the scope of emerging technologies.

The vast majority of thyroid cancers originate from follicular cells. We outline outstanding issues at each step along the path of cancer patient care, from prevention to post-treatment follow-up and highlight how emerging technologies will help address them in the coming years. Three directions will dominate the coming technological landscape. Genomics will reveal tumoral evolutionary history and shed light on how these cancers arise from the normal epithelium and the genomics alteration driving their progression. Transcriptomics will gain cellular and spatial resolution providing a full account of intra-tumor heterogeneity and opening a window on the microenvironment supporting thyroid tumor growth. Artificial intelligence will set morphological analysis on an objective quantitative ground laying the foundations of a systematic thyroid tumor classification system. It will also integrate into unified representations the molecular and morphological perspectives on thyroid cancer.

Inequities in access to primary care among opioid recipients in Ontario, Canada: A population-based cohort study.

BACKGROUND: Stigma and high-care needs can present barriers to the provision of high-quality primary care for people with opioid use disorder (OUD) and those prescribed opioids for chronic pain. We explored the likelihood of securing a new primary care provider (PCP) among people with varying histories of opioid use who had recently lost access to their PCP. METHODS AND FINDINGS: We conducted a retrospective cohort study using linked administrative data among residents of Ontario, Canada whose enrolment with a physician practicing in a primary care enrolment model (PEM) was terminated between January 2016 and December 2017. We assigned individuals to 3 groups based upon their opioid use on the date enrolment ended: long-term opioid pain therapy (OPT), opioid agonist therapy (OAT), or no opioid. We fit multivariable models assessing the primary outcome of primary care reattachment within 1 year, adjusting for demographic characteristics, clinical comorbidities, and health services utilization. Secondary outcomes included rates of emergency department (ED) visits and opioid toxicity events. Among 154,970 Ontarians who lost their PCP, 1,727 (1.1%) were OAT recipients, 3,644 (2.4%) were receiving long-term OPT, and 149,599 (96.5%) had no recent prescription opioid exposure. In general, OAT recipients were younger (median age 36) than those receiving long-term OPT (59 years) and those with no recent prescription opioid exposure (44 years). In all exposure groups, the majority of individuals had their enrolment terminated by their physician (range 78.1% to 88.8%). In the primary analysis, as compared to those not receiving opioids, OAT recipients were significantly less likely to find a PCP within 1 year (adjusted hazard ratio [aHR] 0.55, 95% confidence interval [CI] 0.50 to 0.61, p < 0.0001). We observed no significant difference between long-term OPT and opioid unexposed individuals (aHR 0.96; 95% CI 0.92 to 1.01, p = 0.12). In our secondary analysis comparing the period of PCP loss to the year prior, we found that rates of ED visits were elevated among people not receiving opioids (adjusted rate ratio (aRR) 1.20, 95% CI 1.18 to 1.22, p < 0.0001) and people receiving long-term OPT (aRR 1.37, 95% CI 1.28 to 1.48, p < 0.0001). We found no such increase among OAT recipients, and no significant increase in opioid toxicity events in the period following provider loss for any exposure group. The main limitation of our findings relates to their generalizability outside of PEMs and in jurisdictions with different financial incentives incorporated into primary care provision. CONCLUSIONS: In this study, we observed gaps in access to primary care among people who receive prescription opioids, particularly among OAT recipients. Ongoing efforts are needed to address the stigma, discrimination, and financial disincentives that may introduce barriers to the healthcare system, and to facilitate access to high-quality, consistent primary care services for chronic pain patients and those with OUD.

Testicular cancer follow-up costs in Germany from 2000 to 2015.

PURPOSE: Advances in testicular cancer screening and therapy increased 10-year survival to 97% despite a rising incidence; eventually expanding the population of survivors requiring follow-up. We analyzed 10-year follow-up costs after testicular cancer treatment in Germany during 2000, 2008, and 2015. METHODS: Testicular cancer follow-up guidelines were extracted from the European Association of Urology. Per patient costs were estimated with a micro-costing approach considering direct and indirect medical expenses derived from expert interviews, literature research, and official scales of tariffs. Three perspectives covering costs for patients, providers, and insurers were included to estimate societal costs. Cost progression was compared across cancer histology, stage, stakeholders, resource use, and follow-up years. RESULTS: Mean 10-year follow-up costs per patient for stage I seminomatous germ-cell tumors (SGCT) on surveillance declined from EUR 11,995 in 2000 to EUR 4,430 in 2015 (p < 0.001). Advanced SGCT spending shrank from EUR 13,866 to EUR 9,724 (p < 0.001). In contrast, expenditure for stage II SGCT increased from EUR 7,159 to EUR 9,724 (p < 0.001). While insurers covered 32% of costs in 2000, only 13% of costs were reimbursed in 2015 (p < 0.001). 70% of SGCT follow-up resources were consumed by medical imaging (x-ray, CT, ultrasound, FDG-PET). Spending was unevenly distributed across follow-up years (years 1-2: 50%, years 3-5: 39%, years 5-10: 11%). CONCLUSIONS: The increasing prevalence of testicular cancer survivors caused German statutory insurers to cut per patient cost by up to 80% by budgeting services and decreasing reimbursement rates. The economic burden was gradually redistributed to patients and providers.

