Penicillin allergy reassessment for treatment improvement: A dental office tool to support appropriate penicillin allergy labeling.

BACKGROUND: Dental appointments offer an opportunity to evaluate a documented penicillin (PCN) allergy and determine whether the patient might be a candidate for medical reassessment of their allergy. The authors gathered feedback on the Penicillin Allergy Reassessment for Treatment Improvement (PARTI) tool, designed to enhance dentist-patient communications regarding PCN allergies. METHODS: From January 2022 through May 2023, the authors conducted a mixed-methods study, collecting focus group data from patients with PCN allergies and surveying health care workers (HCWs) regarding the PARTI tool. Feedback focused on reassessment procedures, patient-centered allergy information, and medical records updates. Thematic analysis was used for focus group data. RESULTS: The study included 15 patients in focus groups and 50 HCW survey respondents representing diverse US regions. Patient demographic characteristics included varied races, the mean age was 52 years, and most of the patients were female (53.3%). Most patients had health care interactions within the preceding year, at which 86.6% of patients were asked about drug allergies. HCW respondents primarily consisted of pharmacists (30%) and dentists, dental hygienists, and dental assistants (28%). Feedback on the PARTI tool was constructive, with both patients and HCWs recognizing its potential benefits and providing insights for improvement. Many HCWs (68%) highlighted the importance of step 3 of the PARTI tool, that is, the section on PCN allergy testing. Feedback from participants was incorporated into the final PARTI tool. CONCLUSIONS: Patient and HCW feedback on the PARTI tool was used to finalize a tool for the dental office to provide to patients who are candidates for PCN allergy reassessment. The feedback will also be used to inform an upcoming pilot study in US dental offices, focused on the process for PCN allergy reassessment and health record documentation. PRACTICAL IMPLICATIONS: Deploying the PARTI tool in dental offices is pivotal, as mislabeling patients with PCN allergies could have severe consequences, such as hindering the prescription of lifesaving antibiotics for conditions like endocarditis, in the future. This implementation not only enhances communication between dentists and patients, but it is also crucial for ensuring improved patient safety and maintaining accurate medical records among health care settings.

Incorporating verbal defense into problem-based learning.

INTRODUCTION: The objective of this project was to evaluate the effect of adjusting the solution reporting phase of problem-based learning (PBL) while keeping core components of the pedagogy constant. METHODS: A PBL course for third year pharmacy students changed delivery of the problem solution from a written format to a verbal defense. Comparisons were made between the written format and verbal defense groups. The primary outcome was the change in the motivation domain of the Motivated Strategies for Learning Questionnaire (MSLQ). Secondary outcomes included evaluation of the learning strategies domain of the MSLQ, changes in MSLQ scores within each group, exam scores, and themes identified using focus groups. RESULTS: There was no difference in the change of motivation and learning domains between the groups. However, scores in both groups increased significantly from the beginning to the end of the semester for both motivation and learning. There was no difference in exam scores and facilitator confidence between groups. Themes from focus groups who used the written format were appreciation of PBL outcomes, discomfort with the pedagogy, and disconnect of assessments. Themes from the verbal format group were realism, increased confidence, and comments with course logistics. CONCLUSIONS: No difference in motivation and learning was observed between the groups, although both groups improved over the course of the semester. Changes to PBL approach within the confines of the pedagogy may not impact motivation and learning.

Future Directions for Practice-Based Research Networks (PBRNs): A CERA Survey.

BACKGROUND: Thought leaders from family medicine and practice-based research networks (PBRNs) have put forth definitions and goals recommending future directions for PBRNs. Evidence demonstrating that PBRNs are acting in accordance with these trends supports future investment in PBRN infrastructure, funding, and training of clinician researchers. Our objective was to explore the alignment of PBRN research efforts with thought leader recommendations. METHODS: The 2017 Council of Academic Family Medicine Educational Research Alliance surveyed PBRN directors via emails to 126 respondents. This survey included 6 general background questions about PBRN characteristics. An additional 25 questions focused on current and future research directions, including the training of health care professionals about PBRN research. RESULTS: The survey response rate was 56/126 (44%). Physician faculty receive continuing medical education credit for PBRN training (reported by 12/56 of PBRN directors). PBRN provided continuing medical education for study participation (24/56), reviewing study results (7/56), attending a study results presentation (24/56), and attending study planning meetings (13/56). Practice-based research education of medical students and residents was reported at 11/56 and 14/56, respectively. Current PBRN research efforts were most frequent in the areas of community engagement, practice transformation, and quality improvement projects. CONCLUSION: PBRNs currently thrive on conducting research predominantly in quality improvement and practice transformation. However, the study findings suggest that moving forward, PBRNs should participate more in training the future generations of primary care researchers and to address health policy needs.

