Project ECHO® in Primary Care: Informing Providers about COVID-19 and Its Impact on Health Care Delivery.

BACKGROUND Rural, primary care providers face particular challenges with adapting the delivery of care in the setting of the Coronavirus Disease of 2019 (COVID-19) pandemic. Project ECHO® is a virtual, case-based platform centered on collective learning. As a regional Area Health Education Center (AHEC), we developed two Project ECHO® series aimed at disseminating best practices and creating a community of shared experiences for rural providers.METHODS On March 30, 2020, we launched two Project ECHO® series pertaining to COVID-19: the Primary Care COVID-19 Collaborative series and the Practice Support for COVID-19 Preparedness series. These series each occurred twice weekly, concluding in February 2021, and were free to attend. Topics include COVID-19-specific management as well as strategies for adapting the delivery of care during the pandemic. We assessed engagement per county as well as attendee evaluations.RESULTS In the first month, we hosted 19 sessions with 283 participants from 37 counties in North Carolina. Providers felt the most impactful aspects of the sessions were the changes to their practice and the lateral learning from peers in the region.LIMITATIONS In review of our survey responses, a small percentage of our participants do not appear to have direct patient care roles, so we believe this impacted our survey results particularly in regard to relevance to clinical practice and change to clinical practice.CONCLUSIONS Project ECHO® is an effective platform for quickly disseminating information and creating a sense of community in the midst of the social distancing required during the pandemic.

Geographical variation in surgical care and mortality following hip fracture in England: a cohort study using the National Hip Fracture Database (NHFD).

We describe variation across geographical regions of England in operations undertaken following presentation of hip fracture and in 30-day mortality. Some significant geographic variation in 30-day mortality was observed particularly for patients with trochanteric hip fractures and warrants further investigation of other aspects of post-hip fracture care INTRODUCTION: Mortality after hip fracture has improved considerably in the UK over recent decades. Our aim here was to describe geographical variation in type of operation performed and 30-day mortality amongst patients in England with hip fracture. METHODS: The National Hip Fracture Database was used to carry out a prospective cohort study of nearly all over-60 year olds with hip fracture in England. These data were linked to Hospital Episode Statistics (HES), allowing us to explore regional variation in the operations performed for three fracture types (intracapsular, trochanteric and subtrochanteric), and use logistic regression models adjusted for demographic and clinical factors to describe associated 30-day mortality. RESULTS: NHFD recorded data for 64,211 patients who underwent surgery in England during 2017. Most had an intracapsular (59%) or trochanteric fracture (35%), and we found significant geographical variation across regions of England in use of total hip replacement (THR) (ranging from 10.1 to 17.4%) for intracapsular fracture and in intermedullary nailing (ranging from 14.9 to 27.0%) of trochanteric fracture. Some geographical variation in mortality amongst intracapsular fracture patients was found, with slightly higher mortality in the East of England (adjusted odds ratio [aOR]: 1.22, 95% CI: 1.02-1.46). Trochanteric fractures showed slightly more variation, with higher 30-day mortality (aOR: 1.40, 95%CI: 1.05-1.88) in the East of England and significantly lower mortality in the North East (aOR: 0.65, 95%CI: 0.46-0.93). CONCLUSIONS: We have identified regional differences in operation type and 30-day mortality amongst hip fracture patients in England. The relationship between surgical approach and mortality has been explored, but the extent to which differential mortality reflects variation in approach to medical assessment, anaesthesia and other aspects of care warrants further investigation.

A Cohort Comparison of Differences Between Regional and Buncombe County Patients of a Comprehensive Perinatal Substance Use Disorders Program in Western North Carolina.

