Reducing Acute Hospitalizations at High-Performing CPC+ Primary Care Practice Sites: Strategies, Activities, and Facilitators.

PURPOSE: Despite evidence suggesting that high-quality primary care can prevent unnecessary hospitalizations, many primary care practices face challenges in achieving this goal, and there is little guidance identifying effective strategies for reducing hospitalization rates. We aimed to understand how practices in the Comprehensive Primary Care Plus (CPC+) program substantially reduced their acute hospitalization rate (AHR) over 2 years. METHODS: We used Bayesian analyses to identify the CPC+ practice sites having the highest probability of achieving a substantial reduction in the adjusted Medicare AHR between 2016 and 2018 (referred to here as AHR high performers). We then conducted telephone interviews with 64 respondents at 14 AHR high-performer sites and undertook within- and cross-case comparative analysis. RESULTS: The 14 AHR high performers experienced a 6% average decrease (range, 4% to 11%) in their Medicare AHR over the 2-year period. They credited various care delivery activities aligned with 3 strategies for reducing AHR: (1) improving and promoting prompt access to primary care, (2) identifying patients at high risk for hospitalization and addressing their needs with enhanced care management, and (3) expanding the breadth and depth of services offered at the practice site. They also identified facilitators of these strategies: enhanced payments through CPC+, prior primary care practice transformation experience, use of data to identify high-value activities for patient subgroups, teamwork, and organizational support for innovation. CONCLUSIONS: The AHR high performers observed that strengthening the local primary care infrastructure through practice-driven, targeted changes in access, care management, and comprehensiveness of care can meaningfully reduce acute hospitalizations. Other primary care practices taking on the challenging work of reducing hospitalizations can learn from CPC+ practices and may consider similar strategies, selecting activities that fit their context, personnel, patient population, and available resources.

Implementing Electronic Health Record Default Settings to Reduce Opioid Overprescribing: A Pilot Study.

Objective: To pilot test the effectiveness, feasibility, and acceptability of instituting a 15-pill quantity default in the electronic health record for new Schedule II opioid prescriptions. Design: A mixed-methods pilot study in two health systems, including pre-post analysis of prescribed opioid quantity and focus groups or interviews with prescribers and health system administrators. Methods: We implemented a 15-pill electronic health record default for new Schedule II opioids and assessed opioid quantity before and after implementation using electronic health record data on 6,390 opioid prescriptions from 448 prescribers. We then analyzed themes from focus groups and interviews with four staff members and six prescribers. Results: The proportion of opioid prescriptions for 15 pills increased at both sites after adding an electronic health record default, with one reaching statistical significance (from 4.1% to 7.2% at CHC, P = 0.280, and 15.9% to 37.2% at WVU, P < 0.001). The proportion of 15-pill prescriptions increased among high-prescribing departments and among most high- and low-frequency prescribers, except for low-frequency prescribers at CHC. Sites reported limited challenges in instituting the default, although ease of implementation varied by electronic health record vendor. Most prescribers were not aware of the default change and stated that they made prescribing decisions based on patient clinical characteristics rather than defaults. Conclusions: This pilot provides initial evidence that changing default settings can increase the number of prescriptions at the default level. This low-cost and relatively simple intervention could have an impact on opioid overprescribing. However, default settings should be selected carefully to avoid unintended consequences.

Promoting Children's Physical Activity in Low-Income Communities in Colorado: What Are the Barriers and Opportunities?

