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Purpose: To investigate the prevalence of opioid use disorder (OUD) and medication treatment for OUD (MOUD) receipt in rural primary care settings and identify characteristics associated with MOUD among patients with OUD. Methods: Secondary analyses based on electronic health records of all adult patients who visited 1 of the 6 rural primary care clinic sites from October 2019 to January 2021. Mixed effects logistic regression was conducted to assess MOUD receipt (Y/N) in relation to patient characteristics (eg, demographics, other substance use disorders [SUDs], mental health disorders, and chronic pain) and the number of MOUD prescribers per clinic. Findings: The prevalence of OUD varied from 0.7% to 8.2% (Mean [SD] = 3.3% [95% CI: 0.4, 6.1]) among 36,762 primary care patients across 6 clinic sites. Among 1,164 patients with OUD, on average 50.1% received MOUD (95% CI: 28.0, 72.3). Patients in clinics with more than 3 MOUD prescribers had more than 3 times the odds of receiving MOUD (OR = 3.42; 95% CI, 1.22‐9.62) as those in clinics with fewer than 3 prescribers. MOUD was positively associated with younger age (18‐30 [OR = 6.97; 95% CI, 3.37‐14.42], 31‐64 [OR = 5.03; 95% CI, 2.64‐9.57], relative to those 65 and older), having other co‐occurring SUDs (OR = 3.77; 95% CI, 2.57‐5.52), being male (OR = 1.50; 95% CI, 1.12‐2.01), and negatively associated with having chronic pain disorders (OR = 0.69; 95% CI, 0.50‐0.94). Conclusions: The prevalence of OUD and MOUD are high but vary considerably across rural primary care clinics; primary care MOUD prescribers play a key role on MOUD access in rural settings. [ABSTRACT FROM AUTHOR]

Background: Promoting uptake of evidence-based innovations in healthcare systems requires attention to how innovations are adapted to enhance their fit with a given setting. Little is known about real-world variation in how programs are delivered over time and across multiple populations and contexts, and what motivates adaptations.Methods: As part of the BeneFIT study of mailed fecal immunochemical tests (FIT) to increase colorectal cancer screening, we interviewed 9 leaders from two participating Medicaid/Medicare health insurance plans to examine adaptations to their health plan-initiated mailed FIT outreach programs in the second year of implementation. We applied an adaptation and modification model developed by Stirman and colleagues to document content and context modifications made to the two programs.Results: Both health plans made substantial changes to their programs in the second year; adaptations differed substantially across health plans. In Health Plan Oregon, adaptations generally targeted health centers and member populations, most content adaptations involved tailoring program components, and the program was expanded to four additional health centers. In contrast, Health Plan Washington's second-year content adaptations were primarily at the level of members, and generally involved adding program components. Moreover, Health Plan Washington undertook large-scale context adaptations to the setting where the program was led (local vs. national), the personnel who administered the program (vendor and staffing), and the population selected for outreach (limiting outreach to dual-eligible members).Conclusions: Both programs implemented a variety of adaptations that reflected the values and incentives of the broader health plan contexts. Financial incentives for screening allowed Health Plan Oregon to expand but led Health Plan Washington to offer more targeted outreach to a subset of eligible enrollees. The breadth of changes made by each health system reflects the necessity of evaluating programs in context and adjusting to specific challenges as they are identified. Further research is needed to understand the effects of these types of adaptations on program efficiency and enrollee and health system outcomes. [ABSTRACT FROM AUTHOR]

We use prescription of statin medications and prescription of warfarin to explore the capacity of electronic health record data to (1) describe cohorts of patients prescribed these medications and (2) identify cohorts of patients with evidence of adverse events related to prescription of these medications. This study was conducted in the WWAMI region Practice and Research Network (WPRN)., a network of primary care practices across Washington, Wyoming, Alaska, Montana and Idaho DataQUEST, an electronic data-sharing infrastructure. We used electronic health record data to describe cohorts of patients prescribed statin or warfarin medications and reported the proportions of patients with adverse events. Among the 35,445 active patients, 1745 received at least one statin prescription and 301 received at least one warfarin prescription. Only 3 percent of statin patients had evidence of myopathy; 51 patients (17% of those prescribed warfarin) had a bleeding complication. Primary-care electronic health record data can effectively be used to identify patients prescribed specific medications and patients potentially experiencing medication adverse events. [ABSTRACT FROM AUTHOR]

Background: Patients with chronic kidney disease (CKD) are at high risk for adverse drug events related to medication dosing errors and prescriptions for relatively contraindicated medications, such as non-steroidal anti-inflammatory drugs (NSAIDs).Objectives: To examine the scope of and variation in prescribing relatively contraindicated medications and medications above the recommended dose levels among patients with stage III/IV CKD in primary care practice.Methods: This is a cross-sectional descriptive study that used structured electronic health record data. The study participants were patients aged 18 years and older from three primary care clinics in a practice-based research network. Number/proportion of adult patients with stage III/IV CKD; proportion of these patients with at least one NSAID or other relatively contraindicated medication prescribed over 2 years.Results: Of the 7586 eligible adult patients, 4.9% had stage III/IV CKD; 46.6% of these 373 patients with stage III/IV CKD were prescribed at least one relatively contraindicated drug (acarbose, chlorpropamide, glyburide, nitrofurantoin or any NSAID) during the 2-year study period; and 34.0% of patients with stage III/IV CKD were prescribed NSAIDs.Conclusions: Primary care patients with stage III/IV CKD were frequently prescribed or had documented use of relatively contraindicated drugs and thus were at risk of adverse drug events. Given the significant number of individuals with CKD in the USA, research that examines rates of adverse events related to these prescriptions and that tests primary care-based interventions to decrease inappropriate prescribing of relatively contraindicated medications to these patients is needed. [ABSTRACT FROM AUTHOR]

Background: Point-of-care tests (POCTs) are increasingly used in family medicine clinics in the United States. While the diagnostics industry predicts significant growth in the number and scope of POCTs deployed, little is known about clinic-level attitudes towards implementation of these tests. We aimed to explore attitudes of primary care providers, laboratory and clinic administrative/support staff to identify barriers and facilitators to use of POCTs in family medicine. Methods: Seven focus groups and four semi-structured interviews were conducted with a total of 52 clinic staff from three family medicine clinics in two US states. Qualitative data from this exploratory study was analyzed using the constant comparison method. Results: Five themes were identified which included the impact of POCTs on clinical decision-making; perceived inaccuracy of POCTs; impact of POCTs on staff and workflow; perceived patient experience and patient-provider relationship, and issues related to cost, regulation and quality control. Overall, there were mixed attitudes towards use of POCTs. Participants believed the added data provided by POCT may facilitate prompt clinical management, diagnostic certainty and patient-provider communication. Perceived barriers included inaccuracy of POCT, shortage of clinic staff to support more testing, and uncertainty about their cost-effectiveness. Conclusions: The potential benefits of using POCTs in family medicine clinics are countered by several barriers. Clinical utility of many POCTs will depend on the extent to which these barriers are addressed. Engagement between clinical researchers, industry, health insurers and the primary care community is important to ensure that POCTs align with clinic and patient needs. [ABSTRACT FROM AUTHOR]

BACKGROUND: Studies have shown a mismatch between published cancer screening and genetic counseling referral recommendations and physician-reported screening and referral practices. Inaccurate cancer risk assessment is one potential cause of this mismatch. OBJECTIVE: To assess U.S. physicians' ability to accurately determine a woman's colon and ovarian cancer risk level. DESIGN, PARTICIPANTS: Cross-sectional survey of U.S. family physicians, general internists, and obstetrician-gynecologists. A twelve-page questionnaire with a vignette of a woman's annual examination included a question about the patient's level of colon and ovarian cancer risk. The final study sample included 1,555 physicians weighted to represent practicing U.S. physicians nationally. MAIN MEASURE: Accuracy of physicians' ovarian and colon cancer risk assessments. KEY RESULTS: Overall, most physicians accurately assessed women's risk of ovarian (57.0 %, CI 54.3, 59.6) and colon cancer (62.0 %, CI 59.4, 64.6). However, 27.1 % (CI 23.0, 31.6) of physicians overestimated the ovarian cancer risk among women at the same risk as the general population, and 65.1 % (CI 60.2, 69.7) underestimated ovarian cancer risk among women at much higher risk than the general population. Physicians overestimated colon more than ovarian cancer risk (38.0 %, CI 35.4, 40.6 vs. 27.1 %, CI 23.0, 31.6) for women at the same risk as the general population. CONCLUSIONS: Physicians' misestimation of patient ovarian and colon cancer risk may put average risk patients in jeopardy of unnecessary screening and higher risk patients in jeopardy of missed opportunities for prevention or early detection of cancers. [ABSTRACT FROM AUTHOR]