Length of Stay Beyond Medical Readiness in a Neurosurgical Patient Population and Associated Healthcare Costs.

BACKGROUND: Length of stay beyond medical readiness (LOS-BMR) leads to increased expenses and higher morbidity related to hospital-acquired conditions. OBJECTIVE: To determine the proportion of admitted neurosurgical patients who have LOS-BMR and associated risk factors and costs. METHODS: We performed a prospective, cohort analysis of all neurosurgical patients admitted to our institution over 5 mo. LOS-BMR was assessed daily by the attending neurosurgeon and neuro-intensivist with a standardized criterion. Univariate and multivariate logistic regressions were performed. RESULTS: Of the 884 patients admitted, 229 (25.9%) had a LOS-BMR. The average LOS-BMR was 2.7 ± 3.1 d at an average daily cost of $9 148.28 ± $12 983.10, which resulted in a total cost of $2 076 659.32 over the 5-mo period. Patients with LOS-BMR were significantly more likely to be older and to have hemiplegia, dementia, liver disease, renal disease, and diabetes mellitus. Patients with a LOS-BMR were significantly more likely to be discharged to a subacute rehabilitation/skilled nursing facility (40.2% vs 4.1%) or an acute/inpatient rehabilitation facility (22.7% vs 1.7%, P < .0001). Patients with Medicare insurance were more likely to have a LOS-BMR, whereas patients with private insurance were less likely (P = .048). CONCLUSION: The most common reason for LOS-BMR was inefficient discharge of patients to rehabilitation and nursing facilities secondary to unavailability of beds at discharge locations, insurance clearance delays, and family-related issues.

Project 20: Midwives' insight into continuity of care models for women with social risk factors: what works, for whom, in what circumstances, and how.

INTRODUCTION: Continuity of care models are known to improve clinical outcomes for women and their babies, but it is not understood how. A realist synthesis of how women with social risk factors experience UK maternity care reported mechanisms thought to improve clinical outcomes and experiences. As part of a broader programme of work to test those theories and fill gaps in the literature base we conducted focus groups with midwives working within continuity of care models of care for women with social factors that put them at a higher chance of having poor birth outcomes. These risk factors can include poverty and social isolation, asylum or refugee status, domestic abuse, mental illness, learning difficulties, and substance abuse problems. OBJECTIVE: To explore the insights of midwives working in continuity models of care for women with social risk factors in order to understand the resources they provide, and how the model of care can improve women's outcomes. DESIGN: Realist methodology was used to gain a deeper understanding of how women react to specific resources that the models of care offer and how these resources are thought to lead to particular outcomes for women. Twelve midwives participated, six from a continuity of care model implemented in a community setting serving an area of deprivation in London, and six from a continuity of care model for women with social risk factors, based within a large teaching hospital in London. FINDINGS: Three main themes were identified: 'Perceptions of the model of care, 'Tailoring the service to meet women's needs', 'Going above and beyond'. Each theme is broken down into three subthemes to reveal specific resources or mechanisms which midwives felt might have an impact on women's outcomes, and how women with different social risk factors respond to these mechanisms. CONCLUSIONS/IMPLICATIONS FOR PRACTICE: Overall the midwives in both models of care felt the service was beneficial to women and had a positive impact on their outcomes. It was thought the trusting relationships they had built with women enabled midwives to guide women through a fragmented, unfamiliar system and respond to their individual physical, emotional, and social needs, whilst ensuring follow-up of appointments and test results. Midwives felt that for these women the impact of a trusting relationship affected how much information women disclosed, allowing for enhanced, needs led, holistic care. Interesting mechanisms were identified when discussing women who had social care involvement with midwives revealing techniques they used to advocate for women and help them to regain trust in the system and demonstrate their parenting abilities. Differences in how each team provided care and its impact on women's outcomes were considered with the midwives in the community-based model reporting how their location enabled them to help women integrate into their local community and make use of specialist services. The study demonstrates the complexity of these models of care, with midwives using innovative and compassionate ways of working to meet the multifaceted needs of this population.