BACKGROUND Pregnant patients from rural counties of Western North Carolina face additional barriers when accessing comprehensive perinatal substance use disorders care at Project CARA as compared to patients local to the program in Buncombe County. We hypothesized regional patients would be less engaged in care.METHOD Using a retrospective cohort design, univariate analyses (χ2, t-test; P < .05) compared patients' characteristics, engagement in care, and delivery outcomes. Engagement in care, the primary outcome, was operationalized as: attendance at expected, program-specific prenatal and postpartum visits, utilization of in-house counseling, community-based and/or inpatient substance use disorders treatment, and maternal urine drug screen at delivery negative for illicit substances.RESULTS Regional patients (n = 324) were more likely than Buncombe County patients (n = 284) to have opioid [209 (64.5%) versus 162 (57.0%)] or amphetamine/methamphetamine use disorders (25 [7.7%] versus 13 [4.6%]), but less likely to have cannabis use (19 [5.9%] versus 38 [13.4%]; P = .009) and concurrent psychiatric disorders (214 [66.0%] versus 220 [77.5%]; P = .002). Engagement at postpartum visits was the significantly different outcome between patients (110/221 [49.8%] versus 146/226 [64.6%]; P = .002).LIMITATIONS Outcomes were available for 66.8% of regional and 79.6% of Buncombe County patients of one program in one predominately white, non-Hispanic region of the state.CONCLUSION Contrary to our hypothesis, regional and Buncombe County women engaged in prenatal care equally. However, a more formal transition into the postpartum period is needed, especially for regional women. A "hub-and-spokes" model that extends delivery of perinatal substance use disorders care into rural communities may be more effective for engagement retention.

A case-comparison study of pregnant women with mitochondrial disease - what to expect?

OBJECTIVE: Mitochondrial disease is a disorder of energy metabolism that affects 1 in 4300 adults in the UK. Pregnancy is associated with physiological demands that have implications for energy metabolism. We were interested to know how pregnancy was affected in women with mitochondrial disease, particularly those with the most common pathogenic mutation m.3243A>G. DESIGN: Retrospective case-comparison study. POPULATION/SETTING: Sixty-seven women with genetically confirmed mitochondrial disease from the UK Mitochondrial Diseases Cohort and 69 unaffected women participated. METHODS: Participants answered questionnaires regarding each of their pregnancies. Patients were divided into two groups according to genetic mutation, with those harbouring m.3243A>G comprising a single group. MAIN OUTCOME MEASURES: Pregnancy-related complications, mode of delivery, gestational age and birthweight of newborns. RESULTS: Of 139 live births in the comparison group, 62 were in the m.3243A>G group and 87 were in the 'all other mutations' group. Pregnancies of women with the m.3243A>G mutation had significantly more gestational diabetes (odds ratio [OR] = 8.2, 95% CI 1.3-50.1), breathing difficulties (OR = 7.8, 95% CI 1.0-59.1) and hypertension (OR = 8.2, 95% CI 3.1-21.5) than the comparison group. Only half of the pregnancies in the m.3243A>G group had normal vaginal delivery, with emergency caesarean section accounting for 24.2% of deliveries. Babies were born significantly earlier to mothers harbouring m.3243A>G with 53.3% of them preterm (<37 weeks). These babies were also more likely to require resuscitation and admission. CONCLUSION: Women who carried the m.3243A>G mutation appeared to be at higher risk of complications during pregnancies, caesarean section and preterm delivery than the unaffected women or those with other forms of mitochondrial disease. TWEETABLE ABSTRACT: Pregnant women with mitochondrial disease - m.3243A>G mutation - are at greatly increased risk of complications and preterm delivery.

Evaluation of a pharmacist-led naloxone coprescribing program in primary care.

OBJECTIVES: To determine the impact of a pharmacist-led coprescribing initiative on patient access to naloxone in a primary care setting. SETTING: Family medicine residency practice with embedded pharmacists in western North Carolina. PRACTICE INNOVATION: In June 2016, clinical pharmacists embedded in a primary care clinic initiated a naloxone coprescribing initiative with the aim of increasing access to naloxone for patients on chronic opioid therapy who were on 50 mg or greater morphine-equivalents daily (MED), on a concomitant benzodiazepine, had a history of an overdose, or had a diagnosis of a substance use disorder. Pharmacists' roles included educating providers and clinical staff regarding naloxone, creating quick links within the electronic health record to more easily prescribe naloxone, identifying patients who met criteria for naloxone, and counseling patients about naloxone. EVALUATION: This study was a single-cohort pre- and postintervention study. One year after initiation of the program, data were manually collected to assess the rates of naloxone prescribing and the reason for requiring naloxone. In addition, pharmacy students called pharmacies to determine fill rates and obtain reasons given by patients for not filling naloxone. RESULTS: A total of 234 patients remained candidates for naloxone at the end of 1 year. Naloxone coprescribing increased from 3.4% at baseline to 37.2% at follow-up (P = 0.0001). Seventy-one percent of patients required naloxone because of chronic opioid therapy doses of 50 mg or more MED, 55% were on a benzodiazepine, 6% had a diagnosis of a substance use disorder, and 1% had a history of overdose. Of the patients who received a naloxone prescription, 31.4% filled it. CONCLUSION: Embedded clinical pharmacists in primary care have the potential to increase naloxone coprescribing for high-risk patients treated with chronic opioid therapy for pain.