Background: Ambulatory care sensitive hospitalizations (ACSHs) are commonly used as measures of access to and quality of care. They are defined as hospitalizations for certain acute and chronic conditions; yet, they are most commonly used in analyses comparing different groups without adjustment for individual-level comorbidity. We present an exploration of their roles in predicting ACSHs for acute and chronic conditions. Methods: Using 1998–99 US Medicare claims for 1 06 930 SEER-Medicare control subjects and 1999 Area Resource File data, we modelled occurrence of acute and chronic ACSHs with logistic regression, examining effects of different predictors on model discriminatory power. Results: Flags for the presence of a few comorbid conditions—congestive heart failure, chronic obstructive pulmonary disease, diabetes, hypertension and, for acute ACSHs, dementia—contributed virtually all of the discriminative ability for predicting ACSHs. C-statistics were up to 0.96 for models predicting chronic ACSHs and up to 0.87 for predicting acute ACSHs. C-statistics for models lacking comorbidity flags were lower, at best 0.73, for both acute and chronic ACSHs. Conclusion: Comorbidity is far more important in predicting ACSH risk than any other factor, both for acute and chronic ACSHs. Imputations about quality and access should not be made from analyses that do not control for presence of important comorbid conditions. Acute and chronic ACSHs differ enough that they should be modelled separately. Unaggregated models restricted to persons with the relevant diagnoses are most appropriate for chronic ACSHs. [ABSTRACT FROM PUBLISHER]

Background: No professional society or group recommends routine ovarian cancer screening, yet physicians' enthusiasm for several cancer screening tests before benefit has been proven suggests that some women may be exposed to potential harms. Objective: To provide nationally representative estimates of physicians' reported nonadherence to recommendations against ovarian cancer screening. Design: Cross-sectional survey of physicians offering women's primary care. The 12-page questionnaire contained a woman's annual examination vignette and questions about offers or orders for transvaginal ultrasonography (TVU) and cancer antigen 125 (CA-125). Setting: United States. Participants: 3200 physicians randomly sampled equally from the 2008 American Medical Association Physician Masterfile lists of family physicians, general internists, and obstetrician-gynecologists; 61.7% responded. After exclusions, 1088 respondents were included; their responses were weighted to represent the specialty distribution of practicing U.S. physicians nationally. Measurements: Reported nonadherence to screening recommendations (defined as sometimes or almost always ordering screening TVU or CA-125 or both). Results: Twenty-eight percent (95% CI, 24.5% to 32.9%) of physicians reported nonadherence to screening recommendations for women at low risk for ovarian cancer; 65.4% (CI, 61.1% to 69.4%) did so for women at medium risk for ovarian cancer. Six percent (CI, 4.4% to 8.9%) reported routinely ordering or offering ovarian cancer screening for low-risk women, as did 24.0% (CI, 20.5% to 28.0%) for medium-risk women (P ≤0.001). Thirtythree percent believed TVU or CA-125 was an effective screening test. In adjusted analysis, actual and physician-perceived patient risk, patient request for ovarian cancer screening, and physician belief that TVU or CA-125 was an effective screening test were the strongest predictors of physician-reported nonadherence to published recommendations. Limitation: The results are limited by their reliance on survey methods; there may be respondent-nonrespondent bias. Conclusion: One in 3 physicians believed that ovarian cancer screening was effective, despite evidence to the contrary. Substantial proportions of physicians reported routinely offering or ordering ovarian cancer screening, thereby exposing women to the documented risks of these tests. Primary Funding Source: Centers for Disease Control and Prevention and the National Cancer Institute. [ABSTRACT FROM AUTHOR]

BACKGROUND: Genetic counseling and testing is recommended for women at high but not average risk of ovarian cancer. National estimates of physician adherence to genetic counseling and testing recommendations are lacking. METHODS: Using a vignette-based study, we surveyed 3200 United States family physicians, general internists, and obstetrician/gynecologists and received 1878 (62%) responses. The questionnaire included an annual examination vignette asking about genetic counseling and testing. The vignette varied patient age, race, insurance status, and ovarian cancer risk. Estimates of physician adherence to genetic counseling and testing recommendations were weighted to the United States primary care physician population. Multivariable logistic regression identified independent patient and physician predictors of adherence. RESULTS: For average-risk women, 71% of physicians self-reported adhering to recommendations against genetic counseling or testing. In multivariable modeling, predictors of adherence against referral/testing included black versus white race (relative risk [RR], 1.16; 95% confidence interval [CI], 1.03-1.31), Medicaid versus private insurance (RR, 1.15; 95% CI, 1.02-1.29), and rural versus urban location. Among high-risk women, 41% of physicians self-reported adhering to recommendations to refer for genetic counseling or testing. Predictors of adherence for referral/testing were younger patient age [35 vs 51 years [RR, 1.78; 95% CI, 1.41-2.24]), physician sex (female vs male [RR, 1.30; 95% CI, 1.07-1.64]), and obstetrician/gynecologist versus family medicine specialty (RR, 1.64; 95% CI, 1.31-2.05). For both average-risk and high-risk women, physician-estimated ovarian cancer risk was the most powerful predictor of recommendation adherence. CONCLUSION: Physicians reported that they would refer many average-risk women and would not refer many high-risk women for genetic counseling/testing. Intervention efforts, including promotion of accurate risk assessment, are needed. Cancer 2011;. © 2011 American Cancer Society. [ABSTRACT FROM AUTHOR]

Objective: This project aimed to develop an open-access website providing adaptable resources to facilitate best practices for multisite research from initiation to closeout. Methods: A web-based assessment was sent to the leadership of the Clinical and Translational Science Award (CTSA) Community Engagement Key Functions Committee ( n= 38) and the CTSA-affiliated Primary Care Practice-based Research Networks (PBRN, n= 55). Respondents rated the benefits and barriers of multisite research, the utility of available resources, and indicated their level of interest in unavailable resources. Then, existing research resources were evaluated for relevance to multisite research, adaptability to other projects, and source credibility. Results: Fifty-five (59%) of invited participants completed the survey. Top perceived benefits of multisite research were the ability to conduct community-relevant research through academic-community partnerships (34%) and accelerating translation of research into practice (31%). Top perceived barriers were lack of research infrastructure to support PBRNs and community partners (31%) and inadequate funding to support multisite collaborations (26%). Over 200 resources were evaluated, of which 120 unique resources were included in the website. Conclusion: The PRIMER Research Toolkit () provides an array of peer-reviewed resources to facilitate translational research for the conduct of multisite studies within PBRNs and community-based organizations. Clin Trans Sci 2011; Volume 4: 259-265 [ABSTRACT FROM AUTHOR]

The article discusses research on the relations between geographic variation and racial/ethnic disparities in colorectal cancer (CRC) screening among Medicare patients. An up-to-date CRC screening was conducted among Medicare enrollees within 8 U.S. states on December 31, 2003. Results revealed that racial-ethnic disparities among black and Asian/Pacific Islanders Medicare enrollees varies geographically across the country.

