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Background: Digital cognitive assessment solutions can overcome some barriers to cognitive screening in primary care by providing rapidly‐obtained objective insights without requiring specialty‐trained examiners. The Linus Health Digital Clock and Recall (DCR™) is a three‐part test consisting of three‐word immediate verbal acquisition, the Digital Clock Test (DCTclock™), and delayed recall of the three words. Our objective was to compare performance on the DCR to the Montreal Cognitive Assessment (MoCA; Nasreddine et al., 2005) and the Saint Louis University Mental Status (SLUMS; Tariq et al., 2006), two commonly used screening tests in primary care. Method: Comparative analyses of DCR, MoCA (Total Score and Memory Index Score [MIS]), and SLUMS results were conducted among 80 primary care patients – 65 years and older presenting for any reason – whose DCR performance was indicative of cognitive impairment. Result: Of the 80 patients (mean age 74.0 [±7.8]; 60% female) performing as impaired or borderline impaired on the DCR, 67 completed the MoCA and 13 completed the SLUMS. Comparison between the DCR and MoCA Total Score included 78% (52/67) concordance for identifying impairment (cutoff <26). While the remaining 15 of 67 patients (22%) had normal MoCA Total Scores (≥26), 13 (87%) missed points in at least one MoCA cognitive domain and 8 (53%) missed points in multiple MoCA domains (often language and delayed recall). Comparison between DCR and SLUMS revealed that all 13 patients receiving SLUMS assessment had DCR scores 0‐1 and SLUMS scores <27 (indicating cognitive impairment). See Tables 1 and 2 for breakdown of MoCA, MIS, and SLUMS stratified by DCR performance. Logistic regression found that DCTclock metrics of information processing (z = 2.00, p =.045) and spatial reasoning (z = 2.82 p =.005) discriminated cognitive impairment on MoCA Total Score (cutoff <26). Overall, ROC analysis revealed good accuracy of DCR to identify MoCA performance (AUC =.84; Figure 1). Conclusion: Screening in primary care using the DCR is feasible, takes less time to administer than MoCA or SLUMS, and shows concordant results with these more established screening tools in detecting cognitive impairment. Future research aims to investigate the criterion validity of the DCR among biomarkers for neurodegenerative disease. [ABSTRACT FROM AUTHOR]

Background:In 2020, the Centers for Medicare & Medicaid Services reimbursement structure was relaxed to aid in the rapid adoption nationally of telemedicine during the COVID-19 pandemic. Due to limited access to internet service, cellular phone data, and appropriate devices, many patients may be excluded from telemedicine services. Methods:In this study, we present the findings of a survey of patients at an urban primary care clinic regarding their access to the tools needed for telemedicine before and after the COVID-19 pandemic. Patients provided information about their access to internet services, phone and data plans, and their perceived access to and interest in telemedicine. The survey was conducted in 2019 and then again in September of 2020 after expansion of telemedicine services. Results:In 2019, 168 patients were surveyed; and in 2020, 99 patients participated. In both surveys, 30% of respondents had limited phone data, no data, or no phone at all. In 2019, the patient responses showed a statistically significant difference in phone plan types between patients with different insurance plans (p < 0.10), with a higher proportion (39%) of patients with Medicaid or Medicaid waiver having a prepaid phone or no phone at all compared with patients with commercial insurance (26%). The overall awareness rate increased from 17% to 43% in the 2020 survey. Conclusions:This survey illustrated that not all patients had access to devices, cellular data, and internet service, which are all needed to conduct telemedicine. In this survey, patients with Medicaid or Medicaid waiver insurance were less likely to have these tools than those with a commercial payor. Finally, patients' access to these telemedicine tools correlated with their interest in using telemedicine visits. Providing equitable telemedicine care requires attention to and mitigation strategies for these gaps in access. [ABSTRACT FROM AUTHOR]

