Frequency of newborn bathing in the first 9 weeks of life and related factors: An observational study in a community-based sample from Meta-LARC.

PURPOSE: Environmental factors such as bathing may play a role in atopic dermatitis (AD) development. This analysis utilized data from the Community Assessment of Skin Care, Allergies, and Eczema (CASCADE) Trial (NCT03409367), a randomized controlled trial of emollient therapy for AD prevention in the general population, to estimate bathing frequency and associated factors within the first 9 weeks of life. METHODS: Data were collected from 909 parent/newborn dyads recruited from 25 pediatric and family medicine clinics from the Meta-network Learning and Research Center (Meta-LARC) practice-based research network (PBRN) consortium in Oregon, North Carolina, Colorado, and Wisconsin for the CASCADE trial. Ordinal logistic regression was used to conduct a cross-sectional analysis of the association between bathing frequency (measured in baths per week) and demographic, medical, and lifestyle information about the infant, their family, and their household. Variables were selected using a backwards-stepwise method and estimates from the reduced model are reported in the text. RESULTS: Moisturizer use (OR = 2.03, 95% CI: 1.54-2.68), Hispanic or Latino ethnicity (OR = 1.97, 95% CI: 1.42-2.72), a parental education level lower than a 4-year college degree (OR = 2.48, 95% CI: 1.70-3.62), living in North Carolina or Wisconsin (compared to Oregon; OR = 2.12 and 1.47, 95% CI: 1.53-2.93 and 1.04-2.08, respectively), and increasing child age (in days; OR = 1.02, 95% CI: 1.01-1.02) were significantly associated with more frequent bathing, while pet ownership (OR = 0.67, 95% CI: 0.52-0.87) was significantly associated with less frequent bathing. CONCLUSIONS: We found significant ethnic, geographic, and socioeconomic variation in bathing frequency before 9 weeks of age that may be of relevance to AD prevention studies.

Relationship of primary care clinician characteristics with continuous glucose monitoring use and confidence.

Context: Continuous glucose monitoring (CGM) provides clearer readings of blood glucose levels than traditional finger-stick glucose tests and is associated with improved diabetes outcomes such as reduced HbA1c. CGM can inform insulin dosing and diet decisions, and alert patients to hypoglycemia. A lack of endocrinologists in the majority of U.S. counties, particularly rural areas, and long wait times in many endocrinologists' offices create disparities in CGM access for patients with diabetes. Expanding use of CGM in primary care can improve care and patient diabetes outcomes. Objective: Understand primary care clinicians' experience with CGM to determine feasibility and resources needed to prescribe CGM. Study Design: Quantitative phase of explanatory sequential mixed methods study using cross-sectional online survey. Setting: Primary care. Population studied: Primary care physicians and advanced practice providers across the U.S. Outcome Measures: Past CGM prescribing behaviors, future likelihood to prescribe, resources needed to prescribe. Results: 632 respondents. Role: 72% attending physicians. Organization: Federally Qualified Health-Center (or similar) (27%), hospital-owned (27%), private practice (22%). Half (47%) had seen patients with CGM but never prescribed; two-fifths (39%) had prescribed CGM. Three-fifths (62%) moderately or very likely to prescribe CGM in the future. Likelihood to have prescribed CGM: Post-training physicians more likely than residents (OR=0.303, CI=.160-.575) or PA/NPs (OR=0.356, CI=.165-.766), part-time practice less likely than full-time (OR=0.546, CI=.305-.978), <75% time delivering primary care less likely than 75%+ (OR=0.595, CI=.371-.955), and location greater than 40 miles from an endocrinologist more likely than endocrinologist within 10 miles (OR=1.941, CI=1.17-3.21). Likelihood to prescribe with access to various resources greatest for consultation on insurance issues (72% moderately/very likely) and CGM education/training (72% moderately/very likely). Conclusions: Primary care clinicians have interest in prescribing CGM for patients with diabetes. Clinician type, percentage of time spent practicing, portion of time delivering primary care, and distance from endocrinologist are related to likelihood to prescribe CGM. Previous experience prescribing CGM may improve confidence and likelihood of future prescribing. Consultation, education and training on CGM for primary care clinicians may increase access to CGM.

