Traumatic Self-Inflicted Ventricular Laceration: A Case of Smith-Lemli-Opitz Syndrome in an Adult.

Adults with intellectual and developmental disabilities (IDD) are increasingly living into adulthood, highlighting the need for adult clinicians to expand their familiarity with congenital conditions. Smith-Lemli-Opitz syndrome (SLOS) is a rare autosomal recessive inborn error of cholesterol synthesis. SLOS is commonly diagnosed in childhood, but a number of adults with IDD progress into adulthood without a formal diagnosis. We present an 18-year-old male with a history of IDD and altered pain sensation who was hospitalized following a self-inflicted knife injury resulting in a traumatic ventricular septal defect. Over the following 15 years, the patient continued to exhibit self-injurious behaviors. At the age of 33, caregivers consented to further work-up of his intellectual disability, and whole-exome genetic sequencing revealed a diagnosis of SLOS. The clinical course of this patient represents a unique presentation of altered pain sensation, a delayed diagnosis of SLOS into adulthood, and the challenges of providing care to an adult with IDD. The case further highlights the importance of understanding the typical workup and management of genetic and congenital conditions arising in childhood.

Comprehensive Approach to Opioid Management in a Primary Care Network.

In response to the opioid epidemic, the Centers for Disease Control and Prevention released best practice recommendations for prescribing, yet adoption of these guidelines has been fragmented and frequently met with uncertainty by both patients and providers. This study aims to describe the development and implementation of a comprehensive approach to improving opioid stewardship in a large network of primary care providers. The authors developed a 3-tier approach to opioid management: (1) establishment and implementation of best practices for prescribing opioids, (2) development of a weaning process to decrease opioid doses when the risk outweighs benefits, and (3) support for patients when opioid use disorders were identified. Across 44 primary care practices caring for >223,000 patients, the total number of patients prescribed a chronic opioid decreased from 4848 patients in 2018 to 3106 patients in 2021, a decrease of 36% (P < 0.001). The percent of patients with a controlled substance agreement increased from 13% to 83% (P < 0.001) and the percent of patients completing an annual urine drug screen increased from 17% to 53% (P < 0.001). The number of patients coprescribed benzodiazepines decreased from 1261 patients at baseline to 834 at completion. A total of 6.5% of patients were referred for additional support from a certified alcohol and substance abuse counselor embedded within the program. Overall, the comprehensive opioid management program provided the necessary structure to support opioid prescribing and resulted in improved adherence to best practices, facilitated weaning of opioids when medically appropriate, and enhanced support for patients with opioid use disorders.

Longitudinal impact of COVID-19 pandemic on the utilization of hemoglobin A1c testing in outpatients.

BACKGROUND: During the COVID-19 pandemic, concerns arose about disparate access to health care and laboratory testing. There is limited information about the pandemic's impact on the frequency of diabetic laboratory testing across demographic subgroups (e.g., sex, age over 65 y, and race). METHODS: This retrospective study examined outpatient hemoglobin A1c (HbA1c) testing in a large academic medical center in Upstate New York between March 2019 and March 2021. Multivariate Poisson regression models were used to evaluate the pandemic's effects on HbA1c utilization. RESULTS: Over 190,000 HbA1c results from predominately white (76.1 %) and older (mean age, 60.6 y) outpatients were analyzed. Compared to pre-pandemic time period, the average number of HbA1c tests per patient during COVID time period experienced a small, though significant, drop (1.3 to 1.2; p < 0.001) on aggregate and in outpatients, males, females, and seniors. The modest reduction was not significant by race except for the white seniors (p < 0.001). However, the testing frequency remained within recommendations from the American Diabetes Association for monitoring prediabetic patients and patients with stable glycemic control. CONCLUSION: Given the propensity for healthcare disruptions to widen disparities, it is reassuring that we did not observe a worsening of disparities in rates of HbA1c testing during the COVID-19 pandemic.

Continuity and Health Outcomes in Resident Clinics: A Scoping Review of the Literature.