Genetic risk factors for cognitive decline in Parkinson's disease: a review of the literature.

Parkinson's disease is a highly heterogeneous disorder, where genetic factors are likely to contribute to clinical variability, including susceptibility to cognitive impairment and dementia. Monogenic forms of parkinsonism show distinct cognitive profiles, yet less is known about the impact of common genetic variants on cognition in sporadic Parkinson's disease. In a systematic review of the literature, the current results from genetic association studies of cognitive outcomes are summarized and prospects and challenges for future studies are discussed. Literature searches of the PubMed database were performed and studies using statistical methods to assess associations between genetic variation and any cognitive outcome in Parkinson's disease patients were included. For each of the candidate loci investigated in several studies, the current evidence is summarized and discussed. Sixty-one articles meeting our inclusion criteria were identified, which were highly heterogeneous with respect to study design, size and cognitive outcome measures. GBA mutations have a negative impact on cognition, whereas LRRK2-associated disease may have a milder cognitive phenotype than idiopathic Parkinson's disease. For common variants, reported results are partly conflicting, even across the larger studies, with some evidence to suggest a potential effect of APOE, MAPT, COMT and SNCA on cognitive outcomes. Future investigations should aim to collect high-quality cognitive data in a standardized way that allows for direct comparison across studies and large-scale meta-analysis. Linking genetic profiles to cognitive outcomes may have an important clinical impact, facilitating the stratification of patients for clinical trials and, ultimately, individualized treatment in Parkinson's disease.

Development of a targeted naloxone coprescribing program in a primary care practice.

OBJECTIVES: To develop a targeted naloxone coprescribing program in a primary care practice. SETTING: Large academic family medicine practice in western North Carolina. PRACTICE DESCRIPTION: A robust pain management program was developed at this institution in 2012 which incorporated many of the recommendations later outlined in the 2016 Centers for Disease Control and Prevention (CDC) guidelines for prescribing opioids for chronic pain. The only guideline-recommended initiative that was not addressed involves providing naloxone to patients on chronic opioid therapy at high risk for opioid overdose. PRACTICE INNOVATION: Pharmacists embedded in this practice developed a targeted naloxone coprescribing program for patients who are on chronic opioid therapy and have doses of 50 mg or more morphine equivalents daily (MED), are taking benzodiazepines, have a history of substance use disorder, or have a history of overdose. EVALUATION: A retrospective chart review was conducted to determine the number of patients on chronic opioid therapy who meet the CDC guidelines for offering naloxone. RESULTS: A total of 1297 patients were identified, and 709 met the criteria for chronic opioid use. Nearly one-half (n = 350; 49.4%) of these patients met the criteria for naloxone, although only 3.4% had naloxone on their medication list. Doses of 50 mg or more MED was the primary reason for needing naloxone (n = 216; 61%) with concomitant benzodiazepine use as the second most likely reason (n = 130; 37.1%). For patients taking 50 mg or more MED, 37.5% were also on a benzodiazepine and 4.1% also had a history of substance use disorder. CONCLUSION: Pharmacists embedded in a primary care practice are well poised to develop a targeted naloxone coprescribing program to increase patients' access to naloxone.

Evaluation of a Team-Based, Transition-of-Care Management Service on 30-Day Readmission Rates.

BACKGROUND: Transitions of care from the hospital to the outpatient setting often fail to meet the Triple Aim of improving quality, improving the health of populations, and decreasing the cost of care. A major push to improve the quality of transitions and reduce hospital readmissions is under way. METHODS: We implemented a team-based, transition-of-care model and assessed the impact on 30-day readmission rates. The 3 components of the intervention were contact with a nurse care manager, medication reconciliation, and follow-up with a physician. We compared 30-day readmission rates for the period before versus after implementation of this intervention. RESULTS: The 30-day readmission rate decreased from 14.2% in the usual care group to 5.3% in the intervention group (P = .011). Almost 90% of patients in the intervention group received all 3 components of the intervention. LIMITATIONS: Generalizability is limited to practices with embedded team members. Not all patients received all 3 components of the intervention. CONCLUSIONS: Development of a team-based intervention was associated with a significant reduction in hospital readmissions. This method could be implemented in other primary care offices with team-based care.