Context: The Indian Health Service (IHS), whose per capita expenditure for American Indian and Alaska Native (AI/AN) health services is about half that of the US civilian population, is the only source of health care funding for many rural AI/ANs. Specialty services, largely funded through contracts with outside practitioners, may be limited by low IHS funding levels. Purpose: To examine specialty service access among rural Indian populations in two states. Methods: A 31-item mail survey addressing perceived access to specialty physicians, barriers to access, and access to non-physician clinical services was sent to 106 primary care providers in rural Indian health clinics in Montana and New Mexico (overall response rate 60.4%) and 95 primary care providers in rural non-Indian clinics within 25 miles of the Indian clinics (overall response rate 57.9%). Findings: Substantial proportions of rural Indian clinic providers in both states reported fair or poor non-emergent specialty service access for their patients. Montana's rural Indian clinic providers reported poorer patient access to specialty care than rural non-Indian clinic providers, while New Mexico's rural Indian and non-Indian providers reported comparable access. Indian clinic providers in both states most frequently cited financial barriers to specialty care. Indian clinic providers reported better access to most non-physician services than non-Indian clinic providers. Conclusions: Reported limitations in specialty care access for rural Indian clinic patients appear to be influenced by financial constraints. Health care systems factors may play a role in perceived differences in specialty access between rural Indian and non-Indian clinic patients. [ABSTRACT FROM AUTHOR]

Background: This study examined elderly stage II and III rectal cancer patients' adjuvant chemoradiation therapy adherence, trends in adherence over time, and the relation of levels of adherence to mortality.Methods: The authors studied 2886 stage II and III rectal cancer patients who had surgical resection and who appeared in 1992-1999 linked SEER-Medicare claims data. The authors compared measures of adjuvant radiation and chemotherapy receipt and completion between stage II and III patients. Adjusted risk of cancer-related 5-year mortality was calculated by multivariate logistic regression for different levels of chemoradiation adherence among stage II and III patients.Results: Of the 2886 patients, 45.4% received both adjuvant radiation and chemotherapy. Stage III patients were more likely to receive chemoradiation than stage II patients. The receipt of chemoradiation by stage II patients increased significantly from 1992 to 1999. Stage III patients were more likely to complete radiation therapy (96.6%), chemotherapy (68.2%), and both modalities (67.5%) than stage II patients (91.5%, 49.8%, 47.6%, respectively). Only a complete course of both radiation and chemotherapy for both stage II (relative risk [RR] 0.74; 95% CI, 0.54, 0.97) and III (RR 0.80; 95% CI, 0.65, 0.96) decreased the adjusted 5-year cancer mortality risk compared with counterparts with no adjuvant therapy.Conclusions: Even though stage II rectal cancer patients were less likely than stage III patients to receive and complete adjuvant chemoradiation, both patient groups in the general population had lower cancer-related mortality if they completed chemoradiation. These patients deserve support and encouragement to complete treatment. [ABSTRACT FROM AUTHOR]

The article provides information on a study which evaluated the surgical treatment received by patients with ovarian cancer in nine U.S. states. The study identified the patient, physician, ecologic and hospital-based factors associated with receipt of comprehensive surgical treatment. The research also addressed the issue concerning the absence of published information on the percentage of patients with ovarian cancer in the U.S. who receive surgical care from physicians who perform high volumes of ovarian cancer surgery.

Objective. To determine geographic variation in urban American Indian and Alaska Native (AI/AN) rates of infant mortality, low birth weight, prenatal care use, and maternal-child health care service availability. Methods. This was a retrospective cohort study using data from the 1989 to 1991 birth-death linked database from the National Center for Health Statistics. We examined births from metropolitan areas with a minimum of 300 AI/AN births during the study period. Key outcomes of interest included rates of low birth weight, neonatal mortality, postneonatal mortality, and women receiving inadequate prenatal care using the modified Kessner index. To determine the type of health services tailored to AI/AN mothers residing in these urban areas, we conducted a telephone survey of the 36 urban Indian health programs operating in 1997 using a semistructured survey. Items in the survey included questions about the availability of prenatal and infant health care. Results. During the 1989 to 1991 study period, there were 72 730 singleton births to AI/AN mothers and/or fathers residing in urban areas, representing 49% of all AI/AN births in the United States. Overall 14.4% of urban AI/AN births were to women who received inadequate care during pregnancy, 5.7% of pregnancies resulted in low birth weight infants, and 11.0 infants died per 1000 live births. Death rates for the neonatal period (5.5 per 1000 births) and postneonatal period (5.4 per 1000 births) were similar. Marked disparity in these indicators exist between pregnancies to AI/AN and white women. Among the 54 metropolitan areas, 46 had a rate ratio (AI/AN: white) for inadequate care of ≥1.5 (range: 0.9-8.5). The mean rate ratios for neonatal and postneonatal mortality were 1.6 (range: 0.3-4.0) and 2.0 (range: 0.5-5.5). There was also considerable geographic variation of AI/AN mortality rates between metropolitan areas in all of the outcomes studied. All of the 20 metropolitan areas with the highest... [ABSTRACT FROM AUTHOR]

OBJECTIVE Our goal was to compare the quality of diabetic care received by patients in rural and urban communities. STUDY DESIGN We performed a retrospective analysis of claims data captured by the Medicare program. POPULATION We included all fee-for-service Medicare patients 65 years and older living in the state of Washington who had 2 or more physician encounters for diabetes care during 1994. OUTCOME MEASURES The outcomes were the extent to which patients received 3 specific recommended services: glycated hemoglobin determination, cholesterol measurement, and eye examination. RESULTS A total of 30,589 Medicare patients (8.4%) were considered to have diabetes; 29.1% lived in rural communities. Generalists provided most diabetic care in all locations. Patients living in small rural towns received almost half their outpatient care in larger communities. Patients living in large rural towns remote from metropolitan areas were more likely to have received the recommended tests than patients in all other groups. Patients who saw an endocrinologist at least once during the year were more likely to have received the recommended tests. CONCLUSIONS Large rural towns may provide the best conditions for high-quality care: They are vibrant, rapidly growing communities that serve as regional referral centers and have an adequate--but not excessive--supply of both generalist and specialist physicians. Generalists provide most diabetic care in all settings, and consultation with an endocrinologist may improve adherence to guidelines. [ABSTRACT FROM AUTHOR]

Objectives. Over 80% of US states have implemented expansions in prenatal services for Medicaid-enrolled women, including case management, nutritional and psychosocial counseling, health education, and home visiting. The study evaluated the effect of Washington State's expansion of such services on prenatal care use and low-birthweight rates. Methods. The change in prenatal care use and low-birthweight rates among Washington's Medicaid-enrolled pregnant women before and after initiation of expanded prenatal services was compared with the change in these outcomes in Colorado, a control state. Results. The percentage of expected prenatal visits completed increased significantly, from 84% to 87%, in both states Washington's low-birthweight rate decreased (7.1% to 6.4%, P=12), while Colorado's rate increased slightly (10.4% to 10.6%, P=.74). Washington's improvement was largely due to decrease in low-birthweight rates for medically high-risk women (18.0% to 13.7%, P=.01, for adults, 22.5% to 11.5%, P=.03, for teenagers), especially those with preexisting medical conditions. Conclusions. A statewide Medicaid-sponsored support service and case management program was associated with a decrease in the low-birthweight rate of medically high-risk women. [ABSTRACT FROM AUTHOR]

Context: The National Practitioner Data Bank (NPDB) is believed to be an important source of information for peer review activities by the majority of those who use it. However, concern has been raised that hospitals may be underreporting physicians with performance problems to the NPDB.Objective: To examine variation in clinical privileges action reporting by hospitals to the NPDB, changes in reporting over time, and the association of hospital characteristics with reporting.Design: Retrospective cohort study of privileges action reports to the NPDB between 1991 and 1995, linked with the 1992 and 1995 databases from the Annual Survey of Hospitals conducted by the American Hospital Association.Setting and Participants: A total of 4743 short-term, nonfederal, general medical/surgical hospitals throughout the United States that were continuously open between 1991-1995 and registered with the NPDB.Main Outcome Measures: (1) Reporting of 1 or more privileges actions during the 5-year study period and (2) privileges action reporting rates (numbers of actions reported per 100000 admissions).Results: Study hospitals reported 3328 privileges actions between 1991 and 1995; 34.2% reported 1 or more actions during the period. The range of privileges action reporting rates for these hospitals was 0.40 to 52.27 per 100000 admissions, with an overall rate of 2.36 per 100000 admissions. The proportion of hospitals reporting an action decreased from 11.6% in 1991 to 10.0% in 1995 (P=.008). After adjustment for other factors, urban hospitals had significantly higher reporting than rural hospitals (adjusted odds ratio [OR], 1.21 [95% confidence interval [CI], 1.02-1.43]), while members of the Council of Teaching Hospitals of the Association of American Medical Colleges had significantly lower reporting than nonmembers (adjusted OR, 0.54 [95% CI, 0.40-0.73]). There were notable regional differences in reporting, with the east south Central region having the lowest rate per 100000 admissions (1.49 [95% CI, 1.33-1.65]).Conclusions: The results of this study indicate a low and declining level of hospital privileges action reporting to the NPDB. Several potential explanations exist, 1 of which is that the information reported to the NPDB is incomplete. [ABSTRACT FROM AUTHOR]