Salud digital: una estrategia de continuidad asistencial para personas con enfermedades no transmisibles durante la COVID-19 / Digital Health: a strategy to maintain health care for people living with noncommunicable diseases during COVID-19 / Saúde Digital: uma estratégia para manter a assistência à saúde de pessoas que vivem com doenças não transmissíveis durante a pandemia de COVID-19

Las enfermedades no transmisibles (ENT) son la primera causa de muerte y discapacidad en el mundo. El tratamiento eficaz de estos trastornos crónicos depende en gran medida de la continuidad de unos servicios receptivos, accesibles y de calidad, así como de la participación de los pacientes y su autocuidado. Está comprobado que la salud digital ­en particular la telemedicina y las historias clínicas y recetas electrónicas­ es ventajosa para resguardar la continuidad de la atención, especialmente cuando hay alteraciones de los servicios, además de facilitar el seguimiento y evaluación de las intervenciones contra las ENT

Noncommunicable diseases (NCDs) are the main cause of death and disability worldwide. Effective management of these chronic conditions depends largely on continuous, responsive, accessible, and quality services and successful patient engagement and self-management. Digital health, and in particular telemedicine visits, electronic records, and electronic prescriptions, have already demonstrated having advantages in successfully ensuring continuity of care, especially when services are disrupted, as well as monitoring and evaluating interventions for NCDs

As doenças não transmissíveis (DNTs) são a principal causa de morte e incapacidade em todo o mundo. O controle eficaz dessas doenças crônicas depende em grande parte de serviços continuados, responsivos, acessíveis e de qualidade, além de engajamento e autocontrole satisfatórios por parte dos pacientes. A saúde digital, em especial as teleconsultas médicas, os prontuários eletrônicos e as prescrições eletrônicas, já demonstrou ser vantajosa para assegurar a continuidade da assistência, principalmente quando os serviços são interrompidos, além do monitoramento e da avaliação de intervenções em DNTs

Inpatient Addiction Medicine Consultation and Post-Hospital Substance Use Disorder Treatment Engagement: a Propensity-Matched Analysis.

BACKGROUND: Hospitalizations due to medical and surgical complications of substance use disorder (SUD) are rising. Most hospitals lack systems to treat SUD, and most people with SUD do not engage in treatment after discharge. OBJECTIVE: Determine the effect of a hospital-based addiction medicine consult service, the Improving Addiction Care Team (IMPACT), on post-hospital SUD treatment engagement. DESIGN: Cohort study using multivariable analysis of Oregon Medicaid claims comparing IMPACT patients with propensity-matched controls. PARTICIPANTS: 18-64-year-old Oregon Medicaid beneficiaries with SUD, hospitalized at an Oregon hospital between July 1, 2015, and September 30, 2016. IMPACT patients (n = 208) were matched to controls (n = 416) using a propensity score that accounted for SUD, gender, age, race, residence region, and diagnoses. INTERVENTIONS: IMPACT included hospital-based consultation care from an interdisciplinary team of addiction medicine physicians, social workers, and peers with lived experience in recovery. IMPACT met patients during hospitalization; offered pharmacotherapy, behavioral treatments, and harm reduction services; and supported linkages to SUD treatment after discharge. OUTCOMES: Healthcare Effectiveness Data and Information Set (HEDIS) measure of SUD treatment engagement, defined as two or more claims on two separate days for SUD care within 34 days of discharge. RESULTS: Only 17.2% of all patients were engaged in SUD treatment before hospitalization. IMPACT patients engaged in SUD treatment following discharge more frequently than controls (38.9% vs. 23.3%, p < 0.01; aOR 2.15, 95% confidence interval [CI] 1.29-3.58). IMPACT participation remained associated with SUD treatment engagement when limiting the sample to people who were not engaged in treatment prior to hospitalization (aOR 2.63; 95% CI 1.46-4.72). CONCLUSIONS: Hospital-based addiction medicine consultation can improve SUD treatment engagement, which is associated with reduced substance use, mortality, and other important clinical outcomes. National expansion of such models represents an opportunity to address an enduring gap in the SUD treatment continuum.