Continuous Glucose Monitoring in Primary Care: Understanding and Supporting Clinicians' Use to Enhance Diabetes Care.

PURPOSE: Diabetes affects approximately 34 million Americans and many do not achieve glycemic targets. Continuous glucose monitoring (CGM) is associated with improved health outcomes for patients with diabetes. Most adults with diabetes receive care for their diabetes in primary care practices, where uptake of CGM is unclear. METHODS: We used a cross-sectional web-based survey to assess CGM prescribing behaviors and resource needs among primary care clinicians across the United States. We used descriptive statistics and multivariable regression to identify characteristics associated with prescribing behaviors, openness to prescribing CGM, and to understand resources needed to support use of CGM in primary care. RESULTS: Clinicians located more than 40 miles from the nearest endocrinologist's office were more likely to have prescribed CGM and reported greater likelihood to prescribe CGM in the future than those located within 10 miles of an endocrinologist. Clinicians who served more Medicare patients reported favorable attitudes toward future prescribing and higher confidence using CGM to manage diabetes than clinicians with lower Medicare patient volume. The most-needed resources to support CGM use in primary care were consultation on insurance issues and CGM training. CONCLUSIONS: Primary care clinicians are interested in using CGM for patients with diabetes, but many lack the resources to implement use of this diabetes technology. Use of CGM can be supported with education in the form of workshops and consultation on insurance issues targeted toward residents, recent graduates, and practices without a nearby endocrinologist. Continued expansion of Medicare and Medicaid coverage for CGM can also support CGM use in primary care.

Integration of Improvement and Implementation Science in Practice-Based Research Networks: a Longitudinal, Comparative Case Study.

BACKGROUND: Implementation science (IS) and quality improvement (QI) inhabit distinct areas of scholarly literature, but are often blended in practice. Because practice-based research networks (PBRNs) draw from both traditions, their experience could inform opportunities for strategic IS-QI alignment. OBJECTIVE: To systematically examine IS, QI, and IS/QI projects conducted within a PBRN over time to identify similarities, differences, and synergies. DESIGN: Longitudinal, comparative case study of projects conducted in the Oregon Rural Practice-based Research Network (ORPRN) from January 2007 to January 2019. APPROACH: We reviewed documents and conducted staff interviews. We classified projects as IS, QI, IS/QI, or other using established criteria. We abstracted project details (e.g., objective, setting, theoretical framework) and used qualitative synthesis to compare projects by classification and to identify the contributions of IS and QI within the same project. KEY RESULTS: Almost 30% (26/99) of ORPRN's projects included IS or QI elements; 54% (14/26) were classified as IS/QI. All 26 projects used an evidence-based intervention and shared many similarities in relation to objective and setting. Over half of the IS and IS/QI projects used randomized designs and theoretical frameworks, while no QI projects did. Projects displayed an upward trend in complexity over time. Project used a similar number of practice change strategies; however, projects classified as IS predominantly employed education/training while all IS/QI and most QI projects used practice facilitation. Projects including IS/QI elements demonstrated the following contributions: QI provides the mechanism by which the principles of IS are operationalized in order to support local practice change and IS in turn provides theories to inform implementation and evaluation to produce generalizable knowledge. CONCLUSIONS: Our review of projects conducted over a 12-year period in one PBRN demonstrates key synergies for IS and QI. Strategic alignment of IS/QI within projects may help improve care quality and bridge the research-practice gap.

Improving Quality Improvement Capacity and Clinical Performance in Small Primary Care Practices.