Objectives. This study examined hospital administrators' experiences with the National Practitioner Data Bank. Methods. One hundred forty-nine rural hospital administrators completed questionnaires assessing their perceptions of the data bank. Results. Nearly 90% of respondents rated the data bank as an important source of information for credentialing. Three percent indicated it had directly affected privileging decisions; 43% and 34%, respectively, believed the costs exceeded or equaled the benefits. Twenty percent reported changes that could decrease disciplinary action reports to the data bank. Conclusions. While the National Practitioner Data Bank is an important source of information to rural hospitals, it may affect few credentialing decisions and motivate behavioral changes that could have a paradoxical effect on quality assurance. [ABSTRACT FROM AUTHOR]

Examines the effect of different levels of exposure to malpractice claims on the prenatal care resources and the delivery method used by Washington State physicians. Results suggesting that the malpractice experience of individual physicians is not associated with an increase in the use of prenatal resources or cesarean deliveries for the care of low-risk obstetric.

Evaluates Pike Market Clinic (PMC), a multidisciplinary care center. Medical care for downtown low-income elderly in Seattle; Comparison between PMC users and users of other medical centers; Medical and social service use; Quality of care; Patient satisfaction; Mean annual charges/person; Similarity in demographic and health status characteristics of two groups; Utilization differences.

Objectives: Birth certificates are a major source of population-based data on maternal and perinatal health, but their value depends on the accuracy of the data. This study assesses the validity of information recorded on the birth certificates for women in Washington State who were considered to be low risk at entry into care. Methods: Birth certificates were matched to data abstracted from prenatal and intrapartum clinic and hospital records of a sample of 1937 Washington State obstetrical patients who were considered to be low risk at the beginning of their pregnancies. Accuracy of a variety of pregnancy characteristics (e.g., complications, procedures) on the birth certificate was analyzed using percentage agreement and sensitivity with record abstracts as the “gold standard.” Next, we weighted the data from each source to produce estimates of pregnancy characteristics in the population. We compared these estimates from the two data sources to see whether they provide similar pictures of this subpopulation. Results: Missing data for specific items on the birth certificates ranged from 0% to 24%. The birth certificate accurately captured gravidity and parity, but was less likely to report prenatal and intrapartum complications. The population estimates of the two data sources were significantly different. Conclusions: Because birth certificates significantly underestimated the complications of pregnancies, number of interventions, number of procedures, and prenatal visits, use of these data for health policy development or resource allocation should be tempered with caution. [ABSTRACT FROM AUTHOR]

The article presents a study on the relationship between Medicare coverage, the marketing strategies of computer-aided detection (CAD) mammography, and uptake of CAD in the U.S. The study estimated the prevalence of CAD use during screening mammography among samples of Medicare enrollees. The findings showed that Medicare coverage can be linked with rapid diffusion of preventive technologies. Factors that may have aided the effort to lobby members of Congress to sponsor legislation adding Medicare benefits for digital mammography techniques are explored.

Over the past two decades, the health research enterprise has matured rapidly, and many recognize an urgent need to translate pertinent research results into practice, to help improve the quality, accessibility, and affordability of US healthcare. Streamlining research operations would speed translation, particularly for multisite collaborations. However, the culture of research discourages reusing or adapting existing resources or study materials. Too often, researchers start studies and multisite collaborations from scratch-reinventing the wheel. Our team developed a compendium of resources to address inefficiencies and researchers' unmet needs and compiled them in a research toolkit website (). Through our work, we identified philosophical and operational issues related to disseminating the tool kit to the research community. We explore these issues here, with implications for the nation's investment in biomedical research. Clin Trans Sci 2011; Volume 4: 266-267 [ABSTRACT FROM AUTHOR]

This article presents a study that investigated the impact of thrombolytic therapy on the outcome of acute ischemic stroke. Randomized controlled trials of thrombolysis in acute ischemic stroke have produced variable results. Nonetheless, on the basis of the National Institute of Neurological Disorders and Stroke trial, the U.S. Food and Drug Administration has licensed tissue-plasminogen activator (t-PA) for use within 3 hours of onset of an acute ischemic stroke. The authors performed an extensive search of the published literature using multiple strategies and also contacted investigators for unpublished data. Randomized trials were included if the investigators were blinded to the treatment at its outset, if the study groups differed only with the treatment of interest and if the trials could be analyzed on an intention-to-treat basis. Any trial that did not adequately account for patient follow-up was excluded. Twelve trials with 3435 patients met the inclusion criteria. Three trials used urokinase, four stertokinase and five t-PA. The aggregate study data showed a 6.5 percent absolute reduction in risk of death or dependency with thrombolysis, 61.5 percent with treatment and 68.0 percent for controls.

Background: Most people with alcohol or opioid use disorders (AUD or OUD) are not diagnosed or treated for these conditions in primary care. This study takes a critical step toward quantifying service gaps and directing improvement efforts for AUD and OUD by using electronic health record (EHR) data from diverse primary care organizations to quantify the extent to which AUD and OUD are underdiagnosed and undertreated in primary care practices.Methods: We extracted and integrated diagnosis, medication, and behavioral health visit data from the EHRs of 21 primary care clinics within four independent healthcare organizations representing community health centers and rural hospital-associated clinics in the Pacific Northwest United States. Rates of documented AUD and OUD diagnoses, pharmacological treatments, and behavioral health visits were evaluated over a two-year period (2015-2016).Results: Out of 47,502 adult primary care patients, 1476 (3.1%) had documented AUD; of these, 115 (7.8%) had orders for AUD medications and 271 (18.4%) had at least one documented visit with a non-physician behavioral health specialist. Only 402 (0.8%) patients had documented OUD, and of these, 107 (26.6%) received OUD medications and 119 (29.6%) had at least one documented visit with a non-physician behavioral health specialist. Rates of AUD diagnosis and AUD and OUD medications were higher in clinics that had co-located non-physician behavioral health specialists.Conclusions: AUD and OUD are underdiagnosed and undertreated within a sample of independent primary care organizations serving mostly rural patients. Primary care organizations likely need service models, technologies, and workforces, including non-physician behavioral health specialists, to improve capacities to diagnose and treat AUD and OUD. [ABSTRACT FROM AUTHOR]

The article discusses a study on the factors associated with the decision by physicians to refer patients with a suspected ovarian mass to gynecologic oncologists in the U.S. The study involved 3,200 physicians whose ages ranged between 64 and younger. They were asked to respond to a vignette-based survey that examined their approach to managing care for women's health. The study found that physicians in small and remote rural practice locations were more likely to issue referral.

Background: The aim of this study was to assess the relationship between surgeon and hospital volume and major postoperative complications after rectal cancer surgery, and to define other surgeon and hospital characteristics that may explain observed volume-complication relationships.Study Design: This was a retrospective cohort design using data from the Surveillance, Epidemiology, and End Results (SEER) cancer registry program for individuals with stage I to III rectal cancer diagnosed between 1992 and 1999 and treated with resection. The patients' Surveillance, Epidemiology, and End Results data were linked with Medicare claims data from 1991 to 2000. The primary outcomes were 30-day postoperative procedural interventions (PPI) to treat surgical complications, such as reoperation. The association between surgeon volume and PPI was examined using logistic regression modeling with adjustment for covariates.Results: The odds of a rectal cancer patient requiring a PPI is notably less if the operation is performed by one of a small subset of very high volume surgeons (unadjusted odds ratio 0.53; 95% CI 0.31 to 0.92). Board certification in colorectal surgery did not alter the relationship between surgeon volume and PPI, although surgeon age did, with mid-career surgeons having the lowest rates of PPI, regardless of practice volume. When adjusted for surgeon age, surgeon volume is no longer a marked predictor of complications (adjusted odds ratio 0.57; 95% CI 0.30 to 1.09).Conclusions: Overall, rectal cancer operations are safe, with a low frequency of severe complications. A subset of very high volume rectal surgeons performs these operations with fewer complications that require procedural intervention or reoperation. Surgeon age, as an indicator of experience, also contributes modestly to outcomes. These data do not justify regionalizing rectal cancer care based on safety concerns. [ABSTRACT FROM AUTHOR]