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.ejor.2006.10.003 Byline: Xiuli Qu (a), Ronald L. Rardin (a), Julie Ann S. Williams (b), Deanna R. Willis (c) Keywords: OR in health service; Appointment scheduling; Advanced access; No-show rate Abstract: Advanced access scheduling, introduced in the early 1990s, is reported to significantly improve the performance of outpatient clinics. The successful implementation of advanced access scheduling requires the match of daily healthcare provider capacity with patient demand. In this paper, for the first time a closed-form approach is presented to determine the optimal percentage of open-access appointments to match daily provider capacity to demand. This paper introduces the conditions for the optimal percentage of open-access appointments and the procedure to find the optimal percentage. Furthermore, the sensitivity of the optimal percentage of open-access appointments to provider capacity, no-show rates, and demand distribution is investigated. Our results demonstrate that the optimal percentage of open-access appointments mainly depends on the ratio of the average demand for open-access appointments to provider capacity and the ratio of the show-up rates for prescheduled and open-access appointments. Author Affiliation: (a) Purdue University, School of Industrial Engineering, 315 N. Grant Street, West Lafayette, IN 47907-2023, United States (b) University of West Florida, Department of Management and MIS, 11000 University Parkway, Bldg 76/128, Pensacola, FL 32514-5752, United States (c) Indiana University, Department of Family Medicine, 1110 W Michigan Street, Indianapolis, IN 46202, United States Article History: Received 17 December 2005; Accepted 25 October 2006

Background: Blood‐based biomarker tests are critical tools with the potential to change pathways for dementia diagnosis and care. These tests are less invasive than PET scan or lumbar puncture, potentially more affordable, and thus more accessible across more care settings and in more countries. Utilization in primary care settings together with brief cognitive assessments provides a compelling use case that could transform diagnosis, assessment and care. A critical challenge to the widespread adoption of blood‐based biomarker testing is the issue of disclosure. To date, Alzheimer's Disease and Related Dementias (ADRD) biomarker disclosure recommendations have primarily focused on disclosure in research and/or specialized‐care settings. Primary care clinicians are well situated to conduct biomarker testing, but they are likely to need training and support to develop confidence and capacity to communicate results. Method: Review of literature findings involving biomarker disclosure and input from dementia researchers from six countries reflecting diverse health care systems informed development of a disclosure framework to support the inaugural project of the Davos Alzheimer's Collaborative's (DAC) Systems Preparedness (DAC‐SP) initiative. This project seeks to promote routine uptake of cognitive screening among people ≥ age 60 and, when cognitive impairment is identified, blood‐based biomarker testing. The biomarker testing is completed using a commercially available, CLIA‐certified test that measures the likelihood of amyloid pathology when cognitive impairment is identified. Result: The framework recognizes that biomarker disclosure is part of a comprehensive patient evaluation that includes cognitive assessment and a broader discussion of the patient's health and wellbeing. It divides disclosure into five phases: pre‐test education; consent for and administration of testing; disclosure of results and discussion of treatment plan; provision of educational materials; and follow up (Table 1). This general framework can be adapted for site‐specific factors such as health literacy, health systems operations, legal structures, and cultural relevance. Conclusion: As part of a pragmatic multisite implementation evaluation of a screening and early detection program including high and middle income countries, the authors have developed a framework to guide biomarker disclosure to patients in primary care settings. This provisional framework represents an important first step towards clinical consensus building on biomarker disclosure. [ABSTRACT FROM AUTHOR]