Progress towards universal health coverage in the context of rheumatic diseases in India.

AIM: This study aims to measure current situation with regard to access and financial protection towards healthcare for rheumatic diseases (RDs) in India. METHOD: The first part of this study is quantitative, and uses the data generated by the 71st Round of National Sample Survey 2014, which measured self-reported morbidity, choice of provider and utilization of services and out of pocket expenditure (OOPE) incurred on healthcare services in a sample of 65 932 households and 333 104 individuals from all across India. The second qualitative part of the study was done in one sample district to understand the barriers to access and financial protection. RESULTS: 3.5% of all hospitalizations in the preceding one year and 9.9% of all ambulatory care in the preceding 15 days of this study period were due to RDs. Cost of care for RDs was three times higher in private sector. Cost on medicines comprised the largest share in both sectors. 54% of the households faced catastrophic health expenditure at 10% threshold (CHE-10) and this was nine times higher in private provisioning (OR: 8.8, CI: 6.8-11.4). 24% of the households had to borrow or sell household assets to meet the hospitalization expenditure. Insurance had marginal impact and it did not help in preventing household from facing CHE-10 for the lowermost three economic quintiles. There was significant unmet health care needs and lack of continuity of care of RDs in India. CONCLUSION: Addressing the gaps in access and financial protection for patients with RDs need greater emphasis in policy as well as implementation, if the country has to achieve Universal Health Coverage.

Site of Death, Place of Care, and Health Care Transitions Among US Medicare Beneficiaries, 2000-2015.

Importance: End-of-life care costs are high and decedents often experience poor quality of care. Numerous factors influence changes in site of death, health care transitions, and burdensome patterns of care. Objective: To describe changes in site of death and patterns of care among Medicare decedents. Design, Setting, and Participants: Retrospective cohort study among a 20% random sample of 1 361 870 decedents who had Medicare fee-for-service (2000, 2005, 2009, 2011, and 2015) and a 100% sample of 871 845 decedents who had Medicare Advantage (2011 and 2015) and received care at an acute care hospital, at home or in the community, at a hospice inpatient care unit, or at a nursing home. Exposures: Secular changes between 2000 and 2015. Main Outcomes and Measures: Medicare administrative data were used to determine site of death, place of care, health care transitions, which are changes in location of care, and burdensome patterns of care. Burdensome patterns of care were based on health care transitions during the last 3 days of life and multiple hospitalizations for infections or dehydration during the last 120 days of life. Results: The site of death and patterns of care were studied among 1 361 870 decedents who had Medicare fee-for-service (mean [SD] age, 82.8 [8.4] years; 58.7% female) and 871 845 decedents who had Medicare Advantage (mean [SD] age, 82.1 [8.5] years; 54.0% female). Among Medicare fee-for-service decedents, the proportion of deaths that occurred in an acute care hospital decreased from 32.6% (95% CI, 32.4%-32.8%) in 2000 to 19.8% (95% CI, 19.6%-20.0%) in 2015, and deaths in a home or community setting that included assisted living facilities increased from 30.7% (95% CI, 30.6%-30.9%) in 2000 to 40.1% (95% CI, 39.9%-30.3% ) in 2015. Use of the intensive care unit during the last 30 days of life among Medicare fee-for-service decedents increased from 24.3% (95% CI, 24.1%-24.4%) in 2000 and then stabilized between 2009 and 2015 at 29.0% (95% CI, 28.8%-29.2%). Among Medicare fee-for-service decedents, health care transitions during the last 3 days of life increased from 10.3% (95% CI, 10.1%-10.4%) in 2000 to a high of 14.2% (95% CI, 14.0%-14.3%) in 2009 and then decreased to 10.8% (95% CI, 10.6%-10.9%) in 2015. The number of decedents enrolled in Medicare Advantage during the last 90 days of life increased from 358 600 in 2011 to 513 245 in 2015. Among decedents with Medicare Advantage, similar patterns in the rates for site of death, place of care, and health care transitions were observed. Conclusions and Relevance: Among Medicare fee-for-service beneficiaries who died in 2015 compared with 2000, there was a lower likelihood of dying in an acute care hospital, an increase and then stabilization of intensive care unit use during the last month of life, and an increase and then decline in health care transitions during the last 3 days of life.

Impact of Agency Receipt of Incentives and Reminders on Engagement and Continuity of Care for Clients With Co-Occurring Disorders.

