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Background: Little is known about how primary care clinicians (PCCs) approach chronic pain management in the current climate of rapidly changing guidelines and the growing body of research about risks and benefits of opioid therapy. Objective: To better understand PCCs' approaches to managing patients with chronic pain and explore implications for technological and administrative interventions. Design: We conducted adapted critical decision method interviews with 20 PCCs. Each PCC participated in 1–5 interviews. Participants: PCCs interviewed had a mean of 14 years of experience. They were sampled from 13 different clinics in rural, suburban, and urban health settings across the state of Indiana. Approach: Interviews included discussion of participants' general approach to managing chronic pain, as well as in-depth discussion of specific patients with chronic pain. Interviews were audio recorded. Transcripts were analyzed thematically. Key Results: PCCs reflected on strategies they use to encourage and motivate patients. We identified four associated strategic themes: (1) developing trust, (2) eliciting information from the patient, (3) diverting attention from pain to function, and (4) articulating realistic goals for the patient. In discussion of chronic pain management, PCCs often explained their beliefs about opioid therapy. Three themes emerged: (1) Opioid use tends to reduce function, (2) Opioids are often not effective for long-term pain treatment, and (3) Response to pain and opioids is highly variable. Conclusions: PCC beliefs about opioid therapy generally align with the clinical evidence, but may have some important gaps. These findings suggest the potential value of interventions that include improved access to research findings; organizational changes to support PCCs in spending time with patients to develop rapport and trust, elicit information about pain, and manage patient expectations; and the need for innovative clinical cognitive support. [ABSTRACT FROM AUTHOR]

Background: Little is known about the frequency, patterns, and determinants of readmissions among patients initially hospitalized for an ambulatory care-sensitive condition (ACSC). The degree to which hospitalizations in close temporal proximity cluster has also not been studied. Readmission patterns involving clustering likely reflect different underlying determinants than the same number of readmissions more evenly spaced.Objective: To characterize readmission rates, patterns, and predictors among patients initially hospitalized with an ACSC.Design: Retrospective analysis of the 2010-2014 Nationwide Readmissions Database.Participants: Non-pregnant patients aged 18-64 years old during initial ACSC hospitalization and who were discharged alive (N = 5,007,820).Main Measures: Frequency and pattern of 30-day all-cause readmissions, grouped as 0, 1, 2+ non-clustered, and 2+ clustered readmissions.Key Results: Approximately 14% of patients had 1 readmission, 2.4% had 2+ non-clustered readmissions, and 3.3% patients had 2+ clustered readmissions during the 270-day follow-up. A higher Elixhauser Comorbidity Index was associated with increased risk for all readmission groups, namely with adjusted odds ratios (AORs) ranging from 1.12 to 3.34. Compared to patients aged 80 years and older, those in younger age groups had increased risk of 2+ non-clustered and 2+ clustered readmissions (AOR range 1.27-2.49). Patients with chronic versus acute ACSCs had an increased odds ratio of all readmission groups compared to those with 0 readmissions (AOR range 1.37-2.69).Conclusions: Among patients with 2+ 30-day readmissions, factors were differentially distributed between clustered and non-clustered readmissions. Identifying factors that could predict future readmission patterns can inform primary care in the prevention of readmissions following ACSC-related hospitalizations. [ABSTRACT FROM AUTHOR]