A Financial Model for Team-Based Opioid Use Disorder Treatment.

INTRODUCTION: Opioid use disorder (OUD) affects 2 million Americans, yet many patients do not receive treatment. Lack of team-based care is a common barrier for office-based opioid treatment (OBOT). In 2015, we started OBOT in a family medicine practice. Based on our experiences, we developed a financial model for hiring a team member to provide nonbillable OBOT services through revenue from increased patient volume. METHODS: We completed a retrospective chart review from July 2015 to December 2016 to determine the average difference in medical visits per patient per month pre-OBOT versus post-OBOT. Secondary outcomes were the percentage of visits coded as a Level 3, Level 4, and Level 5, and the percentage of patients with Medicaid, private insurance, or self pay. With this information, we extrapolated to build a financial model to hire a team member to support OBOT. RESULTS: Twenty-three patients received OBOT during the study period. There was a net increase of 1.93 visits per patient per month (P < .001). Fourteen patients were insured by Medicaid, 7 had private insurance, and 2 were self pay. Twenty-three percent of OBOT visits were Level 3, 69% were Level 4, and 8% were Level 5. Assuming all visits were reimbursed by Medicaid and accounting for 20% cost of business, treating 1 existing patient for 1 year would generate $1,439. Treating 1 new patient would generate $1,677. CONCLUSIONS: In a fee-for-service model, the revenue generated from increased medical visits can offset the cost of hiring a team member to support nonbillable OBOT services.

The Value of Treating Opioid Use Disorder in Family Medicine: From the Patient Perspective.

INTRODUCTION: Despite evidence demonstrating that medications for opioid use disorder (OUD) reduce morbidity and mortality, the majority of patients do not receive treatment. The National Academies of Science call for more research exploring the patient's perspective of treatment modalities to increase access to individualized, patient-centered care. We aim to build on existing literature by describing patient experiences treated for OUD in a rural family medicine setting. METHODS: We employed a convenience sampling methodology to complete brief, structured interviews with thematic data analysis for 30 of 57 eligible patients receiving office-based opioid treatment (OBOT) in the primary care setting. RESULTS: Participants' experiences with OBOT were generally positive and shaped by societal structures and institutions, their life before treatment, their treatment history, and the kind of care they received in OBOT. Patients identified accessibility and privacy as advantages to receiving OBOT in primary care. DISCUSSION: This research identifies ways providers can provide individualized and effective OUD treatment within the family medicine setting.

The Impact on Future Prescribing Patterns of Opioid Use Disorder (OUD) Education and Waiver Provision During Residency.

BACKGROUND: Family medicine residency programs vary in the extent of training offered on opioid use disorder (OUD) in their curricula. The purpose of this study was to determine the impact of OUD education and buprenorphine waiver provision on postresidency buprenorphine prescribing patterns. METHODS: Three North Carolina family medicine residency programs differed in the extent to which they taught OUD, including buprenorphine waiver provision. Program A required OUD education and assisted residents in obtaining a waiver; Program B offered OUD education and did not assist with obtaining a waiver; and Program C did not offer OUD education. In November 2019, graduates from these 3 programs were surveyed regarding the extent to which they engaged in treatment of OUD. Descriptive statistics were used to characterize the survey participants and their responses. RESULTS: Of the 62 graduates invited to participate, 49 (79.0%) responded. Across the 3 programs, the percentage of graduates with a waiver varied significantly (P < .0001): Program A (84.2%), Program B (33.3%), and Program C (0.0%). Of those who were not waivered, Program B had a larger percentage that desired to prescribe buprenorphine products (70.0%) as compared with Program C (9.1%) (P = .009). CONCLUSIONS: Family medicine residency graduates from programs with more integrated OUD education were more likely to obtain and use a waiver to prescribe buprenorphine-containing medications postgraduation.