Continuity of care is an essential component of primary care, resulting in improved satisfaction, management of chronic conditions, and adherence to screening recommendations. The impact of continuity of care in teaching practices remains unclear. We performed a scoping review of the literature to understand the impact of continuity on patients and trainees in teaching practices. A systematic search was performed through PubMed to identify articles published prior to January 2020 addressing continuity of care and health outcomes in resident primary care clinic settings. A total of 543 abstracts were evaluated by paired independent reviewers. In total, 24 articles met the inclusion criteria and were abstracted by four authors. These articles included a total of 6,973 residents (median = 96, range = 9-5,000) and over 1,000,000 patients (median = 428, range = 70-1,000,000). Most publications demonstrated that higher continuity was associated with better diabetic care (71%, n = five of seven), receipt of preventive care per guidelines (60%, n = three of five), and lower costs or administrative burden of care (100%, n = three of three). A smaller proportion of publications reported a positive association between continuity and hypertension control (28%, n = two of seven). The majority of publications evaluating patient/resident satisfaction demonstrated that better continuity was associated with higher patient (67%, n = four of six) and resident (67%, n = six of nine) satisfaction. A review of the existing literature revealed that higher continuity of care in resident primary care clinics was associated with better patient health outcomes and patient/resident satisfaction. Interventions to improve continuity in training settings are needed.

The Presence 5 for Racial Justice Framework for anti-racist communication with Black patients.

OBJECTIVE: To identify communication practices that clinicians can use to address racism faced by Black patients, build trusting relationships, and empower Black individuals in clinical care. DATA SOURCES: Qualitative data (N = 112 participants, August 2020-March 2021) collected in partnership with clinics primarily serving Black patients in Leeds, AL; Memphis, TN; Oakland, CA; and Rochester, NY. STUDY DESIGN: This multi-phased project was informed by human-centered design thinking and community-based participatory research principles. We mapped emergent communication and trust-building strategies to domains from the Presence 5 framework for fostering meaningful connection in clinical care. DATA COLLECTION METHODS: Interviews and focus group discussions explored anti-racist communication and patient-clinician trust (n = 36 Black patients; n = 40 nonmedical professionals; and n = 24 clinicians of various races and ethnicities). The Presence 5 Virtual National Community Advisory Board guided analysis interpretation. PRINCIPAL FINDINGS: The emergent Presence 5 for Racial Justice (P5RJ) practices include: (1) Prepare with intention by reflecting on identity, bias, and power dynamics; and creating structures to address bias and structural determinants of health; (2) Listen intently and completely without interruption and listen deeply for the potential impact of anti-Black racism on patient health and interactions with health care; (3) Agree on what matters most by having explicit conversations about patient goals, treatment comfort and consent, and referral planning; (4) Connect with the patient's story, acknowledging socioeconomic factors influencing patient health and focusing on positive efforts; (5) Explore emotional cues by noticing and naming patient emotions, and considering how experiences with racism might influence emotions. CONCLUSION: P5RJ provides a framework with actionable communication practices to address pervasive racism experienced by Black patients. Effective implementation necessitates clinician self-reflection, personal commitment, and institutional support that offers time and resources to elicit a patient's story and to address patient needs.

Going mobile with primary care: smartphone-telemedicine for asthma management in young urban adults (TEAMS).