Background: Rapid HIV testing could increase routine HIV testing. Most previous studies of rapid testing were conducted in acute care settings, and few described the primary care providers' perspective.Objective: To identify characteristics of general internal medicine physicians with access to rapid HIV testing, and to determine whether such access is associated with differences in HIV-testing practices or perceived HIV-testing barriers.Design: Web-based cross-sectional survey conducted in 2009.Participants: A total of 406 physician members of the Society of General Internal Medicine who supervise residents or provide care in outpatient settings.Main Measures: Surveys assessed provider and practice characteristics, HIV-testing types, HIV-testing behavior, and potential barriers to HIV testing.Results: Among respondents, 15% had access to rapid HIV testing. In multivariable analysis, physicians were more likely to report access to rapid testing if they were non-white (OR 0.45, 95% CI 0.22, 0.91), had more years since completing training (OR 1.06, 95% CI 1.02, 1.10), practiced in the northeastern US (OR 2.35; 95% CI 1.28, 4.32), or their practice included a higher percentage of uninsured patients (OR 1.03; 95% CI 1.01, 1.04). Internists with access to rapid testing reported fewer barriers to HIV testing. More respondents with rapid than standard testing reported at least 25% of their patients received HIV testing (51% versus 35%, p = 0.02). However, access to rapid HIV testing was not significantly associated with the estimated proportion of patients receiving HIV testing within the previous 30 days (7.24% vs. 4.58%, p = 0.06).Conclusion: Relatively few internists have access to rapid HIV testing in outpatient settings, with greater availability of rapid testing in community-based clinics and in the northeastern US. Future research may determine whether access to rapid testing in primary care settings will impact routinizing HIV testing. [ABSTRACT FROM AUTHOR]

Background: Health care providers may be concerned that prescribing erectile dysfunction drugs (EDD) will contribute to risky sexual behavior.Objectives: To identify characteristics of men who received EDD prescriptions, determine whether EDD receipt is associated with risky sexual behavior and sexually transmitted diseases (STDs), and determine whether these relationships vary for certain sub-groups.Design: Cross-sectional study.Participants: Two thousand seven hundred and eighty-seven sexually-active, HIV-infected and HIV-uninfected men recruited from eight Veterans Health Affairs outpatient clinics. Data were obtained from participant surveys, electronic medical records, and administrative pharmacy data.Measures: EDD receipt was defined as two or more prescriptions for an EDD, risky sex as having unprotected sex with a partner of serodiscordant or unknown HIV status, and STDs, according to self-report.Results: Overall, 28% of men received EDD in the previous year. Eleven percent of men reported unprotected sex with a serodiscordant/unknown partner in the past year (HIV-infected 15%, HIV-uninfected 6%, P < 0.001). Compared to men who did not receive EDD, men who received EDD were equally likely to report risky sexual behavior (11% vs. 10%, p = 0.9) and STDs (7% vs 7%, p = 0.7). In multivariate analyses, EDD receipt was not significantly associated with risky sexual behavior or STDs in the entire sample or in subgroups of substance users or men who had sex with men.Conclusion: EDD receipt was common but not associated with risky sexual behavior or STDs in this sample of HIV-infected and uninfected men. However, risky sexual behaviors persist in a minority of HIV-infected men, indicating ongoing need for prevention interventions. [ABSTRACT FROM AUTHOR]

Background: The incidence of anal cancer has increased in the past decade, especially among men who have sex with men (MSM) and HIV-infected individuals. There is controversy about whether to routinely screen for anal cancer in MSM.Objectives: To determine whether current anal cancer screening behaviors, intention, and concern differ by HIV serostatus and to identify characteristics of men who intend to seek anal cancer screening.Design and Participants: Cross-sectional analysis of data collected from 901 HIV-infected and 1,016 HIV-uninfected MSM from the Multicenter AIDS Cohort Study (MACS) in 2005-2006.Measurements: Self-reported anal cancer screening history, attitudes, and intentions.Results: A history of anal warts was relatively common in these men (39%), whereas having a recent anal Pap test (5%), intention to seek anal cancer screening in the next 6 months (12%), and concern about anal cancer (8.5%) were less common. Intention to seek anal cancer screening was associated with enabling factors (screening availability, health insurance), need factors (HIV-infection, history of anal warts), concern about anal cancer, and recent sexual risk taking. Among four large US cities, there was significant regional variability in anal cancer screening behaviors, intention, and concern (all p<0.001). Most MSM (76%) indicated they would go to their primary care physician for an anal health problem or question.Conclusions: This study demonstrates a low rate of anal cancer screening and intention to screen among MSM. As more evidence emerges regarding screening, primary care physicians should be prepared to discuss anal cancer screening with their patients. [ABSTRACT FROM AUTHOR]