"I Never Would Have Caught That Before": Pharmacist Perceptions of Using Clinical Decision Support for Antimicrobial Stewardship in the United States.

To systematically improve the appropriateness of antibiotic prescribing, antimicrobial stewardship programs have been developed. There is a paucity of literature examining how pharmacists perform antimicrobial stewardship using a clinical decision support system in a hospital setting. The purpose of this qualitative study was to develop a model exploring how pharmacists perform antimicrobial stewardship to identify areas for programmatic improvement. Semistructured interviews were conducted across a health care system until saturation of themes was reached. Pharmacists identified that self-efficacy and time were vital for antimicrobial stewardship to be performed, while culture of the hospital and attitude facilitated the process of stewardship. Antimicrobial stewardship programs using clinical decision support tools should ensure pharmacists have adequate time to address rules, provide easy-to-use resources and training to support self-efficacy, and engage influential physicians to support a culture of collaboration.

CERA: Clerkships Need National Curricula on Care Delivery, Awareness of Their NCC Gaps.

BACKGROUND AND OBJECTIVES: The Society of Teachers of Family Medicine's (STFM) National Clerkship Curriculum (NCC) was created to standardize and improve teaching of a minimum core curriculum in family medicine clerkships, promoting the Triple Aim of better care and population health at lower cost. It includes competencies all clerkships should teach and tools to support clerkship directors (CDs). This 2014 CERA survey of clerkship directors is one of several needs assessments that guide STFM's NCC Editorial Board in targeting improvements and peer-review processes. METHODS: CERA's 2014 survey of CDs was sent to all 137 CDs at US and Canadian allopathic medical schools. Primary aims included: (1) Identify curricular topics of greatest need, (2) Inventory the percent of family medicine clerkships teaching each NCC topic, and (3) Determine if longitudinal or blended clerkship have unique needs. This survey also assessed use of NCC to advocate for teaching resources and collaborate with colleagues at other institutions. RESULTS: Ninety-one percent of CDs completed the survey. Sixty-four percent reported their clerkship covers all of the NCC minimum core, but on detailed analysis, only 1% teach all topics. CDs need curricula on care delivery topics (cost-effective approach to acute care, role of family medicine in the health care system, quality/safety, and comorbid substance abuse). CONCLUSIONS: Single-question assessments overestimate the percentage of clerkships teaching all of the NCC minimum core. Clerkships need national curricula on care delivery topics and tools to help them find their curricular gaps.

Clinical skills development in student-run free clinic volunteers: a multi-trait, multi-measure study.

BACKGROUND: At Wayne State University School of Medicine (WSU SOM), the Robert R. Frank Student Run Free Clinic (SRFC) is one place preclinical students can gain clinical experience. There have been no published studies to date measuring the impact of student-run free clinic (SRFC) volunteerism on clinical skills development in preclinical medical students. METHODS: Surveys were given to first year medical students at WSU SOM at the beginning and end of Year 1 to assess perception of clinical skills, including self-confidence, self-reflection, and professionalism. Scores of the Year 1 Objective Structured Clinical Exam (OSCE) were compared between SRFC volunteers and non-volunteers. RESULTS: There were a total of 206 (68.2%) and 80 (26.5%) survey responses at the beginning and end of Year 1, respectively. Of the 80 students, 31 (38.7%) volunteered at SRFC during Year 1. Statistically significant differences were found between time points in self-confidence (p < 0.001) in both groups. When looking at self-confidence in skills pertaining to SRFC, the difference between groups was statistically significant (p = 0.032) at both time points. A total of 302 students participated in the Year 1 OSCE, 27 (9%) of which were SRFC volunteers. No statistically significant differences were found between groups for mean score (p = 0.888) and established level of rapport (p = 0.394). CONCLUSIONS: While this study indicated no significant differences in clinical skills in students who volunteer at the SRFC, it is a first step in attempting to measure clinical skill development outside of the structured medical school setting. The findings lend themselves to development of research designs, clinical surveys, and future studies to measure the impact of clinical volunteer opportunities on clinical skills development in future physicians.