Background: With the emergence of novel therapeutics, the importance of early identification of people at risk of developing Alzheimer's disease is more critical than ever. Most asymptomatic at‐risk individuals are primary care patients, who often have limited access to specialty care. Therefore, development of feasible, acceptable, and scalable ways to identify early cognitive impairment in the primary care setting is essential. The DAVOS Alzheimer's Collaborative DIGITAL Demonstration Project was conducted to understand the feasibility, acceptability, and implementation of digital cognitive screening in primary care. Methods: Patients ≥65 years presenting for any issue to one of six Indiana University Health primary care sites between June and December 2022 were asked to complete the Linus Health Digital Clock and Recall (DCR™) cognitive assessment screening tool. Scores on the DCR™ range 0‐5, with 0‐1 categorized as cognitively impaired, 2‐3 as likely cognitively unimpaired, and 4‐5 as cognitively unimpaired. Data regarding number of DCR™ screening attempts that were refused, incomplete, or completed was collected. This pragmatic demonstration project allowed patients to be approached multiple times and complete the screening multiple times within the project time frame. Patients first completed screening test results were analyzed using descriptive statistics. Results: Over the 7‐month project, 3,343 screening attempts were made. The screening test was refused by patients (54.6%) 1,825 times and was attempted but incomplete 64 (1.9%) times. 1,454 (43%) screenings were completed, which represents 1,405 unique patients. Among these, 172 (12%) scored positive for cognitive impairment, 506 (36%) scored likely cognitively impaired, 628 (45%) scored cognitively unimpaired, and 99 (7%) results were unanalyzable. Conclusions: Using the DCR™, cognitive screening was successfully completed in nearly half of the primary care patients approached, regardless of their presenting concern, with 48% scoring either impaired or likely impaired. This cognitive screening approach appears to have utility in developing early detection for cognitive impairment in primary care, which will be an initial step towards identifying patients who could benefit from disease‐modifying therapeutics. [ABSTRACT FROM AUTHOR]

Background: Transaminase elevations can occur from liver injury or in the setting of rhabdomyolysis. The goal of this study is to evaluate indices that could differentiate acetaminophen toxicity from muscle injury in the setting of transaminase elevations.Methods: A retrospective chart review of consecutive cases reported to our regional poison center. Patients with transaminase (AST and ALT) elevation were grouped as those with acetaminophen exposure (AT) and those with elevated creatine phosphokinase (CPK) without evidence of acetaminophen exposure (RHB).Results: Of the 345 patients included in the study, elevated AST/ALT levels were attributed to rhabdomyolysis in 168 patients and attributed to acetaminophen toxicity in 177 patients. The median AST: ALT values also differed between groups, with patients in the RHB group had higher median ratios (p < 0.001). Using an AST: ALT value of 2.02 as a diagnostic cutoff produced a specificity of 0.52 (95% CI: 0.37, 0.64) and sensitivity of 0.84 (95% CI: 0.73, 0.94) for acetaminophen detection in the test dataset (N = 104).Conclusions: Elevated transaminases due to liver injury from acetaminophen ingestion had a different pattern than elevated transaminases due to rhabdomyolysis. Lower AST:ALT ratios were found in acetaminophen cases, however, the specificity using a ratio threshold of ≤1 would be 83%. [ABSTRACT FROM AUTHOR]

Abstract Background Patients who no-show to primary care appointments interrupt clinicians’ efforts to provide continuity of care. Prior literature reveals no-shows among diabetic patients are common. The purpose of this study is to assess whether no-shows to primary care appointments are associated with increased risk of future emergency department (ED) visits or hospital admissions among diabetics. Methods A prospective cohort study was conducted using data from 8,787 adult diabetic patients attending outpatient clinics associated with a medical center in Indiana. The outcomes examined were hospital admissions or ED visits in the 6 months (182 days) following the patient’s last scheduled primary care appointment. The Andersen-Gill extension of the Cox proportional hazard model was used to assess risk separately for hospital admissions and ED visits. Adjustment was made for variables associated with no-show status and acute care utilization such as gender, age, race, insurance and co-morbid status. The interaction between utilization of the acute care service in the six months prior to the appointment and no-show was computed for each model. Results The six-month rate of hospital admissions following the last scheduled primary care appointment was 0.22 (s.d. = 0.83) for no-shows and 0.14 (s.d. = 0.63) for those who attended (p p Conclusions No-show to a primary care appointment is associated with increased risk for hospital admission among diabetics recently hospitalized.