Introduction: Opioid and alcohol use disorders are increasingly being addressed in primary care, yet how medications to treat these disorders are prescribed in rural regions is unknown., Methods: We determined prevalence, types, and duration of medication prescription for opioid and/or alcohol use disorder among adult patients in rural primary clinics. The sample included 1874 adult patients who visited one of six rural primary care sites in the Northeastern and Northwestern United States at least once from October 2019 to January 2021 and had a diagnosis code for opioid use disorder (OUD), alcohol use disorder (AUD), or co-occurring opioid and alcohol use disorder (OUD + AUD) during that time., Results: Patients with OUD + AUD were more likely to be prescribed medication for at least one of these disorders (85.3 %) than patients with OUD only (63.7 %) or AUD only (10.3 %). Further, the OUD + AUD group had the highest number of days on medication (M = 264.7), followed by OUD only (M = 220.5), then the AUD only group (M = 62.5). Only 8.8 % of patients with OUD + AUD were prescribed naltrexone or medication for OUD + AUD to treat both substance use disorders., Conclusions: Medications for treating AUD as well as OUD are available, but few patients with OUD + AUD and even fewer with AUD received pharmacological treatment for AUD. The current work highlights the need for rural clinicians to consider medications for AUD as an important treatment method for patients with AUD only or OUD + AUD., Competing Interests: Declaration of competing interest None., (Copyright © 2024. Published by Elsevier Inc.)

Objectives: Factors associated with treatment retention on medications for opioid use disorder (MOUD) in rural settings are poorly understood. This study examines associations between social determinants of health (SDoH) and MOUD retention among patients with opioid use disorder (OUD) in rural primary care settings., Methods: We analyzed patient electronic health records from 6 rural clinics. Participants (N = 575) were adult patients with OUD and had any prescription for MOUD from October 2019 to April 2020. MOUD retention was measured by MOUD days and continuity defined as continuous 180 MOUD days with no more than a 7-day gap. Mixed-effect regressions assessed associations between the outcomes and SDoH (Medicaid insurance, social deprivation index [SDI], driving time from home to the clinic), telehealth use, and other covariates., Results: Mean patient MOUD days were 127 days (SD = 50.7 days). Living in more disadvantaged areas (based on SDI) (adjusted relative risk [aRR]: 0.98; 95% confidence interval [CI], 0.98-0.99) and having more than an hour (compared with an hour or less) driving time from home to clinic (aRR: 0.95; 95% CI, 0.93-0.97) were associated with fewer MOUD days. Using telehealth was associated with more MOUD days (aRR: 1.23; 95% CI, 1.21-1.26). In this cohort, 21.7% of the participants were retained on MOUD for at least 180 days. SDoH and use of telehealth were not associated with having continuity of MOUD., Conclusions: Addressing SDoH (eg, SDI) and providing telehealth (eg, improvements in public transportation, internet access) may improve MOUD days in rural settings., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 American Society of Addiction Medicine.)

Background: Health insurance plans are increasingly offering mailed fecal immunochemical test (FIT) programs for colorectal cancer (CRC) screening, but few studies have compared the outcomes of different program models (eg, invitation strategies)., Methods: This study compares the outcomes of 2 health plan-based mailed FIT program models. In the first program (2016), FIT kits were mailed to all eligible enrollees; in the second program (2018), FIT kits were mailed only to enrollees who opted in after an outreach phone call. Participants in this observational study included dual-eligible Medicaid/Medicare enrollees who were aged 50 to 75 years and were due for CRC screening (1799 in 2016 and 1906 in 2018). Six-month FIT completion rates, implementation outcomes (eg, mailed FITs sent and reminders attempted), and program-related health plan costs for each program are described., Results: All 1799 individuals in 2016 were sent an introductory letter and a FIT kit. In 2018, all 1906 were sent an introductory letter, and 1905 received at least 1 opt-in call attempt, with 410 (21.5%) sent a FIT. The FIT completion rate was 16.2% (292 of 1799 [95% CI, 14.5%-17.9%]) in 2016 and 14.6% (278 of 1906 [95% CI, 13.0%-16.2%]) in 2018 (P = .36). The overall implementation costs were higher in 2016 ($40,156) than 2018 ($34,899), with the cost per completed FIT slightly higher in 2016 ($138) than 2018 ($126)., Conclusions: An opt-in mailed FIT program achieved FIT completion rates similar to those of a program mailing to all dual-eligible Medicaid/Medicare enrollees., Lay Summary: Health insurance plans can use different program models to successfully mail fecal test kits for colorectal cancer screening to dual-eligible Medicaid/Medicare enrollees, with nearly 1 in 6 enrollees completing fecal testing., (© 2021 American Cancer Society.)

BeneFIT is a 4-year observational study of a mailed fecal immunochemical test (FIT) program in 2 Medicaid/Medicare health plans in Oregon and Washington. In Health Plan Oregon's (HPO) collaborative model, HPO mails FITs that enrollees return to their clinics for processing. In Health Plan Washington's (HPW) centralized model, FITs are mailed directly to enrollees who return them to a centralized laboratory. This paper examines model-specific Year 1 development and implementation costs and estimates costs per screened enrollee. Staff completed activity-based costing spreadsheets. Non-labor costs were from study and external data. Data matched each plan's 2016 development and implementation dates. HPO development costs were $23.0K, primarily administration (eg, clinic recruitment). HPW development costs were $37.3K, 38.8% for FIT selection and mailing/tracking protocols. Year 1 implementation costs were $51.6K for HPO and $139.7K for HPW, reflecting HPW's greater outreach. Labor was 50.4% ($26.0K) of HPO's implementation costs, primarily enrollee eligibility and processing returned FITs, and was shared by HPO ($17.0K) and 6 participating clinics ($9.0K). Labor was 10.5% of HPW's implementation costs, primarily administration and enrollee eligibility. HPO's implementation costs per enrollee were 12.3% higher ($18.36) than for HPW ($16.34). Similar proportions of completed FITs among screening-eligibles produced a 15% lower cost per completed FIT in HPW ($89.75) vs. HPO ($105.79). Implementation costs for HPO only (without clinic costs) were $15.16/mailed introductory letter, $16.09/mailed FIT, and $87.35/completed FIT, comparable to HPW. Results highlight cost implications of different approaches to implementing a mailed FIT program in 2 Medicaid/Medicare health plans.

According to recent guidelines, 46% of U.S. adults have high blood pressure (i.e., hypertension). Traditionally addressed in clinical settings, only 54% of adults successfully manage their hypertension. Community-clinical partnerships that facilitate medication adherence and lifestyle changes are promising avenues to achieve population-level blood pressure control. We examined partnerships for blood pressure control in Washington State, their facilitators and barriers, and ways public health departments could foster partnerships. We conducted 41 semistructured interviews with clinic staff, community-based organization (CBO) staff, pharmacy staff, and community health workers (CHWs). The Centers for Disease Control and Prevention-adapted Himmelman Collaboration Continuum, which describes five levels of partnership intensity, guided our thematic analysis. We found variation across sectors in partnership frequency and intensity. Clinic and pharmacy staff reported fewer partnerships than CBO staff and CHWs, and mostly either low or very high intensity partnerships. CBO staff and CHWs described partnerships at each intensity level. Trust and having a shared mission facilitated partnerships. Competition, lack of time, limited awareness of resources, and lack of shared health records constituted barriers to partnership. Bringing potential partners together to discuss shared goals, increasing technological integration, and building awareness of resources may help bridge clinical and community silos and improve population-level blood pressure control.