Depression screening and treatment in uninsured urban patients.

BACKGROUND: Depression has been widely studied in primary care settings, yet studies of medically uninsured populations are lacking. We sought to determine whether depression screening and treatment improved depression scores of a medically uninsured, mostly African American primary care population. METHODS: The study was a prospective repeated-measures design that recruited uninsured patients. Patients were screened for depression, and the rate of depression diagnosis was compared with baseline. Patients who were diagnosed and accepted treatment were randomized to 1 of 4 treatment arms: (1) usual care; (2) usual care and psychotherapy; (3) usual care and education and psychotherapy; and (4) usual care and education. Patients were then reevaluated at 8, 12, and 24 weeks. RESULTS: A total of 674 patients participated. Depression prevalence was significantly higher among those screened (38%) than at baseline (16%). All treatment groups showed a significant reduction in depression scores over a 6-month period, from a mean score of 15 at baseline to 8.3 at 24 weeks (P < .005). All treatment interventions were equally effective. CONCLUSION: Screening improves the rate of diagnosis of depression in an uninsured, primarily African American population, and subsequent treatment significantly reduces the burden of depression.

A practical method for surveillance of novel H1N1 influenza using automated hospital data.

We report a surveillance method for influenza that is based on automated hospital laboratory and pharmacy data. During the 2009 H1N1 influenza pandemic, this method was objective, easy to perform, and utilized readily available automated hospital data. This surveillance method produced results that correlated strongly with influenza-like illness surveillance data.

Predictors, barriers, and facilitators of lipid-lowering medication use among African Americans in a primary care clinic.

INTRODUCTION: Hypercholesterolemic African Americans are less likely than white Americans to be taking lipid-lowering medications, yet they suffer disproportionately from coronary heart disease (CHD). METHODS: Through medical record abstraction and focus groups with patients and physicians, we sought a better understanding of the predictors, barriers, and facilitators to lipid-lowering medication use in a Detroit primary care clinic. Stepwise regression analysis included 634 African American patients with abnormal cholesterol values (n = 575) or currently prescribed a lipid-lowering medication (n = 59). Focus group transcripts were analyzed with a framework approach. RESULTS: Overall 174 (30.3%) of hypercholesterolemic African Americans were prescribed a lipid-lowering medication. Patients with hypertension or CHD were significantly more likely to have a lipid-lowering medication prescription than those without, adjusted prevalence ratio 2.56 (95% CI, 1.76-3.74) for hypertension and 1.70 (95% CI, 1.45-2.00) for CHD. Focus groups revealed 2 barriers to lipid-lowering medication use named by both physicians (n = 12) and patients (n = 23): cost and forgetting to take medication, often because of lack of symptoms. CONCLUSIONS: Physicians and patients suggested better education by physicians and at the community level to improve lipid-lowering medication use. Simple and direct patient-physician discussions emphasizing long-term benefits are recommended.

Depressive personality disorder, dysthymia, and their relationship to perfectionism.

This paper reports the results of two studies in a nonclinical (n=105) and primary care outpatient sample (n=110), in which Depressive Personality Disorder (DPD), Dysthymia, and depression were assessed for their distinctive relationship with perfectionism. Results from both studies found that self-reported DPD, Dysthymia, and depressive symptoms were all intercorrelated, and that DPD, Dysthymia, and depressive symptoms were correlated with three dimensions of perfectionism-Concern over Mistakes, Doubts about Actions, and Parental Criticism. In the nonclinical sample, variance in measures of DPD was predicted by measures of perfectionism after controlling for depression and Dysthymia symptoms. A similar pattern of findings was observed in the primary care sample. This relationship with perfectionism did not occur when Dysthymia or depressive symptoms were predicted. Nevertheless, much of the variance in measures of DPD, Dysthymia, and depressive symptoms is associated with each other and not perfectionism. It is concluded that a common factor or set of factors underlies these disorders, but that DPD may be more strongly related to perfectionism than Dysthymia and depression. As a common factor(s) is identified, measures of DPD and Dysthymia may be refined, thereby increasing the discriminant validity of their measures.

Object representations and their relationship to psychopathology and physical health status in African-American women in primary care.