INTRODUCTION: Colorado has the highest rate of adult physical activity in the United States. However, children in Colorado have a lower rate of physical activity relative to other states, and the rate is lowest among children in low-income households. We conducted focus groups, surveys, and interviews with parents, youth, and stakeholders to understand barriers to physical activity among children in low-income households in Colorado and to identify opportunities to increase physical activity. METHODS: From April to July 2016, we recruited participants from 5 communities in Colorado with high rates of poverty, inactivity, and obesity; conducted 20 focus groups with 128 parents and 42 youth; and interviewed 8 stakeholders. All focus group participants completed intake surveys. We analyzed focus group and interviews by using constant comparison. RESULTS: We identified 12 themes that reflect barriers to children's physical activity. Within the family context, barriers included parents' work schedules, lack of interest, and competing commitments. At the community level, barriers included affordability, traffic safety, illicit activity in public spaces, access to high-quality facilities, transportation, neighborhood inequities, program availability, lack of information, and low community engagement. Survey respondents most commonly cited lack of affordable options and traffic safety as barriers. Study participants also identified recommendations for addressing these barriers. Providing subsidized transportation, improving parks and recreation centers, and making better use of existing facilities were all proposed as opportunities to improve children's physical activity levels. CONCLUSION: In this formative study of Colorado families, participants confirmed barriers to physical activity that previous research on low-income communities has documented, and these varied by geographic location. Participants proposed a set of solutions for addressing barriers and endorsed community input as an essential first step for planning community-level health initiatives.

What Factors Influence States' Capacity to Report Children's Health Care Quality Measures? A Multiple-Case Study.

Objectives The objective of this study was to describe factors that influence the ability of state Medicaid agencies to report the Centers for Medicare & Medicaid Services' (CMS) core set of children's health care quality measures (Child Core Set). Methods We conducted a multiple-case study of four high-performing states participating in the Children's Health Insurance Program Reauthorization Act (CHIPRA) Quality Demonstration Grant Program: Illinois, Maine, Pennsylvania, and Oregon. Cases were purposively selected for their diverse measurement approaches and used data from 2010 to 2015, including 154 interviews, semiannual grant progress reports, and annual public reports on Child Core Set measures. We followed Yin's multiple-case study methodology to describe how and why each state increased the number of measures reported to CMS. Results All four states increased the number of Child Core Set measures reported to CMS during the grant period. Each took a different approach to reporting, depending on the available technical, organizational, and behavioral inputs in the state. Reporting capacity was influenced by a state's Medicaid data availability, ability to link to other state data systems, past experience with quality measurement, staff time and technical expertise, and demand for the measures. These factors were enhanced by CHIPRA Quality Demonstration grant funding and other federal capacity building activities, as hypothesized in our conceptual framework. These and other states have made progress reporting the Child Core Set since 2010. Conclusion With financial support and investment in state data systems and organizational factors, states can overcome challenges to reporting most of the Child Core Set measures.

Peri-implant bony overgrowth as a cause of revision surgery in auditory osseointegrated implantation.

Implantation of auditory osseointegrated implants, also known as bone-anchored hearing systems (BAHS), represents a surgical option for select pediatric patients aged 5 years or older with hearing loss. Functional indications in this patient population include conductive or mixed hearing loss. Common complications of implantation include skin infections, chronic skin irritation, hypertrophic skin overgrowth, and loose abutments. In a case series of 15 pediatric patients, we discovered an unexpectedly high skin-related complication rate requiring surgical revision of 53%. During revision surgery, we discovered 5 patients who exhibited significant bony overgrowth at the abutment site, a complication infrequently noted in past literature.

Physician Perspectives on Medical Home Recognition for Practice Transformation for Children.

OBJECTIVE: To examine child-serving physicians' perspectives on motivations for and support for practices in seeking patient-centered medical home (PCMH) recognition, changes in practice infrastructure, and care processes before and after recognition, and perceived benefits and challenges of functioning as a PCMH for the children they serve, especially children with special health care needs. METHODS: Semistructured interviews with 20 pediatricians and family physicians at practices that achieved National Committee for Quality Assurance level 3 PCMH recognition before 2011. We coded notes and identified themes using an iterative process and pattern recognition analysis. RESULTS: Physicians reported being motivated to seek PCMH recognition by a combination of altruistic and practical goals. Most said recognition acknowledged existing practice characteristics, but encouraged ongoing, and in some cases substantial, transformation. Although many physicians said recognition helped practices improve financial arrangements with payers and participate in quality initiatives, most physicians could not assess the specific benefits of recognition on patients' use of services or health outcomes. Challenges for practices in providing care for children included managing additional physician responsibilities, communicating with other providers and health systems, and building sustainable care coordination procedures. CONCLUSIONS: PCMH recognition can be valuable to practices as a public acknowledgement to payers and patients that certain processes are in place, and can also catalyze new and continued transformation. Programs and policies seeking to transform primary care for children should leverage physicians' motivations and find mechanisms to build practices' capacity for care management systems and linkages with the medical neighborhood.