Academic underachievement, such as failing a class and the threat of being held back because of academic issues, is common. Family physicians can provide support and guidance for families as they approach their child's unique academic challenges. Specific learning disabilities are a group of learning disorders (e.g., dyscalculia, dysgraphia, dyslexia) that impede a child's ability to learn. Understanding standard educational terms; looking for medical, family, and social risk factors associated with academic underachievement; and investigating the medical differential for academic underachievement can help direct the family to appropriate care. The physician can provide medical documentation to support an individualized education program evaluation and address risk factors that schools may not be aware of or cannot assess. The family physician can support children and families by understanding the connection between risk factors, medical and educational evaluations, and educational resources. [ABSTRACT FROM AUTHOR]

Background and Objectives: The use of incentive compensation in academic family medicine has been a topic of interest for many years, yet little is known about the impact of these systems on individual faculty members. Better understanding is needed about the relationship of incentive compensation systems (ICSs) to ICS satisfaction, motivation, and retention among academic family medicine faculty.Methods: The Council of Academic Family Medicine (CAFM) Educational Research Alliance (CERA) conducted a nationwide survey of its members in 2013. This study reports the results of the incentive compensation question subset of the larger omnibus survey.Results: The overall response rate was 53%. The majority (70% [360/511]) of academic faculty reported that they are eligible for some type of incentive compensation. The faculty reported moderate satisfaction, with only 38% being satisfied or highly satisfied with their ICS. Overall mean motivation and intent to remain in their current position were similar. The percentage of total income available as an incentive explained less than 10% of the variance of those outcomes. Faculty perceptions of appropriateness of the measures, understanding of the measurement and reward systems, and perception of due process are all related to satisfaction with the ICS, motivation, and retention.Conclusions: ICSs are common in academic family medicine, yet most faculty do not find them to motivate their choice of activities or promote staying in their current position. Design and implementation are both important in promoting faculty satisfaction with the ICS, motivation, and retention. [ABSTRACT FROM AUTHOR]

The article presents a court case of a 14-month-old African American male with a history of sickle cell trait and taking no daily medications presented to the emergency department with lethargy. It discusses a case of acquired hemolytic anemia from naphthalene-containing mothballs, along with toxicity related to the pediatric mothball ingestions.

BACKGROUND: Practice-based learning and improvement (PBLI) has been promoted as a key component of competency-based training in medical student education, but little is known about its implementation. Methods: This project is part of a larger CERA omnibus survey of family medicine medical student clerkship directors carried out from July to September 2012. Analyses were conducted to as-sess clerkship infrastructure, learner assessment and feedback, and clerkship director perceptions of PBLI curricula. RESULTS: The majority (69.0%, 58/82) of family medicine clerk-ship directors reported that PBLI is not included in their clerkship. Significant predictors of PBLI in the curriculum include: regularly scheduled centralized teaching (weekly or more versus less than weekly, OR=1.14, 95% Cl=1.01-1.29) and clerkship director belief that students should achieve PBLI competency (agree in compe-tency versus disagree in competency, 0R=1.19, 95% Cl=1.08-1.30). Few (20.5%, 16/78) family medicine clerkship directors reported that the amount of PBLI in their curriculum is likely to increase in the next 12 months. The duration of the clerkship was a significant predictor of reported likelihood of increasing PBLI over the next 12 months (3 weeks versus 8 weeks, OR=1.23, 95% CI-1.00-1.51). CONCLUSIONS: Despite increased emphasis on quality improve-ment activities in practice, most family medicine clerkships do not currently offer PBLI curricula. Additionally, less than one in four family medicine clerkships plan on increasing the amount of PBLI curricula in the next 12 months. Continued research in this area is needed to identify successful models for PBLI curricular offerings. [ABSTRACT FROM AUTHOR]