BeneFIT was a demonstration project that worked with a Medicaid/Medicare health plan to implement a mailed fecal immunochemical test (FIT) program. The goal was to reach age-eligible enrollees who were due for colorectal cancer (CRC) screening and prompt them to complete a FIT. One health insurance plan collaborated with six federally qualified health centers (FQHCs) in Oregon. Reach was defined as the percent of eligible individuals overdue for CRC screening who were mailed a FIT in 2016. We examined patient-level factors associated with reach, using multivariable log binomial regression and FIT completion rates at 6 months. The health plan identified 3386 age-eligible members overdue for CRC screening. Of these, 2615 (77.2%) were reached (mailed FIT kits) and 771 (22.8%) were not; 478 (14.1%) because they were not considered to be clinic patients and 290 (8.6%) because of mailing issues. Patient-level factors associated with not being reached were: being male, being Medicaid-insured (vs. Medicare), and having no primary care visits (vs. 4+ visits) in the last year. Among all enrollees identified as overdue for CRC screening, FIT completion rates at 6 months were 14.8% overall and 18.5% in the subgroup reached. In a mailed FIT program, a health insurance plan attempted to reach as many enrollees overdue for CRC screening as possible, however 22.8% were not mailed a FIT. Additional efforts are needed to ensure that the hardest to reach enrollees can participate in CRC screening.

Objective: Lung cancer is increasingly recognised as a heterogeneous disease. Recent advances with targeted therapies for lung cancer with oncogenic mutations have greatly improved the prognosis for this subset of patients, yet little is known about their experiences. This study aimed to identify the needs and explore the healthcare experiences of these advanced patients with oncogenic mutation driven lung cancer., Design: Qualitative interviews with patients with advanced or metastatic non-small cell lung cancer with oncogenic alterations in anaplastic lymphoma kinase, epidermal growth factor receptor or c-ros oncogene 1., Settings: Patients were recruited from online lung cancer support groups within the USA. Interviews were conducted remotely or in person, transcribed verbatim and analysed using an iterative inductive and deductive process., Participants: We included 39 patients (11 males and 28 females) with a median age of 48., Results: Two primary theme categories emerged: patients' unmet needs and improving healthcare experiences. Unmet needs are related to patients' desire to view their disease as a chronic illness, aspire to live a meaningful existence without financial devastation, desire for understanding along with emotional support and needing help with practical matters. Improving healthcare experiences involved patients' desire to trust the expertise of clinical providers, receive reliable care and be treated holistically and as informed partners., Conclusions: Patients with lung cancer with oncogenic mutations live uncharted experiences. Targeted therapy brings hope, but uncertainty is daunting. Patients grapple with the meaning and purpose of their lives while day-to-day obligations remain challenging. Healthcare teams are instrumental in their care experiences, and patients desire providers who are up-to-date on advances in the field and treat them as whole persons., Competing Interests: Competing interests: MAA, L-MB, LM, MT and DR have no conflict of interest to report. LC received honoraria as a consultant for Amgen. She has also received research funding to institutions that she works with and/or serves on the advisory board for: Novartis, Merck, Lily/Imclone, Bristol Myers Squibb, AstraZeneca/Medimmune, Pfizer, Incyte, Takeda, VentiRx, Sanofi-Genzyme, Seattle Genetics, Dynavax, Genentech, Synthorx and Alkermes., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Colorectal cancer screening rates remain low, especially among certain racial and ethnic groups and the uninsured and Medicaid insured. Clinics and health care systems have adopted population-based mailed fecal immunochemical testing (FIT) programs to increase screening, and now health insurance plans are beginning to implement mailed FIT programs. We report on challenges to and successes of mailed FIT programs during their first year of implementation in two health plans serving Medicaid and dual eligible Medicaid/Medicare enrollees., Methods: This qualitative descriptive study gathered data through in-depth interviews with staff and leaders at each health plan (n = 10). The Consolidated Framework for Implementation Research, field notes from program planning meetings between the research team and the health plans, and internal research team debriefs informed interview guide development. Qualitative research staff used Atlas.ti to code the health plan interviews and develop summary themes through an iterative content analysis approach., Results: We identified first-year implementation challenges in five thematic areas: 1) program design, 2) vendor experience, 3) engagement/communication, 4) reaction/satisfaction of stakeholders, and 5) processing/returning of mailed kits. Commonly experienced challenges by both health plans related to the time-consuming nature of the programs to set up, and complexities and delays in working with vendors. We found implementation successes in the same five thematic areas as well as four additional areas of: 1) leadership support, 2) compatibility with the health plan, 3) broader impacts, and 4) collaboration with researchers. Commonly experienced successes included the ability to adapt the mailed FIT program to the individual health plan culture and needs, and the synchronicity between the programs and their organizational missions and goals., Conclusions: Both health plans successfully adapted mailed FIT programs to their own culture and resources and used their strong quality management resources to maximize success in overcoming the time demands of setting up the program and working with their vendors. Mailed FIT programs administered by health plans, especially those serving Medicaid- and dual eligible Medicaid/Medicare-insured populations, may be an important resource to support closing gaps in colorectal cancer screening among traditionally underserved populations.

Screening rates for colorectal cancer (CRC) remain low, especially among certain populations. Mailed fecal immunochemical testing (FIT) outreach initiated by U.S. health plans could reach underserved individuals, while solving CRC screening data and implementation challenges faced by health clinics. We report the models and motivations of two health insurance plans implementing a mailed FIT program for age-eligible U.S. Medicaid and Medicare populations. One health plan operates in a single state with ~220,000 enrollees; the other operates in multiple states with ~2 million enrollees. We conducted in-depth qualitative interviews with key stakeholders and observed leadership and clinic staff planning during program development and implementation. Interviews were transcribed and coded using a content analysis approach; coded interview reports and meeting minutes were iteratively reviewed and summarized for themes. Between June and September 2016, nine participants were identified, and all agreed to the interview. Interviews revealed that organizational context was important to both organizations and helped shape program design. Both organizations were hoping this program would address barriers to their prior CRC screening improvement efforts and saw CRC screening as a priority. Despite similar motivations to participate in a mailed FIT intervention, contextual features of the health plans led them to develop distinct implementation models: a collaborative model using some health clinic staffing versus a centralized model operationalizing outreach primarily at the health plan. Data are not yet available on the models' effectiveness. Our findings might help inform the design of programs to deliver mailed FIT outreach., (© Society of Behavioral Medicine 2018. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Colorectal cancer screening uptake is low, particularly among individuals enrolled in Medicaid. To the authors' knowledge, little is known regarding the effectiveness of direct-to-member outreach by Medicaid health insurance plans to raise colorectal cancer screening use, nor how best to deliver such outreach., Methods: BeneFIT is a hybrid implementation-effectiveness study of 2 program models that health plans developed for a mailed fecal immunochemical test (FIT) intervention. The programs differed with regard to whether they used a centralized approach (Health Plan Washington) or collaborated with health centers (Health Plan Oregon). The primary implementation outcome of the current study was the percentage of eligible enrollees to whom the plans delivered each intervention component. The primary effectiveness outcome was the rate of FIT completion within 6 months of mailing of the introductory letter., Results: The health plans identified 12,000 eligible enrollees (8551 in Health Plan Washington and 3449 in Health Plan Oregon). Health Plan Washington mailed an introductory letter and FIT kit to 8551 enrollees (100%) and delivered a reminder call to 839 (10.3% of the 8132 attempted). Health Plan Oregon mailed an introductory letter, and a letter and FIT kit plus a reminder postcard to 2812 enrollees (81.5%) and 2650 enrollees (76.8%), respectively. FIT completion rates were 18.2% (1557 of 8551 enrollees) in Health Plan Washington. In Health Plan Oregon, completion rates were 17.4% (488 of 2812 enrollees) among enrollees who were mailed an introductory letter and 18.3% (484 of 2650 enrollees) among enrollees who also were mailed a FIT kit plus reminder postcard., Conclusions: The implementation of mailed FIT outreach by health plans may be effective and could reach many individuals at risk of developing colorectal cancer., (© 2019 The Authors. Cancer published by Wiley Periodicals, Inc. on behalf of American Cancer Society.)

Implementation of population-based colorectal cancer screening programs by Medicaid health plans could address colorectal cancer screening disparities. Our objective is to identify facilitators and barriers to implementation of a population-based colorectal cancer screening program by Washington State Medicaid health plans. We conducted semi-structured interviews with leadership from 2 statewide and 3 national Medicaid plans. We organized the interview questions around the Consolidated Framework for Implementation Research (CFIR). We analyzed interview transcripts, guided by directed content analysis, and identified facilitators and barriers to Medicaid health plan implementation of population-based colorectal cancer screening programs. Robust health plan (inner setting) quality improvement infrastructures were facilitators. Lack of statewide Medicaid policy incentives (external setting) to increase colorectal cancer screening were barriers to potential implementation. Efforts to address identified barriers through local and national policies and statewide data sharing efforts may support Medicaid health plan implementation of population-based colorectal cancer screening programs.