Objective: To compare the ability of 3 brief alcohol screens (Alcohol Use Disorders Identification Test [AUDIT], CRAFFT, and CAGE) to identify adolescents and young adults with a current alcohol use disorder (AUD) and to determine whether there are gender-based or race-based differences in screening performance.Design, Participants, and Setting: Cross-sectional study of 358 young persons (55% males; 49% blacks; age range, 15-24 years; mean age, 20.6 years) who were attending an urban clinic for sexually transmitted diseases and reported alcohol use during the past year.Measurements: Receiver operating characteristic (ROC) curve analysis was used to determine the ability of the 3 screens to discriminate between participants with and without AUDs detected in the Structured Clinical Interview for DSM-IV (SCID).Results: One third (33%) of participants met Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) criteria for a current AUD (24% with alcohol abuse and 9% with alcohol dependence). The AUDIT performed best at a cut score of 9 (sensitivity, 0.76; specificity, 0.79), CRAFFT at a cut score of 2 (sensitivity, 0.94; specificity, 0.33), and CAGE at a cut score of 1 (sensitivity, 0.69; specificity, 0.63). The AUDIT had the best overall performance (area under the curve [AUC], 0.84), followed closely by CRAFFT (AUC, 0.79) and then CAGE (AUC, 0.70). Performance of screens did not differ by gender. The AUDIT performed slightly better in whites than blacks, but no race-based differences were observed for the CAGE or CRAFFT.Conclusions: Clinicians should use the AUDIT or CRAFFT, rather than the CAGE, to screen young persons for AUDs. The AUDIT performs best, but its length may limit its utility in this setting. The CRAFFT is a suitable alternative, with excellent sensitivity and no gender-based or race-based differences. [ABSTRACT FROM AUTHOR]

This cross-sectional study sought to determine the prevalence of smoking, readiness to quit, and preferences for smoking cessation treatments among a sample of 236 homeless adults attending 9 sites serving homeless persons (mean age 41.8 years; 73% male). Two thirds (69%) were current smokers, of whom 37% reported readiness to quit smoking within the next 6 months. In bivariate analyses, persons were significantly ( P < .05) more likely to be ready to quit if they had tried to quit in the past and if they had social support to quit smoking. Nicotine replacement was the most commonly preferred assistance method (44%), and self-efficacy to quit (10-point scale) was significantly greater if assistance was available (7.3 vs 4.9; P < .001). The findings suggest an urgent need to develop and implement smoking cessation programs for homeless persons. [ABSTRACT FROM AUTHOR]

Objective: To examine the relation between problem drinking and medication adherence among persons with HIV infection.Design: Cross-sectional survey.Setting/participants: Two hundred twelve persons with HIV infection who visited 2 outpatient clinics between December 1997 and February 1998.Measurements and Main Results: Nineteen percent of subjects reported problem drinking during the previous month, 14% missed at least 1 dose of medication within the previous 24 hours, and 30% did not take their medications as scheduled during the previous week. Problem drinkers were slightly more likely to report a missed dose (17% vs 12 %, P =.38) and significantly more likely to report taking medicines off schedule (45% vs 26%, P =.02). Among drinking subtypes, taking medications off schedule was significantly associated with both heavy drinking (high quantity/frequency) (adjusted odds ratio [OR], 4.70; 95% confidence interval [95% CI], 1.49 to 14.84; P <.05) and hazardous drinking (adjusted OR, 2.64; 95% CI, 1.07 to 6.53; P <.05). Problem drinkers were more likely to report missing medications because of forgetting (48% vs 35%, P =.10), running out of medications (15% vs 8%, P =.16), and consuming alcohol or drugs (26 % vs 3 %, P <.001).Conclusion: Problem drinking is associated with decreased medication adherence, particularly with taking medications off schedule during the previous week. Clinicians should assess for alcohol problems, link alcohol use severity to potential adherence problems, and monitor outcomes in both alcohol consumption and medication adherence. [ABSTRACT FROM AUTHOR]

The article reviews the article "Routine Rapid HIV Screening in Six Community Health Centers Serving Populations at Risk," by Janet J. Myers, Cheryl Modica, Mi-Suk Kang Dufor, Caryn Bernstein, and Kathleen McNamara, which appeared within this issue of the "Journal of General Internal Medicine."