PURPOSE: We undertook a study to assess whether implementing 7 evidence-based strategies to build improvement capacity within smaller primary care practices was associated with changes in performance on clinical quality measures (CQMs) for cardiovascular disease. METHODS: A total of 209 practices across Washington, Oregon, and Idaho participated in a pragmatic clinical trial that focused on building quality improvement capacity as measured by a validated questionnaire, the 12-point Quality Improvement Capacity Assessment (QICA). Clinics reported performance on 3 cardiovascular CQMs-appropriate aspirin use, blood pressure (BP) control (<140/90 mm Hg), and smoking screening/cessation counseling-at baseline (2015) and follow-up (2017). Regression analyses with change in CQM as the dependent variable allowed for clustering by practice facilitator and adjusted for baseline CQM performance. RESULTS: Practices improved QICA scores by 1.44 points (95% CI, 1.20-1.68; P <.001) from an average baseline of 6.45. All 3 CQMs also improved: aspirin use by 3.98% (average baseline = 66.8%; 95% CI for change, 1.17%-6.79%; P = .006); BP control by 3.36% (average baseline = 61.5%; 95% CI for change, 1.44%-5.27%; P = .001); and tobacco screening/cessation counseling by 7.49% (average baseline = 73.8%; 95% CI for change, 4.21%-10.77%; P <.001). Each 1-point increase in QICA score was associated with a 1.25% (95% CI, 0.41%-2.09%, P = .003) improvement in BP control; the estimated likelihood of reaching a 70% BP control performance goal was 1.24 times higher (95% CI, 1.09-1.40; P <.001) for each 1-point increase in QICA. CONCLUSION: Improvements in clinic-level performance on BP control may be attributed to implementation of 7 evidence-based strategies to build quality improvement capacity. These strategies were feasible to implement in small practices over 15 months.

Effect of a Pragmatic, Cluster-randomized Controlled Trial on Patient Experience With Care: The Transforming Outcomes for Patients Through Medical Home Evaluation and reDesign (TOPMED) Study.

BACKGROUND: Health reform programs like the patient-centered medical home are intended to improve the triple aim. Previous studies on patient-centered medical homes have shown mixed effects, but high value elements (HVEs) are expected to improve the triple aim. OBJECTIVE: The aim of this study is to understand whether focusing on HVEs would improve patient experience with care. METHODS: Eight clinics were cluster-randomized in a year-long trial. Both arms received practice facilitation, IT-based reporting, and financial incentives. Intervention practices were encouraged to choose HVEs for quality improvement goals. To assess patient experience, 1597 Consumer Assessment of Healthcare Providers and Systems surveys were sent pretrial and posttrial to a stratified random sample of patients. Difference-in-difference multivariate analysis was used to compare patient responses from intervention and control practices, adjusting for confounders. RESULTS: The response rate was 43% (n=686). Nonrespondent analysis showed no difference between arms, although differences were seen by risk status and age. The overall difference in difference was 2.8%, favoring the intervention. The intervention performed better in 9 of 11 composites. The intervention performed significantly better in follow-up on test results (P=0.091) and patients' rating of the provider (P=0.091), whereas the control performed better in access to care (P=0.093). Both arms also had decreases, including 4 of 11 composites for the intervention, and 8 of 11 for the control. DISCUSSION: Practices that targeted HVEs showed significantly more improvement in patient experience of care. However, contemporaneous trends may have affected results, leading to declines in patient experience in both arms.

Performance of a Patient Reported Outcomes Measurement Information System (PROMIS) Short Form in Older Adults with Chronic Musculoskeletal Pain.

OBJECTIVE: To assess reliability, validity, and responsiveness of a 29-item short-form version of the Patient Reported Outcomes Measurement Information System (PROMIS) and a novel "impact score" calculated from those measures. DESIGN: Prospective cohort study. SETTING: Rural primary care practices. SUBJECTS: Adults aged ≥ 55 years with chronic musculoskeletal pain, not currently receiving prescription opioids. METHODS: Subjects completed the PROMIS short form at baseline and after 3 months. Patient subsets were compared to assess reliability and responsiveness. Construct validity was tested by comparing baseline scores among patients who were or were not applying for Worker's Compensation; those with higher or lower catastrophizing scores; and those with or without recent falls. Responsiveness was assessed with mean score changes, effect sizes, and standardized response means. RESULTS: Internal consistency was good to excellent, with Cronbach's alpha between 0.81 and 0.95 for all scales. Among patients who rated their pain as stable, test-retest scores at 3 months were around 0.70 for most scales. PROMIS scores were worse among patients seeking or receiving worker's compensation, those with high catastrophizing scores, and those with recent falls. Among patients rating pain as "much less" at 3 months, absolute effect sizes for the various scales ranged from 0.24 (Depression) to 1.93 (Pain Intensity). CONCLUSIONS: Results indicate that the PROMIS short 29-item form may be useful for the study of patients with chronic musculoskeletal pain. Our findings also support use of the novel "impact score" recommended by the National Institutes of Health (NIH) Task Force on Research Standards for Chronic Low Back Pain.