Objectives: The purpose of this article is to describe our experience in implementing a primary care-based dementia and depression care program focused on providing collaborative care for dementia and late-life depression. Methods: Capitalizing on the substantial interest in the US on the patient-centered medical home concept, the Aging Brain Care Medical Home targets older adults with dementia and/or late-life depression in the primary care setting. We describe a structured set of activities that laid the foundation for a new partnership with the primary care practice and the lessons learned in implementing this new care model. We also provide a description of the core components of this innovative memory care program. Results: Findings from three recent randomized clinical trials provided the rationale and basic components for implementing the new memory care program. We used the reflective adaptive process as a relationship building framework that recognizes primary care practices as complex adaptive systems. This framework allows for local adaptation of the protocols and procedures developed in the clinical trials. Tailored care for individual patients is facilitated through a care manager working in collaboration with a primary care physician and supported by specialists in a memory care clinic as well as by information technology resources. Conclusions: We have successfully overcome many system-level barriers in implementing a collaborative care program for dementia and depression in primary care. Spontaneous adoption of new models of care is unlikely without specific attention to the complexities and resource constraints of health care systems. [ABSTRACT FROM AUTHOR]

The article reports on the refill program developed to manage controlled substance refill. It states that controlled substance refill is an unexpected event which leads to the discontinuity of care if not administered by patient's provider. It mentions that the refill program utilizes a recurring-calendar-event function in Microsoft Outlook or Lotus iNotes. Moreover, it says that randomizing toxicology screens is provided to determine the actual number of urine toxicology screen (UTS).

This article presents information on the relationship between patients and physicians. Patients sometimes escalate their behavior when they feel they aren't getting the services they expect or when they feel their needs aren't being addressed. Taking time to sit down with the patient with the goal of better understanding the underlying expectations or needs that are driving his or her behavior can be valuable. Some patients have unreasonable expectations, but for others, understanding the point they're trying to make can go a long way in repairing the relationship. Sometimes, no matter what one does, there is no hope of resurrecting the relationship.

The article focuses on the ways by which family physicians can improve the office efficiency. The key is to employ proven quality improvement techniques used throughout the business world to increase efficiency and quality while decreasing costs. For each process in the practice, such as checking in patients or making referrals, a series of steps must be accomplished correctly, in the right order and at the right time to produce the best outcome. Improving office flow requires everyone, from the front desk staff to the physicians, to be involved in the improvement process. Every office has the potential to achieve efficient flow throughout all of its processes. INSETS: SPEEDBAR;10 RULES FOR AN EFFICIENT PROCESS;KEY POINTS;CYCLE TIME

Gives advice on how to decide whether to buy a new medical equipment or not. Non-financial considerations of these investments; Pros and cons of making a capital investment on a medical equipment; Need to determine alternative investment opportunities that the practice have; Financial impact of making an investment on a medical equipment.

This article focuses on using bilingual staff members as interpreters. Caring for Hispanic patients who speak little or no English can be a challenge. Most bilingual staff members have not been trained to provide interpretation services. To help them fulfill this role, one should encourage them to seek training in this area. Using the universal form of the language is especially important when patients are from a different region or country than the staff member doing the interpreting. Introducing the interpreter to the patient prior to the medical encounter will give the interpreter an opportunity to explain his or her role. Doing so may also make the patient more comfortable.

A letter is presented in response to the article "A Proactive Approach to Controlled Substance Refills" by Jean Antonucci, Deanna R. Willis, Gerald Eaton, and Palmer MacKie in November/December 2010 issue along with the authors' response to the same.

The article discusses the role of cancer fatalism, which is the belief that when cancer is present death is inevitable, as a barrier to screening for colorectal cancer (CRC). According to the authors, African Americans have a high incidence and mortality rate from CRC. They note that the higher incidence and mortality rate is due to a lower participation in CRC screening. Statistics related to the rate of fatalism in African Americans is presented.

A letter to the editor is presented in response to the article "PCMH and ACO: Opposed or Mutually Supportive?," by David Kibbe in the November and December 2010 issue.

A letter to the editor and a response are presented on the article "A Proactive Approach to Controlled Substance Refills," by Deanna R. Willis, Gerald Eaton, and Palmer MacKie in the November and December 2010 issue.