Object relations theories hypothesize a relationship between self/other representations and level of psychopathology. Research has lent support to this hypothesis. This study was conducted to examine the link between object representation and psychopathology, stress, physical health status, and alcohol abuse in 110 African-American women in primary care. Object representations were assessed through spontaneous descriptions of parents. Psychopathology and physical health status were assessed with the Patient Health Questionnaire and the Medical Outcomes Study Short-Form Health Survey, both of which were designed for medical settings. The results support the link between dimensions of object representations (developmental level, benevolence, punitiveness) and psychopathology and between object representations and aspects of health status. Punitive maternal and paternal representations were most robustly associated with psychopathology and health status and were the only representational variables associated with alcohol abuse. The findings provide additional support for the object representations-psychopathology link and extend the research by demonstrating associations among object representations, alcohol abuse, and health status.

Physical and psychological symptoms in emotionally abused and non-abused women.

BACKGROUND: This brief report compares emotionally abused and non-abused female family practice patients on physical and emotional symptoms, alcohol use problems, and social support problems. METHODS: We conducted a secondary analysis of data from a cross-sectional, multicenter study of victimization of family practice patients. Forty-seven adult women meeting criteria for emotional abuse (within the past year) and no physical abuse were matched demographically with 47 non-abused women. Each woman completed demographic and health history questionnaires, including questions about physical and emotional abuse. RESULTS: Emotionally abused women reported a greater number of physical (P < .001) and psychological (P < .0001) symptoms than non-abused controls. Emotionally abused women reported a significantly greater number of social support problems than non-abused women (P < .04). CONCLUSIONS: This study supports a growing literature that demonstrates an association between emotional abuse and physical and emotional symptoms in women who are currently suffering emotional abuse at the hands of their partner or ex-partner. It is recommended that physicians inquire about emotional abuse in female patients with multiple psychosocial and physical symptoms.

Challenges in making therapeutic lifestyle changes among hypercholesterolemic African-American patients and their physicians.

OBJECTIVE: We explored challenges faced by hypercholesterolemic African-American primary care patients and their physicians regarding therapeutic lifestyle changes (TLC) and provide patient-influenced recommendations to physicians. METHODS: In this qualitative study, 23 urban family medicine patients and their physicians (N=12) participated in separate focus groups, where they were asked semistructured, open-ended questions about knowledge and barriers to lifestyle treatment of high cholesterol. RESULTS: During the focus groups, barriers mentioned by physicians were: lack of time for TLC counseling, inadequate knowledge about counseling patients, and patient readiness and responsibility to change. Patient-revealed barriers included difficulty adhering to a diet/exercise regimen and a lack of knowledge about high cholesterol. Patients who were successful with adopting a healthy lifestyle identified personal experiences or those of family and friends as motivating. CONCLUSION: Physicians desire training and resources to better help patients adopt diet and exercise regimens specific to their general and health literacy and their access to healthy foods, along with their readiness to change. Patients desire that physicians tailor their TLC advice to be specific to their context and they want help from physicians in setting realistic goals. Such a patient-centered counseling approach may improve adherence to lifestyle guidelines and, thus, clinical outcomes.

Functional health status and its relationship to depressive personality disorder, dysthymia, and major depression: preliminary findings.

Controversy continues on the extent to which depressive personality disorder (DPD) and dysthymic disorder (DYST) may be differentiated. Although affective disorders often are accompanied by changes in functional health status, to date no study has examined how functional health associated with affective disorders may assist in differentiating the two disorders. In this study, we hypothesized that measures of DPD would have fewer correlations with functional health status than would measures of DYST and major depressive disorder (MDD). African American women (n=110) completed questionnaires that assessed for depressive disorders, somatic concerns, and physical health. Measures of DPD, DYST, and MDD were all significantly correlated with functional health status. When symptoms of MDD were controlled, DYST was more associated with functional health status than was a DSM-IV measure of DPD, although a self-report measure of DPD--the Depressive Personality Disorder Inventory [DPDI; Huprich et al., 1996: J Clin Psychol 52:152-159]--remained significantly correlated with functional health status. When symptoms of DYST were controlled, DSM-IV symptoms of DPD were not strongly associated with functional health status, although measures of MDD and the DPDI were correlated with functional health status. We concluded that despite the overlap in depressive symptoms and functional health status, DPD may be less associated with functional health status in a primary care population than DYST and MDD. Implications for the assessment of DPD are provided.