OBJECTIVE: This study examined whether having co-occurring substance use and mental disorders influenced treatment engagement or continuity of care and whether offering financial incentives, client-specific electronic reminders, or a combination to treatment agencies improved treatment engagement and continuity of care among clients with co-occurring disorders. METHODS: The study used a randomized cluster design to assign agencies (N=196) providing publicly funded substance use disorder treatment in Washington State to a research arm: incentives only, reminders only, incentives and reminders, and a control condition. Data were analyzed for 76,044 outpatient, 32,797 residential, and 39,006 detoxification admissions from Washington's treatment data system. Multilevel logistic regressions were conducted, with clients nested within agencies, to examine the effect of the interventions on treatment engagement and continuity of care. RESULTS: Compared with clients with a substance use disorder only, clients with co-occurring disorders were less likely to engage in outpatient treatment or have continuity of care after discharge from residential treatment, but they were more likely to have continuity of care after discharge from detoxification. The interventions did not influence treatment engagement or continuity of care, except the reminders had a positive impact on continuity of care after residential treatment among clients with co-occurring disorders. CONCLUSIONS: In general, the interventions did not result in improved treatment engagement or continuity of care. The limited number of significant results supporting the influence of incentives and alerts on treatment engagement and continuity of care add to the mixed findings reported by previous research. Multiple interventions may be needed for performance improvement.

Agency-level financial incentives and electronic reminders to improve continuity of care after discharge from residential treatment and detoxification.

BACKGROUND: Despite the importance of continuity of care after detoxification and residential treatment, many clients do not receive further treatment services after discharged. This study examined whether offering financial incentives and providing client-specific electronic reminders to treatment agencies lead to improved continuity of care after detoxification or residential treatment. METHODS: Residential (N = 33) and detoxification agencies (N = 12) receiving public funding in Washington State were randomized into receiving one, both, or none (control group) of the interventions. Agencies assigned to incentives arms could earn financial rewards based on their continuity of care rates relative to a benchmark or based on improvement. Agencies assigned to electronic reminders arms received weekly information on recently discharged clients who had not yet received follow-up treatment. Difference-in-difference regressions controlling for client and agency characteristics tested the effectiveness of these interventions on continuity of care. RESULTS: During the intervention period, 24,347 clients received detoxification services and 20,685 received residential treatment. Overall, neither financial incentives nor electronic reminders had an effect on the likelihood of continuity of care. The interventions did have an effect among residential treatment agencies which had higher continuity of care rates at baseline. CONCLUSIONS: Implementation of agency-level financial incentives and electronic reminders did not result in improvements in continuity of care, except among higher performing agencies. Alternative strategies at the facility and systems levels should be explored to identify ways to increase continuity of care rates in specialty settings, especially for low performing agencies.

Charting A Pathway To Better Health.

In Toledo and other communities nationwide, a new approach to care coordination is reaching patients where they live.

Increasing the Continuity of Care between Primary Care Provider and a Psychiatric Hospital in Singapore.

INTRODUCTION: People who have a mental illness and who are stable on their current treatment may be suitable for follow-up care with a community-based general practitioner. A general practitioner-partnership programme was designed in an institute in Singapore to facilitate the transition to community services. However, the rates of successful referrals were low. METHODS: Our study followed the format of a quality improvement project, and used administrative data from April 2014 to June 2016 to gauge the impact of the interventions chosen to improve uptake of referrals. Three potential areas of improvement were found based on interviews with 25 service users. RESULTS: During the 11 months of pre-intervention period (April 2014 to February 2015), 64% of potentially suitable service users (152 of 238 referrals) transitioned to community services. Low transition was linked to 3 identified causes and consequently, case managers developed personalised financial counselling for service users, assisted in the application for financial supports, and dispelled misconceptions about service provider inability to treat mental illness. Over the 16 months of intervention period (March 2015 to June 2016), the follow-up rate for referrals rose to 92% (260 / 283 referrals). CONCLUSION: Given that financial support entitlements change, it is important for case managers to remain aware of changing policy. Misconceptions of service provider qualifications may have a great impact on service user's willingness to seek services from primary care providers.

A Randomized Controlled Trial of a Citywide Emergency Department Care-Coordination Program to Reduce Prescription Opioid-Related Visits: An Economic Evaluation.