The care transitions innovation (C-TraIn) for socioeconomically disadvantaged adults: results of a cluster randomized controlled trial.

BACKGROUND: Despite growing emphasis on transitional care to reduce costs and improve quality, few studies have examined transitional care improvements in socioeconomically disadvantaged adults. It is important to consider these patients separately as many are high-utilizers, have different needs, and may have different responses to interventions. OBJECTIVE: To evaluate the impact of a multicomponent transitional care improvement program on 30-day readmissions, emergency department (ED) use, transitional care quality, and mortality. DESIGN: Clustered randomized controlled trial conducted at a single urban academic medical center in Portland, Oregon. PARTICIPANTS: Three hundred eighty-two hospitalized low-income adults admitted to general medicine or cardiology who were uninsured or had public insurance. INTERVENTION: Multicomponent intervention including (1) transitional nurse coaching and education, including home visits for highest risk patients; (2) pharmacy care, including provision of 30 days of medications after discharge for those without prescription drug coverage; (3) post-hospital primary care linkages; (4) systems integration and continuous quality improvement. MEASUREMENTS: Primary outcomes included 30-day inpatient readmission and ED use. Readmission data were obtained using state-wide administrative data for all participants (insured and uninsured). Secondary outcomes included quality (3-item Care Transitions Measure) and mortality. Research staff administering questionnaires and assessing outcomes were blinded. RESULTS: There was no significant difference in 30-day readmission between C-TraIn (30/209, 14.4 %) and control patients (27/173, 16.1 %), p = 0.644, or in ED visits between C-TraIn (51/209, 24.4 %) and control (33/173, 19.6 %), p = 0.271. C-TraIn was associated with improved transitional care quality; 47.3 % (71/150) of C-TraIn patients reported a high quality transition compared to 30.3 % (36/119) control patients, odds ratio 2.17 (95 % CI 1.30-3.64). Zero C-TraIn patients died in the 30-day post-discharge period compared with five in the control group (unadjusted p = 0.02). CONCLUSIONS: C-TraIn did not reduce 30-day inpatient readmissions or ED use; however, it improved transitional care quality.

Study protocol: Collaboration Oriented Approach to Controlling High blood pressure (COACH) in adults - a randomised controlled trial.

INTRODUCTION: Hypertension, the clinical condition of persistent high blood pressure (BP), is preventable yet remains a significant contributor to poor cardiovascular outcomes. Digital self-management support tools can increase patient self-care behaviours to improve BP. We created a patient-facing and provider-facing clinical decision support (CDS) application, called the Collaboration Oriented Approach to Controlling High BP (COACH), to integrate home BP data, guideline recommendations and patient-centred goals with primary care workflows. We leverage social cognitive theory principles to support enhanced engagement, shared decision-making and self-management support. This study aims to measure the effectiveness of the COACH intervention and evaluate its adoption as part of BP management. METHODS AND ANALYSIS: The study design is a multisite, two-arm hybrid type III implementation randomised controlled trial set within primary care practices across three health systems. Randomised participants are adults with high BP for whom home BP monitoring is indicated. The intervention arm will receive COACH, a digital web-based intervention with effectively enhanced alerts and displays intended to drive engagement with BP lowering; the control arm will receive COACH without the alerts and a simple display. Outcome measures include BP lowering (primary) and self-efficacy (secondary). Implementation preplanning and postevaluation use the Consolidated Framework for Implementation Research and Reach-Effectiveness-Adoption-Implementation-Maintenance metrics with iterative cycles for qualitative integration into the trial and its quantitative evaluation. The trial analysis includes logistic regression and constrained longitudinal data analysis. ETHICS AND DISSEMINATION: The trial is approved under a single IRB through the University of Missouri-Columbia, #2091483. Dissemination of the intervention specifications and results will be through open-source mechanisms. TRIAL REGISTRATION NUMBER: NCT06124716.

Development and Evaluation of Serious Illness Conversation Training for Interprofessional Primary Care Teams.