The cutest little baby face: a hormonal link to sensitivity to cuteness in infant faces.

We used computer image manipulation to develop a test of perception of subtle gradations in cuteness between infant faces. We found that young women (19-26 years old) were more sensitive to differences in infant cuteness than were men (19-26 and 53-60 years old). Women aged 45 to 51 years performed at the level of the young women, whereas cuteness sensitivity in women aged 53 to 60 years was not different from that of men (19-26 and 53-60 years old). Because average age at menopause is 51 years in Britain, these findings suggest the possible involvement of reproductive hormones in cuteness sensitivity. Therefore, we compared cuteness discrimination in pre- and postmenopausal women matched for age and in women taking and not taking oral contraceptives (progestogen and estrogen). Premenopausal women and young women taking oral contraceptives (which raise hormone levels artificially) were more sensitive to variations of cuteness than their respective comparison groups. We suggest that cuteness sensitivity is modulated by female reproductive hormones.

Knowledge, attitudes, and use of emergency contraception among Hispanic women of North Carolina.

INTRODUCTION: This project was designed to determine the knowledge, attitudes and self-reported use of emergency contraception (EC) of Spanish-speaking women of western North Carolina. MATERIALS AND METHODS: Using a cross-sectional survey, a convenience sample of patients completed the survey in exam or interview rooms of an obstetric and gynecology residency program in western North Carolina. Participants included 213 Spanish-speaking women of childbearing age (18 to 44-years-old) presenting for routine care between August 2004 and October 2006. RESULTS: Seventy percent of the sexually active respondents (N = 196) reported inconsistent use of birth control. Only 22% reporting knowing about EC; an additional 26% knew about the morning after pill. Overall, 12% reported previous use of EC. Very few (15%) reported a moral or religious objection to EC. Only 21% reported having discussed EC with a care provider. DISCUSSION: Considerable opportunity exists to expand patient education about all contraceptive options, including EC with Hispanic women of western North Carolina.

A survey of mothers' comfort discussing contraception with infant providers at well-child visits.

OBJECTIVE: To determine whether mothers feel comfortable with their infants' providers discussing contraception with them at their infants' well-child checks. METHODS: A cross-sectional survey was conducted using a convenience sample of 114 mothers presenting at a community family medicine residency program for well-child visits among infants up to 17 months old. RESULTS: Almost all mothers (87%) felt comfortable talking with their infants' providers about contraception and were likely to accept the advice of their infants' providers to see their own doctors regarding contraception (83%) or to use a prescription from their infants' providers for contraception (75%). CONCLUSION: Many mothers miss or delay their postpartum visits but see their infants' doctor multiple times within the first year. Mothers are comfortable talking with infant providers about contraception. By discussing contraception with mothers at well-child visits, physicians may encourage mothers to use contraception and prevent unintended pregnancies.

Teaching Opioid Tapering Through Guided Instruction.

BACKGROUND AND OBJECTIVES: Given the current opioid epidemic, national practice guidelines and many state laws are shifting the treatment paradigm for chronic, noncancer pain to a judicious use of opioids. This has prompted a need to teach family medicine residents how to appropriately taper opioids. We created a multifaceted approach to integrate teaching of opioid tapering into a family medicine curriculum with an emphasis on guided instruction. We assessed the degree to which this curriculum affected guideline-concordant opioid prescribing within the family medicine practice. METHODS: A retrospective chart review of 707 patients on chronic opioid therapy (COT) for noncancer pain was conducted before and after the incorporation of a guided instruction experience to the residency curriculum. The primary outcomes included the number of patients on chronic opioids, the average morphine equivalent daily (MED) per patient, the percentage of patients on >50 MED or >90 MED, and the number of patients on concomitant benzodiazepines. RESULTS: Of the original 707 patients, 188 tapered off COT. Of those remaining on COT, the average MED did not change (53.4±76.9 vs 58.5+89.1, P=0.053). The percentage of patients on >50 MED and >90 MED decreased significantly (30.6% vs 25.0%, P=0.001; 19.4% vs 14.0%, P=0.027). The total number of patients on concomitant benzodiazepine decreased from 212 to 131. CONCLUSIONS: Providing opportunities for guided instruction with opioid tapering allowed for an increased concordance with national practice guidelines.