BACKGROUND: The majority of adults with persistent asthma have chronically uncontrolled disease and interventions to improve outcomes are needed. We evaluated the efficacy, feasibility, and acceptability of a multi-component smartphone-telemedicine program (TEAMS) to deliver asthma care remotely, support provider adherence to asthma management guidelines, and improve patient outcomes. METHODS: TEAMS utilized: (1) remote symptom monitoring, (2) nurse-led smartphone-telemedicine with self-management training for patients, and (3) Electronic medical record-based clinical decision support software. Adults aged 18-44 (N = 33) and primary care providers (N = 4) were recruited from a safety-net practice in Upstate New York. Asthma control, quality of life, and FEV1 were measured at 0, 3 and 6 months. Acceptability was assessed via survey and end-of-study interviews. Paired t-test and mixed effects modeling were used to evaluate the effect of the intervention on asthma outcomes. RESULTS: At baseline, 80% of participants had uncontrolled asthma. By 6-months, 80% classified as well-controlled. Improvements in control and quality of life were large (d = 1.955, d = 1.579). FEV%pred increased 4.2% (d = 1.687) with the greatest gain in males, smokers, and lower educational status. Provider adherence to national guidelines increased from 43.3% to 86.7% (CI = 22.11-64.55) and patient adherence to medication increased from 45.58% to 85.29% (CI = 14.79-64.62). Acceptability was 95.7%; In follow up interviews, 29/30 patients and all providers indicated TEAMS worked better than usual care, supported effective self-management, and reduced symptoms over time, which led to greater self-efficacy and motivation to manage asthma. DISCUSSION: Based on these findings, we conclude that smartphone telemedicine could substantially improve clinical asthma management, adherence to guidelines, and patient outcomes.

Criteria-Based Assessment of a Teleophthalmology Diabetic Retinopathy Evaluation Program in a Primary Care Setting.

Background:Studies have shown that teleophthalmology programs using a nonmydriatic camera in primary care settings can improve rates of diabetic retinopathy (DR) screening. However, such programs are not yet widespread due to common challenges in sustainability.Purpose:To comprehensively evaluate clinical and operational measures of an urban primary care clinic's 1-year pilot teleophthalmology DR evaluation program.Materials and Methods:This retrospective analysis used five metrics to evaluate the program: clinical diabetic retinal exam (DRE) rate, visual acuity and pathology, camera utilization, billing and insurance reimbursements, and outcomes of follow-up referrals.Results:Two hundred eleven patients were screened over 14 months. The DRE rate had more than doubled (34-75%). Of the patients, 55.9% had vision better than 20/50 in each eye and 21% with at least 1 eye worse than or equal to 20/70. DR was noted in 11% of patients. The program's first few months saw greatest camera use. Government and Medicare Advantage insurers were significantly (p < 0.001) less likely to reimburse than commercial insurers. Twenty-seven percent of patients screened had documented follow-up with an eye care provider within 16 months of their screening. Patients diagnosed with DR or recommended follow-up within 1 month were significantly (p < 0.001) more likely to schedule an appointment.Discussion:Challenges to program sustainability include efficient utilization, reimbursement from governmental insurers, and adherence to follow-up recommendations.Conclusions:Assessing teleophthalmology programs with the aforementioned five metrics allows for a comprehensive evaluation of impact and sustainability. This may be utilized to standardize the implementation and evaluation of such programs across diverse settings.

Perspectives of internal medicine residency clinics: A national survey of US medical directors.

Background: Ambulatory training is an integral component of internal medicine residency programs, yet details regarding operational processes in resident continuity clinics remain limited. Methods: We surveyed a convenience sample of medical directors of residency practices between 2015 and 2019 (n = 222) to describe and share operational and scheduling processes in internal medicine resident continuity clinics in the US. Results: Among residency practices, support for the medical director role ranged substantially, but was most commonly reported at 11%-20% full-time-equivalent support. By the end of the survey period, the majority of programs (65.1%) reported obtaining patient-centered medical home (PCMH) certification (level 1-3). For new patient appointments, 34.9% of programs reported a 1-7 day wait and 25.8% reported an 8-14 day wait. Wait times for new appointments were generally shorter for PCMH certified practices (P = 0.029). No-show rates were most commonly 26%-50% for new patients and 11%-25% for established patients. Most programs reported that interns see 3-4 patients per ½-day and senior residents see 5-6 patients per ½-day. Most interns and residents maintain a panel size of 51-120 patients. Discussion: Creating high-performing residency clinics requires a focus on core building blocks and operational processes. Based on the survey results and consensus opinion, we provide five summary recommendations related to (1) support for the medical director leadership role, (2) patient-centered and coordinated models of care, (3) support for patient scheduling, (4) recommended visit lengths, and (5) ancillary support, such as social work.