Background: Early advance care planning (ACP) conversations are essential to deliver patient-centered care. While primary care is an ideal setting to initiate ACP, such as Serious Illness Conversations (SICs), many barriers exist to implement such conversations in routine practice. An interprofessional team approach holds promises to address barriers. Objective: To develop and evaluate SIC training for interprofessional primary care teams (IP-SIC). Design: An existing SIC training was adapted for IP-SIC and then implemented and evaluated for acceptability and effectiveness. Setting/Context: Interprofessional teams in 15 primary care clinics in five US states. Measures: Acceptability of the IP-SIC training and participants' self-reported likelihood to engage in ACP after the training. Results: The 156 participants were a mix of physicians and advanced practice providers (APPs) (44%), nurses and social workers (31%), and others (25%). More than 90% of all participants rated the IP-SIC training positively. While nurse/social worker and other groups were less likely than physician and APP group to engage in ACP before training (4.4, 3.7, and 6.4 on a 1-10 scale, respectively), all groups showed significant increase in likelihood to engage in ACP after the IP-SIC training (8.5, 7.7, and 9.2, respectively). Both physician/APP and nurse/social worker groups showed significant increase in likelihood to use the SIC Guide after the IP-SIC training, whereas an increase in likelihood to use SIC Guide among other groups was not statistically significant. Conclusion: The new IP-SIC training was well accepted by interprofessional team members and effective to improve their likelihood to engage in ACP. Further research exploring how to facilitate collaboration among interprofessional team members to maximize opportunities for more and better ACP is warranted. ClinicalTrials.gov ID: NCT03577002.

Integrating Patient-generated Digital Health Data into Electronic Health Records (EHRs) in Ambulatory Care Settings: EHR Vendor Survey and Interviews.

Data traditionally collected in a clinic or hospital setting is now collected electronically in everyday environments from patients, known as patient-generated health data (PGHD). We conducted informal interviews and collected survey data from major ambulatory care EHR vendors that serve the majority of the U.S. market to collect information on how their clients are integrating PGHD into EHRs. Of the 9 EHR vendors contacted, 6 completed the survey and 5 participated in a 45-minute interview. Feedback from the vendors included how PGHD use has steadily risen over the past decade and how the COVID-19 pandemic accelerated PGHD use. Pathways for data from devices or surveys to be brought securely into the EHR are increasing. While promising, adoption of health IT systems has its challenges. There are disparities in EHRs, devices, and applications. We concluded that more supportive policies are needed to advance PGHD integration.

Serious complications within 30 days of screening and surveillance colonoscopy are uncommon.

BACKGROUND & AIMS: The risk of serious complications after colonoscopy has important implications for the overall benefits of colorectal cancer screening programs. We evaluated the incidence of serious complications within 30 days after screening or surveillance colonoscopies in diverse clinical settings and sought to identify potential risk factors for complications. METHODS: Patients age 40 and over undergoing colonoscopy for screening, surveillance, or evaluation based an abnormal result from another screening test were enrolled through the National Endoscopic Database (CORI). Patients completed a standardized telephone interview approximately 7 and 30 days after their colonoscopy. We estimated the incidence of serious complications within 30 days of colonoscopy and identified risk factors associated with complications using logistic regression analyses. RESULTS: We enrolled 21,375 patients. Gastrointestinal bleeding requiring hospitalization occurred in 34 patients (incidence 1.59/1000 exams; 95% confidence interval [CI], 1.10-2.22). Perforations occurred in 4 patients (0.19/1000 exams; 95% CI, 0.05-0.48), diverticulitis requiring hospitalization in 5 patients (0.23/1000 exams; 95% CI, 0.08-0.54), and postpolypectomy syndrome in 2 patients (0.09/1000 exams; 95% CI, 0.02-0.30). The overall incidence of complications directly related to colonoscopy was 2.01 per 1000 exams (95% CI, 1.46-2.71). Two of the 4 perforations occurred without biopsy or polypectomy. The risk of complications increased with preprocedure warfarin use and performance of polypectomy with cautery. CONCLUSIONS: Complications after screening or surveillance colonoscopy are uncommon. Risk factors for complications include warfarin use and polypectomy with cautery.

Adverse events associated with anticoagulation therapy in the periendoscopic period.

