Automatic medication refills to improve glycaemic control among patients with diabetes and low medication adherence.

BACKGROUND: Medication adherence impacts health outcomes. Healthcare organisations implementing system-level interventions have potential for greater spread and sustainability than individual-level interventions. Within the integrated US Veterans Health Administration, a multidisciplinary team developed and evaluated a pilot quality improvement programme to assess the feasibility of automatic mailed prescription refills for patients with diabetes and low medication adherence (assessed by medication possession ratio <80%). METHODS: Patients were randomised to usual care with self-initiated refills versus automatic mailed refills for 6 months. Process outcomes included glycaemic control measures (HgbA1C), medication possession ratios for both automatic and self-initiated (reference) refills of medications, patient satisfaction and workforce effort (pharmacist time). RESULTS: Overall, 199 patients were randomised to automatic refills (n=99; 40 of whom participated) versus usual care (n=100). In multivariable analysis adjusting for baseline differences, after 6 months there was no difference in the proportion of patients with follow-up HgbA1C <8% (60.8% automatic refills vs 60.5% usual care, p=0.96). In the automatic refill group, the medication possession ratio for reference medicines was significantly higher than usual care (63.9% vs 54.5%, 95% CI (for difference) 3.1% to 15.9%, p<0.01). CONCLUSIONS: Implications and lessons from this pilot programme include potential beneficial indirect effects from automatic medication refills on patient self-initiated refills of other medications; the importance of tailoring solutions to patient subgroups and specific adherence barriers; and recognition that the rapid deployment, iteration and evaluation of the project was facilitated by a multidisciplinary team embedded within an organisational learning health system.

Breast Cancer Risk Assessment: A Step-Wise Approach for Primary Care Providers on the Front Lines of Shared Decision Making.

Breast cancer-screening guidelines increasingly recommend that clinicians perform a risk assessment for breast cancer to inform shared decision making for screening. Precision medicine is quickly becoming the preferred approach to cancer screening, with the aim of increased surveillance in high-risk women, while sparing lower-risk women the burden of unnecessary imaging. Risk assessment also informs clinical care by refining screening recommendations for younger women, identifying women who should be referred to genetic counseling, and identifying candidates for risk-reducing medications. Several breast cancer risk-assessment models are currently available to help clinicians categorize a woman's risk for breast cancer. However, choosing the appropriate model for a given patient requires a working knowledge of the strengths, weaknesses, and performance characteristics of each. The aim of this article is to provide a stepwise approach for clinicians to assess an individual woman's risk for breast cancer and describe the features, appropriate use, and performance characteristics of commonly encountered risk-prediction models. This approach will help primary care providers engage in shared decision making by efficiently generating an accurate risk assessment and make clear, evidence-based screening and prevention recommendations that are appropriately matched to a woman's risk for breast cancer.

Changes in Resident Well-Being at One Institution Across a Decade of Progressive Work Hours Limitations.

PURPOSE: To measure changes in markers of resident well-being over time as progressive work hours limitations (WHLs) were enforced, and to investigate resident perceptions of the 2011 WHLs. METHOD: A survey study of internal medicine residents was conducted at the University of Washington's multihospital residency program in 2012. The survey included validated well-being questions: the Maslach Burnout Inventory, the two-question PRIME-MD depression screen, and career satisfaction questions. Chi-square tests were used to compare 2012 well-being questionnaire responses against nearly identical surveys conducted in 2001 and 2004 at the same institution. In addition, residents were asked to rate the impact of WHLs on resident well-being and education as well as patient care, and to state preferences for future WHLs. RESULTS: Significantly different proportions of residents met burnout criteria across time, with fewer meeting criteria in 2012 than in 2001 (2001: 76% [87/115]; 2004: 64% [75/118]; 2012: 61% [68/112]; P = .039). Depression screening results also differed across time, with fewer screening positive in 2012 than in 2004 (2001: 45% [52/115]; 2004: 55% [65/118]; 2012 [35/112]: 31%; P = .001). Residents, especially seniors, reported perceived negative impacts of WHLs on their well-being, education, and patient care. Most senior residents favored reverting to the pre-July 2011 system of WHLs. Interns were more divided. CONCLUSIONS: Validated measures of resident well-being changed across the three time points measured. Residents had the lowest rates of burnout and depression in 2012. Resident perceptions of the 2011 WHLs, however, were generally negative.

Osteoporosis: screening, prevention, and management.

Osteoporosis is characterized by low bone mineral density (BMD) and abnormal bone architecture. Common fracture sites are vertebrae, proximal femur, and distal forearm. Osteoporosis is underdiagnosed and undertreated. All women 65 and older should be screened. Consider screening younger postmenopausal women with elevated risk. Osteoporosis is diagnosed based on T score or a fragility fracture. Women with osteoporosis or who have a 10-year risk of any major fracture of 20% or hip fracture of 3% should be evaluated for causes of low bone density and treated with an osteoporosis-specific medication, lifestyle interventions, and calcium and vitamin D intake.

Low back pain.

Low back pain is a common, frequently recurring condition that often has a nonspecific cause. Most nonspecific acute low back pain will improve within several weeks with or without treatment. The diagnostic workup should focus on evaluation for evidence of systemic or pathologic causes. Psychosocial distress, poor coping skills, and high initial disability increase the risk for a prolonged disability course. All patients with acute or chronic low back pain should be advised to remain active. The treatment of chronic nonspecific low back pain involves a multidisciplinary approach targeted at preserving function and preventing disability. Surgical referral is indicated in the presence of severe or progressive neurologic deficits or signs and symptoms of cauda equina syndrome.