Stinging Nettle (Urtica dioica): An Unusual Case of Galactorrhea.

BACKGROUND The increasing popularity and availability of herbal supplements among patients necessitates a better understanding of their mechanism of action and the effects they have on the body, both intended and unintended. Stinging nettle (Urtica dioica) is an herbaceous shrub found throughout the world that has been used for medicinal purposes for centuries. CASE REPORT A 30-year-old woman with obesity and GERD presented to a primary care clinic with new-onset galactorrhea. A urine pregnancy test was negative. Prolactin, thyroid-stimulating hormone (TSH), and a metabolic panel were all within normal limits. A mammogram demonstrated scattered areas of fibroglandular density and benign-appearing calcifications in the left breast. The breast ultrasound showed no suspicious findings. Her medications included intermittent Echinacea, etonogestrel implant 68 mg subdermal, and the supplement stinging nettle 500 mg, which she had been taking over the past month for environmental allergies. After consultation with a clinical pharmacist, the stinging nettle was discontinued. No additional changes to her medications or supplements were made. One week after discontinuation, she returned to the clinic with complete resolution of the galactorrhea. CONCLUSIONS Stinging nettle (Urtica dioica) is a common supplement and has effects on (1) sex hormone-binding globulin, (2) histamine-induced prolactin release, and (3) serotonin-induced release of thyrotropin-releasing hormone. The local estrogen bioactivity in breast tissue may subsequently lead to gynecomastia and/or galactorrhea. Supplements are an often overlooked but a critical component of medication reconciliation and potential clinical adverse effects.

Association Between Physician Risk Assessment, Hierarchical Condition Categories, and Utilization of Medical Services.

Hierarchical Condition Categories (HCCs) are a common risk adjustment tool that may support alignment of care management resources with the clinical needs of a population. The authors examined the association between HCC scores and physician-determined clinical risk (CR) scores, annual charges, and utilization of medical care. CR score was defined as the anticipated risk for "ED or a hospital admission" within the following year. For each of the top 50 high-risk patients identified by total HCC score, the patient's primary care physician (PCP) entered a CR score based on their judgement. A total of 128 PCPs entered scores on 6167 patients of all ages across 31 primary care practices in the Finger Lakes Region of New York. Multiple correlation between HCC scores and physician CR scores was 44.0% (P < 0.001); only 18.5% of PCPs had a correlation >60%. There was a positive association between CR score and charges (slope 19.7K; P < 0.001) and between HCC score and charges (slope 25.7K; P < 0.001). Both HCC and CR scores were positively correlated (P < 0.001) with medical/surgical admissions, emergency department (ED) visits, and utilization of advanced imaging. Across a broad range of patients, HCC scores had a moderate-to-weak correlation with physician-determined CR scores for patients' risk of an ED visit or hospital admission. Both CR scores and HCCs scores were positively associated with charges and utilization. HCCs may assist in the allocation of health resources, but the relatively weak correlation with physician-determined CR scores warrants caution.

Impact of Patient-Centered Medical Home Transformation on Providers, Staff, and Quality.

The Patient-Centered Medical Home (PCMH) has become a widely implemented model to transform the delivery of care, but little evidence exists regarding the model's impact on providers, nurses, and staff. This study examined the impact of the PCMH model on (1) provider and staff satisfaction, (2) work-life balance, (3) teamwork, (4) professional experience, (5) patient care factors, and (6) quality outcomes. The authors confidentially surveyed physicians, advanced practice providers (APPs), nurses, care managers, and office staff in 2011 prior to implementation of the PCMH model and in 2016 after implementation at 34 primary care offices providing care to 171,045 patients. A total of 349 pre-PCMH implementation surveys (84% response rate) and 549 follow-up surveys (92% response rate) were received. Implementation of the PCMH model did not result in changes in provider, nurse, and staff responses to composite measures of satisfaction (P = 0.45), work-life balance (P = 0.68), teamwork (P = 0.26), patient care (P = 0.62), or professional experience (P = 0.14). Physicians and APPs experienced a negative, but mostly nonsignificant, change in all composite measures with implementation of the PCMH model. Quality markers improved for diabetes control HbA1c <8 (62.6% to 67.9%; P < 0.001), hypertension control (60.9% to 75.0%; P < 0.001), breast cancer screening (53.9% to 77.4%; P < 0.001), and colorectal cancer screening (43.9% to 70.3%; P < 0.001). Across a large primary care network, implementation of the PCMH model failed to improve overall satisfaction, work-life balance, teamwork, patient care, or professional experience. The model, combined with financial incentives, did result in improvements across multiple patient quality domains.