BACKGROUND: Chronic anticoagulation has been demonstrated to be a risk factor for GI bleeding (GIB) in patients undergoing endoscopic procedures. OBJECTIVE: The aim of this study was to determine the incidence of GIB prospectively in a large cohort of patients enrolled in the Clinical Outcomes Research Initiative (CORI) database. DESIGN: Anticoagulated patients undergoing endoscopic procedures were interviewed by phone 30 to 45 days after the procedure to determine potential adverse events and management of warfarin therapy in the periendoscopic period. SETTING: Participating CORI sites, Stanford University Hospital, Veterans Administration Palo Alto Health Care System. MAIN OUTCOME MEASUREMENT: Postprocedural hemorrhagic or thrombotic events. RESULTS: Thirteen CORI sites agreed to participate, including 120,886 procedures in 95,807 patients. We contacted 929 patients on warfarin therapy and enrolled 483 patients (52%). The majority of the patients were men with atrial fibrillation undergoing colonoscopy. Warfarin was temporarily suspended in 437 (90%) of the patients before the procedure, and 114 (22%) received periprocedural heparin therapy. There were 10 major hemorrhagic events (2%), and the rate of hemorrhage was not higher in the patients receiving periprocedural heparin therapy (P = .1). However, polypectomy was a risk factor for postprocedural hemorrhage (P = .02). One fatal stroke (0.2%) occurred in a patient 2 weeks after endoscopy; however, information regarding warfarin management was not available. LIMITATIONS: Small number of enrolled patients and lack of control group. Lack of information regarding prothrombin time before procedure, concurrent antiplatelet agents, and timing of bleeding in 50% of the cases. The study was underpowered to definitively conclude benefits of current guidelines regarding thrombosis or bleeding. CONCLUSIONS: Postprocedural hemorrhagic events were not increased in anticoagulated patients. Most patients receiving bridging therapy were managed according to current society guidelines.

Acid-related upper endoscopy findings in patients with diabetes versus non-diabetic patients.

BACKGROUND: The relationship between diabetes, GERD symptoms and acid-related mucosal damage has not been well studied. AIMS: To better quantify risk of acid-related mucosal damage among patients with and without diabetes. METHODS: A prospective study using 10 sites from the Clinical Outcomes Research Initiative (CORI) National Endoscopy Database surveyed patients undergoing EGD by telephone within 30 days on medical history, symptoms and demographics. Varices and feeding tube indications were excluded. Acid-related damage was defined as any of these findings recorded in CORI: Barrett's esophagus; esophageal inflammation (unless non-acid-related etiology); healed ulcer, duodenal, gastric or esophageal ulcer; stricture; and mucosal abnormality with erosion or ulcer. RESULTS: Of 1,569 patients, 16% had diabetes, 95% being type 2. Diabetic patients were significantly more likely to be male, older and have a higher body mass index, and less likely to report frequent heartburn and non-steroidal anti-inflammatory drug use. No significant differences were found in acid reflux and proton pump inhibitor (PPI) use between groups. In unadjusted analyses, diabetic patients had a similar risk for acid-related damage than non-diabetic patients (OR 1.09; 95% CI: 0.83, 1.42) which persisted after adjusting for gender, age, acid reflux, acid indication and PPI use (OR 1.04; 95% CI: 0.79, 1.39). CONCLUSIONS: No difference in risk of acid-related mucosal damage was found, even after adjustment for potential confounders. Our data do not support the need for a lower threshold to perform endoscopy in diabetic patients.

Prognostic Indices for Advance Care Planning in Primary Care: A Scoping Review.

BACKGROUND: Patient identification is an important step for advance care planning (ACP) discussions. OBJECTIVES: We conducted a scoping review to identify prognostic indices potentially useful for initiating ACP. METHODS: We included studies that developed and/or validated a multivariable prognostic index for all-cause mortality between 6 months and 5 years in community-dwelling adults. PubMed was searched in October 2018 for articles meeting our search criteria. If a systematic review was identified from the search, we checked for additional eligible articles in its references. We abstracted data on population studied, discrimination, calibration, where to find the index, and variables included. Each index was further assessed for clinical usability. RESULTS: We identified 18 articles with a total of 17 unique prognostic indices after screening 9154 titles. The majority of indices (88%) had c-statistics greater than or equal to 0.70. Only 1 index was externally validated. Ten indices, 8 developed in the United States and 2 in the United Kingdom, were considered clinically usable. CONCLUSION: Of the 17 unique prognostic indices, 10 may be useful for implementation in the primary care setting to identify patients who may benefit from ACP discussions. An index classified as "clinically usable" may not be easy to use because of a large number of variables that are not routinely collected and the need to program the index into the electronic medical record.