Purpose: Gender affirming medical care (GAMC) aims to alleviate gender dysphoria by helping people align their physical body more closely with their gender identity. Bills seeking to limit or prohibit GAMC for trans children and adolescents have become a controversial topic. This study aimed to examine whether exposures to GAMC during adolescence are associated with adult psychological and general health outcomes, and to demonstrate the mechanism through which state-level legislation may work to moderate the association. Methods: We conducted analyses using data from the 2015 U.S. Transgender Survey, which surveyed 27,715 transgender and gender diverse (TGD) adults between August and September of 2015. The study compared the health outcomes of those who had GAMC exposures during adolescence with those who did not. Moderation analysis with propensity score matching was used to adjust for potential confounding factors. The general and psychological health outcomes measured were past-month severe psychological distress, past-year suicidal ideation, participant's general health, and past-year health care avoidance due to possible mistreatment. Results: GAMC during adolescence was negatively associated with severe psychological distress in adulthood. When examining past-year health care avoidance due to possible mistreatment, the effect sizes differed significantly between those in a trans-supportive state and those in a trans-unsupportive state. Conclusion: Our work highlights the importance of state-level policy stigma in understanding the association between GAMC and health outcomes. Findings point to the importance of enacting long-term legislative safeguards against TGD discrimination and removing barriers to access the full spectrum of care for adolescents who identify as TGD.

Background: In 2020, the Centers for Medicare & Medicaid Services reimbursement structure was relaxed to aid in the rapid adoption nationally of telemedicine during the COVID-19 pandemic. Due to limited access to internet service, cellular phone data, and appropriate devices, many patients may be excluded from telemedicine services. Methods: In this study, we present the findings of a survey of patients at an urban primary care clinic regarding their access to the tools needed for telemedicine before and after the COVID-19 pandemic. Patients provided information about their access to internet services, phone and data plans, and their perceived access to and interest in telemedicine. The survey was conducted in 2019 and then again in September of 2020 after expansion of telemedicine services. Results: In 2019, 168 patients were surveyed; and in 2020, 99 patients participated. In both surveys, 30% of respondents had limited phone data, no data, or no phone at all. In 2019, the patient responses showed a statistically significant difference in phone plan types between patients with different insurance plans ( p < 0.10), with a higher proportion (39%) of patients with Medicaid or Medicaid waiver having a prepaid phone or no phone at all compared with patients with commercial insurance (26%). The overall awareness rate increased from 17% to 43% in the 2020 survey. Conclusions: This survey illustrated that not all patients had access to devices, cellular data, and internet service, which are all needed to conduct telemedicine. In this survey, patients with Medicaid or Medicaid waiver insurance were less likely to have these tools than those with a commercial payor. Finally, patients' access to these telemedicine tools correlated with their interest in using telemedicine visits. Providing equitable telemedicine care requires attention to and mitigation strategies for these gaps in access.

Introduction: An economically mature health care market has led to increased cost competition. Subsequently, a perceived need for productivity-based physician compensation has developed. While some institutions have rewarded individual productivity based on specific facets of academic responsibility, such as teaching, research, and patient care, we chose to develop an incentive compensation system that rewards both individual and group productivity., Program Development: We developed a physician incentive compensation system that rewards individual and group productivity by capturing multiple aspects of work activity. Faculty members are given compensation value points for clinical productivity, scholarship activities, teaching activities, service activities, and achievement of the department's goals. The system was implemented in a graduated fashion in the Department of Family Medicine at Indiana University beginning July 1, 2000., Program Evaluation: In April 2003, all faculty physicians (n=18) participated in a survey about the compensation system. The majority of faculty view the system as a necessity for the department (72.2%); 35.2% were satisfied with the system overall; 35.3% were neutral; and 27.4% were dissatisfied or not sure of their overall satisfaction., Conclusions: A comprehensive physician incentive compensation system incorporating department goals can be designed and implemented in an academic setting.