A mixed-methods analysis of younger adults' perceptions of asthma, self-management, and preventive care: "This isn't helping me none".

BACKGROUND: Young adults (ages 18-44) have increased emergency department use for asthma and poor adherence to medications. The objective of this mixed-methods study was to understand experiences with and approaches to managing asthma, of which little is known in this age group. METHODS: Surveys (Asthma Control Questionnaire, Asthma Quality of Life Questionnaire) and 1:1 semi-structured interviews were used to explore experiences with asthma, symptoms, self-management behaviours, and relationship to asthma control and quality of life. Qualitative data were analysed using content analysis techniques. Descriptive statistics and bivariate correlations were used to examine distributive characteristics and associations between variables. RESULTS: Forty urban adults participated (mean age 32.7 ± 6.2, 1σ). Coughing was reported nearly 46% more often than wheezing, with 42.5% (17/40) coughing until the point of vomiting most days. Most participants delayed using medication for symptoms due to misperceptions about inhalers. Higher symptom frequency and worse asthma control were associated with greater use of non-pharmacologic symptom management strategies (r = 0.645, P < .001; r = 0.360, P = .022, respectively). Five themes were identified regarding young adults experiences with asthma: (1) having asthma means being limited and missing out on life; (2) health care for asthma is burdensome, and other things are more important; (3) there is not enough personal benefit in medical interactions to make preventive care worthwhile; (4) there are insufficient support and education about asthma for adults; and (5) people normalize chronic symptoms over time and find ways of coping that fit with their lifestyle. CONCLUSIONS AND CLINICAL RELEVANCE: Young adults may tolerate symptoms without using quick-relief medication or seeking preventive care. Increasing engagement with preventive services will require decreasing perceived burdens and increasing the personal benefits of care. Evaluating for non-pharmacologic approaches to managing symptoms and asthma-related coughing may identify uncontrolled asthma. Enhanced training for clinicians in patient-centric asthma care may be needed.

Differences in Rates of High-Value and Low-Value Care Between Community Health Centers and Private Practices.

BACKGROUND: Community health centers (CHCs) are an integral part of the health care safety net. As health systems seek to improve value, it is important to understand the quality of care provided by CHCs. OBJECTIVE: To evaluate the performance of CHCs compared with private practices on a comprehensive set of high-value and low-value care measures. DESIGN: This cross-sectional study used data from the National Ambulatory Medical Care Survey from 2010 through 2012. We compared CHCs with private practices using logistic regression models that adjusted for age, sex, race/ethnicity, insurance, number of chronic illnesses, rural versus urban location, region of country, and survey year. SETTING/PARTICIPANTS: We included outpatient visits to generalist physicians at either CHCs or private practices by patients 18 years and older. MAIN MEASURES: We examined 12 measures of high-value care and 7 measures of low-value care. RESULTS: A total of 29,155 physician visits, representing 584,208,173 weighted visits, from 2010 through 2012 were included. CHCs were more likely to provide high-value care by ordering beta-blockers in CHF (46.9% vs. 36.5%; aOR 2.56; 95%CI 1.18-5.56), statins in diabetes (37.0% vs 35.5%; aOR 1.35; 95%CI 1.02-1.79), and providing treatment for osteoporosis (35.7% vs 23.2%; aOR 1.77; 95%CI 1.05-3.00) compared with private practices. CHCs were more likely to avoid low-value screening EKGs (98.7% vs. 88.0%; aOR 11.03; 95%CI 2.67-45.52), CBCs (75.9% vs. 65.7%; aOR 1.72; 95%CI 1.18-2.53), or urinalyses (86.0% vs. 80.5%; aOR 1.87; 95%CI 1.11-3.14) during a general medical exam. CHCs were also less likely to prescribe antibiotics for a URI (48.3% vs. 63.1%; aOR 0.59; 95%CI 0.40-0.88). CONCLUSIONS: On a number of high-value and low-value measures of care, CHCs performed similar to or better than private practices. As healthcare delivery reforms continue to progress, CHCs are well positioned to provide high-value healthcare.