Polyp size and advanced histology in patients undergoing colonoscopy screening: implications for CT colonography.

BACKGROUND & AIMS: Colorectal cancer screening with diagnostic imaging can detect polyps. The management of patients whose largest polyp is less than 10 mm is uncertain. The primary aim of this study was to determine rates of advanced histology in patients undergoing colorectal cancer screening whose largest polyp is 9 mm or less. METHODS: Subjects include all asymptomatic adults receiving colonoscopy for screening during 2005 from 17 practice sites, which provide both colonoscopy and pathology reports to the Clinical Outcomes Research Initiative repository. Patients were classified by size of largest polyp. Advanced histology was defined as an adenoma with villous or serrated histology, high-grade dysplasia, or an invasive cancer. Risk factors for advanced histology were determined using Pearson chi(2) and Fisher exact tests. RESULTS: Among 13,992 asymptomatic patients who had screening colonoscopy, 6360 patients (45%) had polyps, with complete histology available in 5977 (94%) patients. The proportion with advanced histology was 1.7% in the 1- to 5-mm group, 6.6% in the 6- to 9-mm group, 30.6% in the greater than 10-mm group, and 72.1% in the tumor group. Distal location was associated with advanced histology in the 6- to 9-mm group (P = .04) and in the greater than 10-mm group (P = .002). CONCLUSIONS: One in 15 asymptomatic patients whose largest polyp is 6 to 9 mm will have advanced histology and would undergo surveillance at 3 years based on current guidelines. Because histology is necessary for this decision, most of these patients should be offered colonoscopy. Further study should determine whether patients whose largest polyp is 1-5 mm can be safely followed without polypectomy.

Defining High Value Elements for Reducing Cost and Utilization in Patient-Centered Medical Homes for the TOPMED Trial.

INTRODUCTION: Like most patient-centered medical home (PCMH) models, Oregon's program, the Patient-Centered Primary Care Home (PCPCH), aims to improve care while reducing costs; however, previous work shows that PCMH models do not uniformly achieve desired outcomes. Our objective was to describe a process for refining PCMH models to identify high value elements (HVEs) that reduce cost and utilization. METHODS: We performed a targeted literature review of each PCPCH core attribute. Value-related concepts and their metrics were abstracted, and studies were assessed for relevance and strength of evidence. Focus groups were held with stakeholders and patients, and themes related to each attribute were identified; calculation of HVE attainment versus PCPCH criteria were completed on eight primary care clinics. Analyses consisted of descriptive statistics and criterion validity with stakeholder input. RESULTS: 2,126 abstracts were reviewed; 22 met inclusion criteria. From these articles and focus groups of stakeholders/experts (n = 49; 4 groups) and patients (n = 7; 1 group), 12 HVEs were identified that may reduce cost and utilization. At baseline, clinics achieved, on average, 31.3 percent HVE levels compared to an average of 87.9 percent of the 35 PCMH measures. DISCUSSION: A subset of measures from the PCPCH model were identified as "high value" in reducing cost and utilization. HVE performance was significantly lower than standard measures, and may better calibrate clinic ability to reduce costs. CONCLUSION: Through literature review and stakeholder engagement, we created a novel set of high value elements for advanced primary care likely to be more related to cost and utilization than other models.

Protocol for a Cluster Randomized Trial Comparing Team-Based to Clinician-Focused Implementation of Advance Care Planning in Primary Care.

Introduction: For many patients, primary care is an appropriate setting for advance care planning (ACP). ACP focuses on what matters most to patients and ensuring health care supports patient-defined goals. ACP may involve interactions between a clinician and a patient, but for seriously ill patients ACP could be managed by a team. Methods: We are conducting a cluster randomized trial comparing team-based to clinician-focused ACP using the Serious Illness Care Program (SICP) in 42 practices recruited from 7 practice-based research networks (PBRNs). Practices were randomized to one of the two models. Patients are referred to the study after engaging in ACP in primary care. Our target enrollment is 1260 subjects. Patient data are collected at enrollment, six months and one year. Primary outcomes are patient-reported goal-concordant care and days at home. Secondary outcomes include additional patient measures, clinician/team experience, and practice-level measures of SICP implementation. Study Implementation: This trial was designed and is conducted by the Meta-network Learning and Research Center (Meta-LARC), a consortium of PBRNs focused on integrating engagement with patients, families, and other stakeholders into primary care research and practice. The trial pairs a comparative effectiveness study with implementation of a new program and is designed to balance fidelity to the assigned model with flexibility to allow each practice to adapt implementation to their environment and priorities. Our dissemination will report the results of comparing the two models and the implementation experience of the practices to create guidance for the spread of ACP in primary care.