BACKGROUND: Care provided in the emergency department (ED) can cost up to five times as much as care received for comparable diagnoses in alternative settings. Small groups of patients, many of whom suffer from an opioid use disorder, often account for a large proportion of total ED visits. We recently conducted, and demonstrated the effectiveness of, the first randomized controlled trial of a citywide ED care-coordination program intending to reduce prescription-opioid-related ED visits. All EDs in the metropolitan study area were connected to a Web-based information exchange system. OBJECTIVE: The objective of this article was to perform an economic evaluation of the 12-month trial from a third-party-payer perspective. METHODS: We modeled the person-period monthly for the 12-month observation period, and estimated total treatment costs and return on investment (ROI) with regard to cost offsets, over time, for all visits where the patient was admitted to and discharged from the ED. RESULTS: By the end of month 4, the mean cumulative cost differential was significantly lower for intervention relative to treatment-as-usual participants (-$1370; p = 0.03); this figure climbed to -$3200 (p = 0.02) by the end of month 12. The ROI trended upward throughout the observation period, but failed to reach statistical significance by the end of month 12 (ROI = 3.39, p = 0.07). CONCLUSION: The intervention produced significant cost offsets by the end of month 4, which continued to accumulate throughout the trial; however, ROI was not significant. Because the per-patient administrative costs of the program are incurred at the time of enrollment, our results highlight the importance of future studies that are able to follow participants for a period beyond 12 months to more accurately estimate the program's ROI.

Are Nurse Leaders Prepared to Lead Across the Continuum of Care in the New Paradigm?

The movement toward linking reimbursement with outcomes necessitates providing care across a continuum of settings, leading to the need for a new healthcare paradigm. Issues related to shifting to this new paradigm include disagreement about what this paradigm encompasses, the fragmentation of the healthcare system, and overreliance on the medical model as a framework for driving health policy decisions. We advocate for nurse leaders to guide the development of this new paradigm.

A pilot randomised trial of community-based care following discharge from hospital with a recent spinal cord injury in Bangladesh.

OBJECTIVES: To explore the feasibility of conducting a full trial designed to determine the effectiveness of a model of community-based care for people with spinal cord injury in Bangladesh. STUDY DESIGN: A pilot randomised trial. SETTING: Community, Bangladesh. SUBJECTS: Participants were 30 people with recent spinal cord injury who were wheelchair-dependent and soon to be discharged from hospital. INTERVENTION: Participants randomised to the intervention group received a package of care involving regular telephone contact and three home visits over two years. Participants randomised to the control group received usual care consisting of a telephone call and an optional home visit. MAIN MEASURES: Participants were assessed at baseline and two years after randomization. The primary outcome was mortality and secondary outcomes were measures of complications, depression, participation and quality of life. RESULTS: A total of 24 participants had a complete spinal cord injury and six participants had an incomplete spinal cord injury. Median (interquartile) age and time since injury at baseline were 31 years (24 to 36) and 7 months (4 to 13), respectively. Two participants, one in each group, died. Five participants had pressure ulcers at two years. There were no notable impediments to the conduct of the trial and no significant protocol violations. The phone calls and home visits were delivered according to the protocol 87% and 100% of the time, respectively. Follow-up data were 99% complete. CONCLUSION: This pilot trial demonstrates the feasibility of a full clinical trial of 410 participants, which has recently commenced. SPONSORSHIP: University of Sydney, Australia.

Patient empanelment: A strategy to improve continuity and quality of patient care.

PROBLEM: In some Federally-Qualified Community Health Centers (FQHCs), patients do not have a designated primary care provider (PCP). Patients see any provider who is available. This leads to fragmented care, poorer outcomes, and higher costs. DESIGN: Patients were empaneled to a designated PCP. Continuity, quality, and efficiency measures were collected at baseline, 6-, and 12-months postempanelment. BACKGROUND AND SETTING: Three rural FQHCs on the coast of Northern California performing about 18,000 patient visits annually. KEY MEASURES FOR IMPROVEMENT: Patient cycle time, percentage of patient visits with designated PCPs, completion of cervical and colorectal cancer screenings; blood pressure, low-density lipoprotein, and hemoglobin A1c control in patients with diabetes. STRATEGIES FOR CHANGE: The senior Leadership Team initiated the patient empanelment project with the assistance of an outside consultant. EFFECTS OF CHANGE: After 12 months, 100% of the FQHC's patients were assigned a PCP and saw that provider on ≥63% of visits. Quality indicators improved by an average of 9% and cycle time decreased by 12 min. per patient allowing providers to see approximately four more patients and generate an additional $2212 per day. LESSONS LEARNT: Project outcomes supported the importance of a designated PCP to achieve improved quality and efficiency of care.