Ambulatory Training Program to Expand Procedural Skills in Primary Care.

INTRODUCTION: Outpatient procedures are an important component of primary care, yet few programs incorporate procedural training into their curriculum. We examined a 4-year procedural curriculum to improve understanding of ambulatory procedures and increase the number of procedures performed. METHODS: A total of 56 resident and 8 faculty physicians participated in a procedural curriculum directed at joint injections (knee, shoulder, elbow, trochanteric bursa, carpal tunnel, wrist, and ankle), subdermal contraceptive insertion/removal, skin biopsies, and ultrasound use in primary care. We administered annual surveys and used generalized estimating equations to model changes. RESULTS: Across the 4 years, there was an average 96% response rate. Mean comfort level with the indications for procedures increased for both resident (62.5 to 78.8; P < .0001) and faculty physicians (61.5 to 94.8; P < .0001). Similarly, mean comfort with performing procedures increased for both resident (32.1 to 62.3; P < .0001) and faculty physicians (42.2 to 85.4; P < .0001). Residents' comfort level performing procedures increased for all individual procedures measured. The mean number of procedures performed per year increased for resident (1.9 to 8.2; P < .0001) and faculty physicians (14.7 to 25.2; P = .087). CONCLUSIONS: A longitudinal ambulatory-based procedural curriculum can increase resident and faculty physician understanding and comfort performing primary-care-based procedures. This, in turn, increased the total number of procedures performed.

Addressing Medication Costs During Primary Care Visits: A Before-After Study of Team-Based Training.

Background: Medications contribute to patients' out-of-pocket costs, yet most clinicians do not routinely screen for patients' cost-of-medication (COM) concerns. Objective: To assess whether a single training session improves COM conversations. Design: Before-after cross-sectional surveys of patients and qualitative interviews with clinicians and staff. Setting: 7 primary care practices in 3 U.S. states. Participants: In total, 700 patients were surveyed from May 2017 to January 2018: 50 patients per practice before the intervention and another 50 patients per practice after the intervention. Eligibility criteria included age 18 years or older and taking 1 or more long-term medications. Qualitative interviews with 45 staff members were conducted. Intervention: A single 60-minute training session for clinicians and staff from each practice on COM importance, team-based screening, and cost-saving strategies. Measurements: Patient data (demographics, number of long-term medications, total monthly out-of-pocket medication costs, and history of cost-related medication nonadherence) were obtained immediately before and 3 months after the intervention. Practice staff were interviewed 3 months after the intervention. Results: A total of 700 patient surveys were completed. Frequency of COM discussion improved in 6 of the 7 practices and remained unchanged in 1 practice. Overall, COM conversations with patients increased from 17% at baseline to 32% postintervention (P = 0.00). There was substantial heterogeneity among sites in before-after differences in patient-reported out-of-pocket COM. Qualitative analyses from key informant interviews showed wide variation in implementation of screening approaches, workflow, adoption of a team-based approach, and strategies for addressing COM. Limitation: It is not known whether improvements in COM conversations were sustained beyond 3 months. Conclusion: A single team training to screen and address patients' medication cost concerns improved COM discussions over the short term. Further research is needed to assess sustained effects and impact on patient costs and medication adherence and to determine whether more intensive, scalable interventions are needed. Primary Funding Source: Robert Wood Johnson Foundation.