Evaluation of Amniotic Multipotential Tissue Matrix to Augment Healing of Demineralized Bone Matrix in an Animal Calvarial Model.

Amniotic multipotential tissue matrix (AmnioMTM) is a membrane material derived from placental tissues and rich in growth factors that have been reported to have potential in healing bone. This study hypothesized that demineralized bone matrix (DBM) supplemented with AmnioMTM would accelerate healing and bone formation as compared with DBM alone in a critical size (10 mm) rat calvarial bone defect model. Five DBM grafts and 5 DBM supplemented with AmnioMTM grafts were implanted in a 10-mm critical sized defect in 10 rats (1 implant per rat). After 4 weeks, animals were euthanized and defects evaluated by microCT and histology. There were no statistical differences in microCT data for mineral density, percent bone fill, or bone surface to volume ratios between groups, though the bone surface to volume ratio for the amnio-supplemented group suggested increased osteoid activity as compared with the DBM alone group. Histological data also indicated active osteoid activity and induced bone formation in the center of defects implanted with AmnioMTM supplemented graft as compared with DBM graft alone suggesting some potential osteoinductive potential. However, there was no significant difference at the mean percent of newly mineralized bone in the DBM group defect as compared with the AmnioMTM supplemented graft material. These data suggest that while bone formation was not increased at this early time point, the increased osteoid activity and the induction of new bone in the middle of the defect by the AmnioMTM indicates that further study is needed to assess its potential benefit to bone healing and regeneration.

Pediatric mandibular reconstruction following resection of oral squamous cell carcinoma: a case report.

PURPOSE: Squamous cell carcinoma is a common entity among adult head and neck cancer patients, with many requiring reconstruction post resection. Conversely, this entity is rare among children with major reconstruction even more unique. This case and the concomitant review of literature highlight the intricacies of pediatric facial reconstruction. METHODS: The case described is of a 6-year-old African-American boy with poor dentition and a painful, 1.5 cm epiphytic lesion on the alveolar ridge of the left mandible. Incisional biopsy and computerized tomography were employed to obtain diagnosis and extent of disease. Surgical resection and reconstruction followed. RESULTS: Incisional biopsy confirmed the diagnosis of squamous cell carcinoma. Maxillofacial computerized tomography confirmed the extent of the mandibular lesion. After interdisciplinary discussion and weighing options with the family, a segmental mandibulectomy, neck dissection, and right fibula free flap reconstruction with titanium 2.0 mm metal plate fixation was performed. Re-examination post-operatively showed complete coverage of the defect and the ability to restore excised dentition. CONCLUSION: Squamous cell carcinoma within the pediatric population occurs less often than sarcomas, but may necessitate major reconstruction. Without rigid reconstruction, contracture may result. The current consensus favors microvascular bone reconstruction. However, a lack of consensus exists regarding the timing of dental rehabilitation.

Management of the aging forehead and brow.

The appearance of the forehead and brow conveys both a state of aging as well as the dynamic status of human emotion. Maintaining a youthful and pleasant appearance of this region is often integral to facial rejuvenation. Conditions that are often addressed include transverse rhytids and glabellar frown lines, ptotic eyebrows, skin deterioration, and volume loss. Surgical treatments to improve the forehead/brow might be open, endoscopic or combined. Common nonsurgical methods used to improve the region include neuromodulation, volume replacement, ablative and nonablative skin resurfacing, as well as phototherapy. Whatever treatments might be indicated, aim is to achieve optimum and natural-looking results.

Canine distemper outbreak in pet store puppies linked to a high-volume dog breeder.

