Quality of pulmonary function testing in 3 large primary care pediatric clinics in rural North Carolina.

BACKGROUND: Pulmonary function testing (eg, spirometry) is recommended by the National Heart, Lung, and Blood Institute as part of basic asthma management. Previous research has shown that spirometry is feasible in primary care settings. OBJECTIVES: In this retrospective study, we sought to describe the proportion of spirometries meeting American Thoracic Society (ATS) and European Respiratory Society (ERS) quality criteria in children with asthma evaluated in North Carolina primary care pediatric clinics and to characterize predictors of spirometry that meets ATS/ERS quality criteria. METHODS: Medical records and spirometries from January 1, 2001, to August 1, 2009, were reviewed and analyzed from children enrolled in a larger asthma study that focused on communication between physicians, children, and caregivers. Children were eligible for the larger study if they were between the ages of 8 and 16 years and had received a previous diagnosis of persistent asthma. Children were enrolled from primary care pediatric practices. RESULTS: Spirometry was not acceptable, on the basis of ATS/ERS criteria, in 75% of cases. Approximately 19% of spirometries used incorrect or outdated predictive sets. CONCLUSIONS: More than three-quarters of spirometries in these primary care pediatric clinics were unacceptable. Changes or lack of changes in asthma management may be based on unacceptable spirometry. Additional education and training regarding accurate spirometry and interpretation are warranted.

Contrasting measures of adherence with simple drug use, medication switching, and therapeutic duplication.

BACKGROUND: Multiple measures of adherence have been reported in the research literature and it is difficult to determine which is best, as each is nuanced. Occurrences of medication switching and polypharmacy or therapeutic duplication can substantially complicate adherence calculations when adherence to a therapeutic class is sought. OBJECTIVE: To contrast the Proportion of Days Covered (PDC) adherence metric with 2 variants of the Medication Possession Ratio (MPR, truncated MPR). METHODS: This study was a retrospective analysis of the North Carolina Medicaid administrative claims data from July 1999 to June 2000. Data for patients with schizophrenia (ICD-9-CM code 295.xx) who were not part of a health maintenance organization, not hospitalized, and not pregnant, taking at least one antipsychotic, were aggregated for each person into person-quarters. The numerator for PDC was defined as the number of days one or more antipsychotics was available and the MPR numerator was defined as the total days' supply of antipsychotics; both were divided by the total days in each person-quarter. Adherence rates were estimated for subjects who used only one antipsychotic, switched medications, or had therapeutic duplication in the quarter. RESULTS: The final sample consisted of 25,200 person-quarters from 7069 individuals. For person-quarters with single antipsychotic use, adherence to antipsychotics as a class was: PDC 0.607, truncated MPR 0.640, and MPR 0.695 (p < 0.001). For person-quarters with switching, the average MPR was 0.690, truncated MPR was 0.624, and PDC was 0.562 (p < 0.001). In the presence of therapeutic duplication, the PDC was 0.669, truncated MPR was 0.774, and MPR was 1.238 (p < 0.001). CONCLUSIONS: The PDC provides a more conservative estimate of adherence than the MPR across all types of users; however, the differences between the 2 methods are more substantial for persons switching therapy and prescribed therapeutic duplication, where MPR may overstate true adherence. The PDC should be considered when a measure of adherence to a class of medications is sought, particularly in clinical situations in which multiple medications within a class are often used concurrently.

Physician reported communication about depression and psychosocial issues during postpartum visits.

OBJECTIVE: Postpartum depression occurs in 13% of women after delivery making it one of the most common puerperial complications. The purpose of the study was to examine: (1) the extent to which obstetricians/gynecologists and family physicians report discussing depression and other psychosocial issues during postpartum visits and (2) how physician specialty and gender are related to whether physicians report discussing depression and other psychosocial issues with patients during postpartum visits. METHODS: A survey was sent to a random sample of 600 obstetricians/gynecologists and 600 family practitioners in North Carolina. PRINCIPAL FINDINGS: The overall response rate was 42%. Forty-six percent of the responding physicians (N=228) reported that they had seen women for postpartum visits during the past 3 months. Of physicians conducting postpartum visits within this time period, 43% of physicians were almost certain to ask whether the woman felt down, depressed, or hopeless and 27% were almost certain to ask about the woman's interest in her usual activities. Seventy-nine percent of physicians stated that they were unlikely to use a formal screen for depression. Obstetricians/gynecologists were less likely to ask about a womans social support network (OR=0.33, 95% CI=0.14, 0.75), to ask about her relationship with her partner (OR=0.40, 95% CI=0. 18, 0.87), and to use a formal depression screen (OR= 0. 16, 95% CI=0.04, 0.57) than family practitioners. LIMITATIONS: The study only examined physician self-report of the extent to which they communicated about different issues with women during postpartum visits. CONCLUSIONS: Communication about depression and related psychosocial issues during postpartum visits is substantially limited, likely contributing to the underdiagnosis of this common disorder.