A community-wide quality improvement initiative to improve hypertension control and reduce disparities.

Initiatives to improve hypertension control within academic medical centers and closed health systems have been extensively studied, but large community-wide quality improvement (QI) initiatives have been both less common and less successful in the United States. The authors examined a community-wide QI initiative across 226 843 patients from 198 practices in nine counties across upstate New York to improve hypertension control and reduce disparities. The QI initiative focused on (a) providing population and practice-level comparative data, (b) community engagement, especially in underserved communities, and (c) practice-level quality improvement assistance, but was not designed to examine causality of specific components. Across the nine counties, hypertension control rates improved from 61.9% in 2011 to 69.5% in 2016. Improvements were greatest among whites (73.7%-81.5%) and more modest among black patients (58.8%-64.7%). The authors noted a considerable improvement in BP within the group of patients with the highest risk (defined as a BP ≥ 160/100) and a decrease in disparities within this group. The quality collaborative identified five key lessons to help guide future community initiatives: (a) anticipate a plateauing of response; (b) distinguish the needs of disparate populations and create subpopulation-specific strategies to address and reduce disparities; (c) recognize the variation across low SES practices; (d) remain open to the refinement of outcome measures; and (e) continually seek best practices and barriers to success. Overall, a large community-wide QI initiative, involving multiple different stakeholders, was associated with improvements in BP control and modest reductions in some targeted disparities.

Health conditions, functional status and health care utilization in adults with cerebral palsy.

Aim: Health conditions in children with cerebral palsy (CP) are well described, yet health is less defined with advancing age. We examined health conditions, functional status and health care utilization in adults with CP across age groups. Methods: We collected cross-sectional data on health conditions, functional status and utilization from the medical records of adults with CP across a large university-affiliated primary care network using the Rochester Health Status Survey IV (RHSS-IV), a 58-item validated survey. Data from the National Health and Nutrition Examination Survey and National Health Interview Survey provided prevalence estimates for the general population as comparison. Results: Compared to the general population, adults with CP had higher rates of seizure disorder, obesity and asthma across all ages. Adults with CP under 30 years of age had higher rates of hypertension (16.7 versus 5.6%; P = 0.04), urinary incontinence (41.7 versus 10.5%; P < 0.001) and depression (16.7 versus 6.9%; P = 0.07). Conversely, there were lower rates of alcohol misuse, tobacco/nicotine and sexually transmitted illnesses. Independence with all activities of daily living decreased from 37.5% at 18-29 years of age to 22.5% in those 60 and over. Seizure disorders, urinary incontinence and gastroesophageal reflux disease were all independently associated with lower functional status. As expected, health care utilization increased with advancing age. Conclusions: Adults with CP should be monitored for conditions occurring at higher prevalence in CP, as well as common conditions occurring with advancing age. Age-related functional decline should be anticipated, especially with coexisting seizure disorders and urinary incontinence.

Patient Experience With Care and Its Association With Adherence to Hypertension Medications.

BACKGROUND: Medication adherence is crucial to effective chronic disease management, yet little is known about the influence of the patient-provider interaction on medication adherence to hypertensive regimens. We aimed to examine the association between the patient's experience with care and medication adherence. METHODS: We collected 2,128 surveys over 4 years from a convenience sample of hypertensive patients seeking care at three urban safety-net practices in upstate New York. The survey collected adherence measures using the Morisky Medication Adherence Scale (MMAS-8) and patient experience measures. We used regression models to adjust for age, gender, race/ethnicity, self-reported health status, and clustering by patients. The primary outcome was reporting of medium-to-high adherence (MMAS ≥ 6) vs. low adherence. RESULTS: A total of 62.5% of respondents reported medium-to-high medication adherence. The concern the provider demonstrated for patient questions or worries (adjusted odds ratio [AOR] 1.4; 95% confidence interval [CI] 1.1-1.7), provider efforts to include the patient in decisions (AOR 1.5; 95% CI 1.8-1.9), information given (AOR 1.3; 95% CI 1.0-1.6), and the overall rating of care received (AOR 1.4; 95% CI 1.1-1.8) were associated with higher medication adherence. The amount of time the provider spent was not associated with medication adherence (AOR 1.2; 95% CI 0.9-1.4). Medium-to-high medication adherence was in turn associated with increased hypertension control rates. CONCLUSIONS: Overall, better experiences with care were associated with higher adherence to hypertension regimens. However, the amount of time the provider spent with the patient was not statistically associated with medication adherence, suggesting that the quality of communication may be more important than the absolute quantity of time.