Objective: Routine ovarian cancer screening is ineffective; therefore, no professional organization recommends this screening in asymptomatic patients. However, many physicians have recommended screening, exposing patients to unnecessary risk. Little research exists on how nonprofessional experience with cancer influences physicians' screening practices. This study examines the association between physicians' nonprofessional experience with cancer and reported adherence to ovarian cancer screening guidelines., Materials and Methods: A mail questionnaire with an annual examination vignette and questions about cancer screening recommendations was sent to a random sample of 3,200 U.S. family physicians, general internists, and obstetrician-gynecologists. This analysis included 497 physicians who received a vignette of a woman at average ovarian cancer risk and weighted results to represent these physician groups nationally. The outcome measure was adherence to ovarian cancer screening guidelines. Stepwise multivariate logistic regression estimated adjusted risk ratios for guideline adherence., Results: In unadjusted analyses, 86.0% of physicians without nonprofessional cancer experience reported adherence to ovarian cancer screening guidelines compared with 69.2% of physicians with their own history of cancer, or a family member or close friend/coworker with cancer (p = 0.0045). In adjusted analyses, physicians with cancer themselves or in a family member or close friend/coworker were 0.82 times less likely (CI: 0.73-0.92) to report adhering to ovarian cancer screening recommendations than those without nonprofessional cancer experience., Conclusions: Despite recommendations to the contrary, many physicians reported recommending ovarian cancer screening in low-risk women. Physicians with nonprofessional cancer experience were more likely to report offering or ordering nonrecommended screening than physicians without this experience.

Objectives: Interest is increasing in collaborations between public health and primary care to address the health of a community. Although the understanding of how these collaborations work is growing, little is known about the barriers facing these partners at the local level. The objective of this study was to identify barriers to collaboration between primary care and public health at the local level in 4 states., Methods: The study team, which comprised 12 representatives of Practice-Based Research Networks (networks of practitioners interested in conducting research in practice-based settings), identified 40 key informants from the public health and primary care fields in Colorado, Minnesota, Washington State, and Wisconsin. The key informants participated in standardized, semistructured telephone interviews with 8 study team members in 2014 and 2015. Interviews were audio recorded and transcribed verbatim. We analyzed key themes and subthemes by drawing on grounded theory., Results: Primary care and public health participants identified similar barriers to collaboration. Barriers at the institutional level included the challenges of the primary care environment, in which providers feel overwhelmed and resources are tight; the need for systems change; a lack of partnership; and geographic challenges. Barriers to collaboration included mutual awareness, communication, data sharing, capacity, lack of resources, and prioritization of resources., Conclusions: Some barriers to collaboration (eg, changes to health care billing, demands on provider time) require systems change to overcome, whereas others (eg, a lack of shared priorities and mutual awareness) could be addressed through educational approaches, without adding resources or making a systemic change. Overcoming these common barriers may lead to more effective collaboration.

Background: The challenge of responding to prescription opioid overuse within the United States has fallen disproportionately on the primary care clinic setting. Here we describe a framework comprised of 6 Building Blocks to guide efforts within this setting to address the use of opioids for chronic pain., Methods: Investigators conducted site visits to thirty primary care clinics across the United States selected for their use of team-based workforce innovations. Site visits included interviews with leadership, clinic tours, observations of clinic processes and team meetings, and interviews with staff and clinicians. Data were reviewed to identify common attributes of clinic system changes around chronic opioid therapy (COT) management. These concepts were reviewed to develop narrative descriptions of key components of changes made to improve COT use., Results: Twenty of the thirty sites had addressed improvements in COT prescribing. Across these sites a common set of 6 Building Blocks were identified: 1) providing leadership support; 2) revising and aligning clinic policies, patient agreements (contracts) and workflows; 3) implementing a registry tracking system; 4) conducting planned, patient-centered visits; 5) identifying resources for complex patients; and 6) measuring progress toward achieving clinic objectives. Common components of clinic policies, patient agreements and data tracked in registries to assess progress are described., Conclusions: In response to prescription opioid overuse and the resulting epidemic of overdose and addiction, primary care clinics are making improvements driven by a common set of best practices that address complex challenges of managing COT patients in primary care settings., Competing Interests: Conflicts of Interest: None declared., (© Copyright 2017 by the American Board of Family Medicine.)

Introduction: Federally Qualified Health Centers (FQHCs) provide primary care to low-income and uninsured patients in the United States. FQHCs are required to report annual measurements and provide evidence of improvement for quality measures; effective methods to improve quality in FQHCs are needed. Systems of Support (SOS) is a proactive, mail-based, colorectal cancer screening program that was developed and tested in an integrated health care system. The objective of this study was to adapt SOS for use in an FQHC system, guided by the Consolidated Framework for Implementation Research (CFIR)., Methods: We conducted qualitative semi-structured interviews in 2014 with organizational leadership, medical staff, and nursing staff to identify facilitators of and barriers to implementation of SOS in an FQHC system. The interview guide was based on the CFIR framework. Interview transcripts were analyzed using Template Analysis. We adapted SOS and planned implementation strategies to address identified barriers., Results: Facilitators of implementation of SOS were previous quality improvement experience and engagement of clinic and administrative leadership. Barriers to implementation were a more diverse patient population, a decentralized administrative structure, and communication challenges throughout the organization. Program adaptations focused on patient instructions and educational materials as well as elimination of follow-up phone calls. Implementation strategies included early and frequent engagement with organizational leadership and a smaller pilot program before organization-wide implementation., Conclusions: Use of CFIR identified facilitators of and barriers to implementation of the evidence-based colorectal cancer screening program. Program adaptations and implementation strategies based on this study may generalize to other FQHC systems that are considering implementation of a proactive, mail-based colorectal cancer screening program.

Background: Practice-based research networks (PBRNs) promote the conduct of research in real-world settings by engaging primary care clinicians as champion research collaborators. Card studies are brief surveys administered to patients or clinicians at the point of care. The objective of this paper is to describe the design and evaluation of a card study methodology that the WWAMI Region Practice and Research Network (WPRN) used to develop research partnerships across multiple member sites., Methods: We used a collaborative model to develop, implement and disseminate the results of a network-wide card study to assess patient preferences for weight loss in primary care. After the card study data collection was completed, we conducted individual and focus group interviews and a brief survey of participating practice champions., Results: Increased research engagement and personal and professional developments were the primary motivators for participating in the development of the card study. Increasing research activity at practices and learning information about patients were motivators for implementing the study. Their participation resulted in champions reporting increased confidence in collaborating on research projects as well as the development of new clinical services for patients., Discussion: This collaborative model positively influenced research capacity in the WPRN and may be a useful strategy for helping PBRNs conducted translational research., (© 2015 Wiley Periodicals, Inc.)

Background: Colonoscopy outcomes, such as polyp detection or complication rates, may differ by procedure indication., Objectives: To develop methods to classify colonoscopy indications from administrative data, facilitating study of colonoscopy quality and outcomes., Research Design: We linked 14,844 colonoscopy reports from the Clinical Outcomes Research Initiative, a national repository of endoscopic reports, to the corresponding Medicare Carrier and Outpatient File claims. Colonoscopy indication was determined from the procedure reports. We developed algorithms using classification and regression trees and linear discriminant analysis (LDA) to classify colonoscopy indication. Predictor variables included ICD-9CM and CPT/HCPCS codes present on the colonoscopy claim or in the 12 months prior, patient demographics, and site of colonoscopy service. Algorithms were developed on a training set of 7515 procedures, then validated using a test set of 7329 procedures., Results: Sensitivity was lowest for identifying average-risk screening colonoscopies, varying between 55% and 86% for the different algorithms, but specificity for this indication was consistently over 95%. Sensitivity for diagnostic colonoscopy varied between 77% and 89%, with specificity between 55% and 87%. Algorithms with classification and regression trees with 7 variables or LDA with 10 variables had similar overall accuracy, and generally lower accuracy than the algorithm using LDA with 30 variables., Conclusions: Algorithms using Medicare claims data have moderate sensitivity and specificity for colonoscopy indication, and will be useful for studying colonoscopy quality in this population. Further validation may be needed before use in alternative populations.