Canine distemper is uncommon in the pet trade in the United States, in large part due to effective vaccines against Canine distemper virus (CDV). This is a report of CDV affecting 24 young dogs of multiple breeds shortly after sale by 2 pet stores in Wyoming during August-October 2010. Cases were diagnosed over 37 days. Diagnosis was established by a combination of fluorescent antibody staining, reverse transcription polymerase chain reaction, negative stain electron microscopy, and necropsy with histopathology. Viral hemagglutinin gene sequences were analyzed from 2 affected dogs and were identical (GenBank accession no. JF283477). Sequences were distinct from those in a contemporaneous unrelated case of CDV in a Wyoming dog (JF283476) that had no contact with the pet store dogs. The breeding property from which the puppies originated was quarantined by the Kansas Animal Health Department. Puppies intended for sale were tested for CDV. Canine distemper was diagnosed on site in November 2010. At that point 1,466 dogs were euthanized to eliminate dispersal of the disease through commercial channels. The investigation underscores the risks inherent in large-scale dog breeding when vaccination and biosecurity practices are suboptimal.

Promoting environmental justice through community-based participatory research: the role of community and partnership capacity.

Community-based participatory research (CBPR) increasingly is being used to study and address environmental justice. This article presents the results of a cross-site case study of four CBPR partnerships in the United States that researched environmental health problems and worked to educate legislators and promote relevant public policy. The authors focus on community and partnership capacity within and across sites, using as a theoretical framework Goodman and his colleagues' dimensions of community capacity, as these were tailored to environmental health by Freudenberg, and as further modified to include partnership capacity within a systems perspective. The four CBPR partnerships examined were situated in NewYork, California, Oklahoma, and North Carolina and were part of a larger national study. Case study contexts and characteristics, policy-related outcomes, and findings related to community and partnership capacity are presented, with implications drawn for other CBPR partnerships with a policy focus.

Multi-dimensional quality of life among long-term (5+ years) adult cancer survivors.

Survival from cancer has improved over the past decade resulting in more long-term survivors. The literature on multi-dimensional quality of life (QOL) among long-term (5+ years) adult survivors is reviewed for each of seven cancer sites (i.e. breast, ovarian, cervical, prostate, colorectal, head and neck, and Hodgkin's disease survivors). Overall, long-term survivors experience good to excellent QOL. Physical domain QOL was the most frequently measured while spiritual domain QOL was the least frequently measured. QOL varies according to treatment received and by age for all groups with older persons (excepting head and neck and Hodgkin's disease survivors) reporting better QOL. QOL improves with time for breast cancer survivors and tends to decrease over time for prostate cancer survivors. Issues regarding sexual functioning affected the social domain-especially for breast and prostate cancer survivors. Social support improves psychological domain QOL for breast, cervical, and colorectal survivors. Review of findings may assist researchers and clinicians wishing to enhance the QOL of the long-term survivor population by identifying the most pressing and widely experienced concerns and by providing directions for future research.

Using community-based participatory research to shape policy and prevent lead exposure among Native American children.

PROBLEM: In the mid 1990s, the Indian Health Service (IHS) observed that the percent of Native American children in northeast Oklahoma with elevated blood lead levels was higher than in other comparable areas. Tribal Efforts Against Lead (TEAL) was designed and implemented to study and address this problem using a lay health advisor model. PURPOSE: Using a case study approach, we studied the impacts of this community-based participatory research (CBPR) project on health-promoting public policy. We present TEAL's advocacy and policy steps, activities, and accomplishments in the policy arena, and recommendations for others interested in using CBPR to promote healthy public policy. KEY POINTS: Using a CBPR approach that incorporates Native American social networks can be effective in helping to achieve policy changes to address lead poisoning in a rural community. CONCLUSION: Using a CBPR approach that incorporated Native American social networks, TEAL played a major role in placing and maintaining lead poisoning on the policy agenda and in encouraging the local County Health Department and IHS to fully implement blood lead screening and parental notification for young children.