Developing Patient-Refined Messaging for a Mailed Colorectal Cancer Screening Program in a Latino-Based Community Health Center.

INTRODUCTION: Colon cancer is the second leading cause of cancer death in the United States, and screening rates are disproportionately low among Latinos. One factor thought to contribute to the low screening rate is the difficulty Latinos encounter in understanding health information, and therefore in taking appropriate health action. Therefore, we used Boot Camp Translation (BCT), a patient engagement approach, to engage Latino stakeholders (ie, patients, clinic staff) in refining the messages and format of colon cancer screening reminders for a clinic-based direct mail fecal immunochemical testing (FIT) program. METHODS: Patient participants were Latino, ages 50 to 75 years, able to speak English or Spanish, and willing to participate in the in-person kickoff meeting and follow-up phone calls over a 3-month period. We held separate BCT sessions for English- and Spanish-speaking participants. As part of the in-person meetings, a bilingual colon cancer expert presented on colon health and screening messages and BCT facilitators led interactive sessions where participants reviewed materials and reminder messages in various modalities (eg, letter, text). Participants considered what information about colon cancer screening was important, the best methods to share these messages, and the timing and frequency with which these messages should be delivered to patients to encourage FIT completion. We used follow-up phone calls to iteratively refine materials developed based on key learnings from the in-person meeting. RESULTS: Twenty-five adults participated in the in-person sessions (English [n = 12]; Spanish [n = 13]). Patient participants were primarily enrolled in Medicaid/uninsured (76%) and had annual household incomes less than $20,000 (67%). Key themes distilled from the sessions included increasing awareness that screening can prevent colon cancer, stressing the urgency of screening, emphasizing the motivating influence of family, and using personalized messages from the practice such as 'I' or 'we' statements in letters or automated phone call reminders delivered by humans. Participants in both sessions noted the importance of receiving an automated or live alert before a FIT kit is mailed and a reminder within 2 weeks of FIT kit mailing. DISCUSSION: Using BCT, we successfully incorporated participant feedback to adapt culturally relevant health messages to promote FIT testing among Latino patients served by community clinics. Materials will be tested in the larger Participatory Research to Advance Colon Cancer Prevention (PROMPT) trial.

The Burden of Childhood Atopic Dermatitis in the Primary Care Setting: A Report from the Meta-LARC Consortium.

BACKGROUND: Little is known about the burden of atopic dermatitis (AD) encountered in US primary care practices and the frequency and type of skin care practices routinely used in children. OBJECTIVE: To estimate the prevalence of AD in children 0 to 5 years attending primary care practices in the United States and to describe routine skin care practices used in this population. DESIGN: A cross-sectional survey study of a convenience sample of children under the age of 5 attending primary care practices for any reason. SETTING: Ten primary care practices in 5 US states. RESULTS: Among 652 children attending primary care practices, the estimated prevalence of ever having AD was 24% (95% CI, 21-28) ranging from 15% among those under the age of 1 to 38% among those aged 4 to 5 years. The prevalence of comorbid asthma was higher among AD participants compared to those with no AD, namely, 12% and 4%, respectively (P < .001). Moisturizers with high water:oil ratios were most commonly used (ie, lotions) in the non-AD population, whereas moisturizers with low water:oil content (ie, ointments) were most common when AD was present. CONCLUSIONS: Our study found a large burden of AD in the primary care practice setting in the US. The majority of households reported skin care practices that may be detrimental to the skin barrier, such as frequent bathing and the routine use of moisturizers with high water: oil ratios. Clinical trials are needed to identify which skin care practices are optimal for reducing the significant burden of AD in the community.