Factors Associated With Resident Continuity in Ambulatory Training Practices.

BACKGROUND: Continuity of care is a critical element of residents' educational experience in primary care programs. OBJECTIVE: We examined how continuity in resident practices compares to nonteaching practices, identified factors associated with increased continuity, and explored the association between continuity and quality measures. METHODS: We analyzed 117 235 patient visits to 4 resident practices (26 resident teams in internal medicine, pediatrics, family medicine, and medicine-pediatrics) and 270 242 visits to nonteaching community practices between July 2013 and May 2014. We defined continuity from both clinician and patient perspectives, and used logistic regression models to examine the influence of factors on continuity while controlling for postgraduate year, patient age, gender, race, and insurance. RESULTS: Continuity was greater at nonteaching sites compared to resident practices (87.3% versus 56.2%, P < .001). Resident continuity ranged from 33.1% to 83.7% among resident sites. Factors associated with improved resident continuity included absence of advanced practice providers (71.5% versus 52.3%); consistent use of scheduling protocols (77.5% versus 33.1%); rescheduling policies (71.5% versus 41.3%); increased faculty clinical time (71.5% versus 46.3%); and dismissal policies for excessive missed appointments (71.5% versus 62.5%, P < .001 for all). Increased continuity was associated with improved rates of diabetic control (62.8% versus 54.6%); hypertension control (82.8% versus 57.5%); screening colonoscopy (69.2% versus 31.9%); and mammography (74.8% versus 38.2%, P < .001 for all). CONCLUSIONS: Increased clinical faculty time, scheduling protocols, and absence of advanced practice providers were most strongly associated with increasing continuity. Increased continuity was associated with improved quality measures.

Factors Associated with the Accurate Diagnosis of Obesity.

Obesity is a growing epidemic, yet few patients with obesity receive a clinical diagnosis of obesity or appropriate counseling. We examined the socioeconomic and demographic factors associated with the accurate diagnosis of obesity during ambulatory care visits. We used data from the National Hospital Ambulatory and National Ambulatory Medical Care Surveys (NHAMCS and NAMCS) to determine if a patient with obesity had been clinically diagnosed with obesity during the visit by either of the following: (1) a diagnosis listed in the patient's record; or (2) the provider's answer to the question "despite the diagnoses listed, does this patient have obesity?" We used multivariate models to examine the association between the accurate diagnosis of obesity and socioeconomic and demographic factors. We examined 885,291,770 weighted office visits involving individuals 5 years of age and older between 2006 and 2010. Providers were less likely to diagnose obesity at office visits involving children (5-12 years) with obesity (23.4 %) than at visits for adolescents (13-21 years; 39.7 %), young adults (22-34 years; 45.4 %), adults (35-64 years; 43.9 %) or elderly adults (≥65 years; 39.6 %; P < 0.001 for all). Individuals with obesity residing in more highly educated areas were more likely to be diagnosed than those living in less highly educated areas (44.2 vs. 40.9 %; AOR 1.4; 95 % CI 1.2-1.6). Males with obesity were less likely to be diagnosed than females with obesity (36.1 vs. 45.8 %; AOR 0.7; 95 % CI 0.6-0.8). After controlling for socioeconomic-status we did not find a consistent difference in the diagnosis of obesity by race. The diagnosis of obesity was made at less than half of all office visits involving patients with obesity. Children, adolescents, elderly, males, and those living in less educated areas were less likely to be accurately diagnosed with obesity.