There is increasing interest in medical text messaging interventions being used to achieve positive patient outcomes across a range of clinical research and health practice environments. Short messaging service (SMS) is a low-cost tool that provides an easy communication route to engage potentially broad populations through text messaging, and is part of the growing social trend toward increased adoption of personal communication technologies by patient populations. Testing the effectiveness and impact of various communication strategies requires navigation of a complex web of clinical and research regulations and oversight mechanisms. We describe a case study of the implementation of SMS to provide bidirectional communications between physicians and patients involved in routine care reminders to illustrate the review processes and governance structures needed. By mapping the regulatory and approval processes required to manage and steward a research study across clinical and community boundaries, we provide a guide for other translational health researchers who may utilize similar kinds of personally owned technology interventions as research tools., (© 2014 Wiley Periodicals, Inc.)

Background: Geographic barriers and limited availability of cancer specialists may influence early prostate cancer treatment options for rural men. This study compares receipt of different early prostate cancer treatments between rural and urban patients., Methods: Using 2004-2006 SEER Limited-Use Data, 51,982 early prostate cancer patients were identified (T1c, T2a, T2b, T2c, T2NOS; no metastases) who were most likely to benefit from definitive treatment (< 75 years old, Gleason score < 8, PSA ≤ 20). Definitive treatment included radical prostatectomy, daily external beam radiation for 5 to 8 weeks, brachytherapy, or combination external beam radiation/brachytherapy. Adjusted definitive treatment rates were calculated by rural-urban residence overall, and for different sociodemographic and cancer characteristics, and different states based on logistic regression analyses, using general estimating equation methods to account for clustering by county., Results: Adjusted definitive treatment rates were lower for rural (83.7%) than urban (87.1%) patients with early-stage prostate cancer (P ≤ .01). Rural men were more likely than urban men to receive non-definitive surgical treatment and no initial treatment. The lowest definitive treatment rates were among rural subgroups: 70 to 74 years (73.9%), African Americans (75.6%), American Indians/Alaska Natives (77.8%), single/separated/divorced (76.8%), living in New Mexico (69.3%), and living in counties with persistent poverty (79.6%)., Conclusions: Between 2004 and 2006, this adjusted analysis found that men who were living in rural areas were less likely to receive definitive treatment for their early-stage prostate cancer than those living in urban areas. Certain rural patient groups with prostate cancer need particular attention to ensure their access to appropriate treatment. Rural providers, rural health care systems, and cancer advocacy and support organizations should ensure resources are in place so that the most vulnerable rural groups (men between 60 and 74 years of age; African American men; men who are single, separated, or divorced; and men living in rural New Mexico) can make informed prostate cancer treatment choices based on their preferences., (Copyright © 2013 American Cancer Society.)

Background: Computer-aided detection (CAD) has rapidly diffused into screening mammography practice despite limited and conflicting data on its clinical effect., Objective: To determine associations between CAD use during screening mammography and the incidence of ductal carcinoma in situ (DCIS) and invasive breast cancer, invasive cancer stage, and diagnostic testing., Design: Retrospective cohort study., Setting: Medicare program., Participants: Women aged 67 to 89 years having screening mammography between 2001 and 2006 in U.S. SEER (Surveillance, Epidemiology and End Results) regions (409 459 mammograms from 163 099 women)., Measurements: Incident DCIS and invasive breast cancer within 1 year after mammography, invasive cancer stage, and diagnostic testing within 90 days after screening among women without breast cancer., Results: From 2001 to 2006, CAD prevalence increased from 3.6% to 60.5%. Use of CAD was associated with greater DCIS incidence (adjusted odds ratio [OR], 1.17 [95% CI, 1.11 to 1.23]) but no difference in invasive breast cancer incidence (adjusted OR, 1.00 [CI, 0.97 to 1.03]). Among women with invasive cancer, CAD was associated with greater likelihood of stage I to II versus III to IV cancer (adjusted OR, 1.27 [CI, 1.14 to 1.41]). In women without breast cancer, CAD was associated with increased odds of diagnostic mammography (adjusted OR, 1.28 [CI, 1.27 to 1.29]), breast ultrasonography (adjusted OR, 1.07 [CI, 1.06 to 1.09]), and breast biopsy (adjusted OR, 1.10 [CI, 1.08 to 1.12])., Limitation: Short follow-up for cancer stage, potential unmeasured confounding, and uncertain generalizability to younger women., Conclusion: Use of CAD during screening mammography among Medicare enrollees is associated with increased DCIS incidence, the diagnosis of invasive breast cancer at earlier stages, and increased diagnostic testing among women without breast cancer., Primary Funding Source: Center for Healthcare Policy and Research, University of California, Davis.

Background & Aims: We investigated the rate and predictors of anesthesia assistance during outpatient colonoscopy and whether anesthesia assistance is associated with colonoscopy interventions and outcomes., Methods: We performed a retrospective cohort study using a 20% sample of Medicare administrative claims submitted during the 2003 calendar year. We analyzed data from 328,177 adults, 66 years old or older, who underwent outpatient colonoscopy examinations., Results: Overall, 8.7% of outpatient colonoscopies were performed with anesthesia assistance. In multivariate analysis, independent predictors of anesthesia assistance included black race, female sex, and a nonscreening indication; anesthesia assistance increased with median income and comorbidities. General and colorectal surgeons, fewer years in their practice, and nonhospital site of service were also significantly associated with anesthesia assistance. The strongest predictor of anesthesia assistance was the Medicare carrier, with odds ratios ranging from 0.22 (95% confidence interval: 0.12-0.43) for the Arkansas carrier (crude rate 0.9%) to 9.90 (95% confidence interval: 7.92-12.39) for the Empire carrier in New York area (crude rate 35.3%) compared with the Wisconsin carrier (crude rate 4.3%). There was also considerable variation among endoscopists; 75% of providers had no colonoscopies with anesthesia assistance recorded in their dataset, and 4.5% of providers had anesthesia assistance in at least three quarters of their examinations. Anesthesia assistance was not associated with the diagnosis of polyps, the performance of biopsy or polypectomy, or complications in multivariate analyses., Conclusions: There are significant variations among regions and sites of service in anesthesia assistance during outpatient colonoscopies of Medicare beneficiaries. Although this variation has considerable economic implications, it was not associated with measures of patient risk or outcomes, such as polyp detection or procedure-related complications., (Copyright © 2013 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background: Little is known about the prevalence of physicians offering nonrecommended breast or colorectal cancer screening for young women., Purpose: The goal of the current paper was to examine the percentage of primary care physicians nationally who self-report offering breast or colorectal cancer screening tests for young women, and physician/practice characteristics associated with such recommendations., Methods: Analysis was performed in 2011 on data from a 2008 cross-sectional survey presenting a vignette of a health maintenance visit by an asymptomatic woman aged 35 years. This study included surveys sent to 1546 U.S. family physicians, general internists, and obstetrician-gynecologists aged <65 years, randomly selected from the AMA Physician Masterfile (60.6% response rate). Relevant respondent subsamples were used for the breast (n=505) and colorectal (n=721) cancer screening analyses. Responses were weighted to represent physicians nationally. The main outcome was physician self-report of offering breast or colorectal cancer screening tests., Results: 75.3% (95% CI =71.0%, 79.2%) of physicians offered breast cancer screening tests; most commonly these physicians reported offering mammography alone (76.5%, 95% CI= 71.6%, 80.8%). A total of 39.3% (95% CI=35.5%, 43.2%) of physicians offered colorectal cancer screening tests; most commonly these physicians reported offering FOBT alone (43.3%, 95% CI=37.2%, 49.6%). In adjusted analysis, physician factors associated with offering breast and colorectal cancer screening tests were: estimating higher patient breast/colorectal cancer risk, and not listing the U.S. Preventive Services Task Force as a top influential organization., Conclusions: A high percentage of physicians report offering nonrecommended breast or colorectal cancer screening tests for young women. Physicians' higher cancer-risk estimation accounted for some overscreening, but even physicians who estimated the patient to be at the same risk as the general population reported offering nonrecommended screening tests., (Copyright © 2012 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)