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The article discusses a study conducted to determine the association between practice member perceptions of relational coordination and reciprocal learning with the presence of Chronic Care Model(CCM) elements in community-based primary care practices. Strategies to strengthen relational coordination and reciprocal learning among team members should be incorporated while implementing complex models of care.

* OBJECTIVE We investigated the relationship between continuity of care and the quality of care received by patients with type 2 diabetes mellitus. * STUDY DESIGN We used a cross-sectional patient survey and medical record review. * POPULATION Consecutive patients with an established diagnosis of type 2 diabetes mellitus presented to 1 of 6 clinics within the Residency Research Network of South Texas, a network of 6 family practice residencies affiliated with the University of Texas Health Science Center at San Antonio. * OUTCOMES MEASURED Continuity was measured as the proportion of visits within the past year to the patient's usual primary care provider. A quality of care score was computed based on the American Diabetes Association's Provider Recognition Program criteria from data collected through medical record review and patient surveys. Each patient was awarded points based on the presence or absence of each criterion. *RESULTS The continuity score was associated significantly with the quality of care score in the anticipated direction (r = .15, P = .04). Patients who had seen their usual providers within the past year were significantly more likely to have had an eye examination, a foot examination, 2 blood pressure measurements, and a lipid analysis. * CONCLUSIONS Continuity of care is associated with the quality of care received by patients with type 2 diabetes mellitus. Continuity of care may influence provider and patient behaviors in ways that improve quality. Further research on how continuity contributes to improved quality is needed. [ABSTRACT FROM AUTHOR]

The Institute of Medicine (IOM) suggests that linkages between primary care practices and community-based resources can improve health in lower income and minority patients, but examples of these are rare. We conducted a prospective, mixed-methods observational study to identify indicators of primary care-community linkage associated with the frequency of visits to community-based senior centers and improvements in diabetes-related outcomes among 149 new senior center members (72% Hispanic). We used semistructured interviews at baseline and 9-month follow-up, obtaining visit frequency from member software and clinical assessments including hemoglobin A1c (HbA1c) from colocated primary care clinics. Members' discussion of their activities with their primary care providers (PCPs) was associated with increased visits to the senior centers, as well as diabetes-related improvements. Direct feedback from the senior centers to their PCPs was desired by the majority of members and may help to reinforce use of community resources for self-management support.

Objective: To measure the incidence of treatment failure and associated costs in patients with methicillin-resistant Staphylococcus aureus skin and soft tissue infections (SSTIs)., Methods: This was a prospective, observational study in 13 primary care clinics. Primary care providers collected clinical data, wound swabs, and 90-day follow-up information. Patients were considered to have "moderate or complicated" SSTIs if they had a lesion ≥5 cm in diameter or diabetes mellitus. Treatment failure was evaluated within 90 days of the initial visit. Cost estimates were obtained from federal sources., Results: Overall, treatment failure occurred in 21% of patients (21 of 98) at a mean additional cost of $1,933.71 per patient. In a subgroup analysis of patients who received incision and drainage, those with moderate or complicated SSTIs had higher rates of treatment failure than those with mild or uncomplicated SSTIs (36% vs. 10%; P=.04)., Conclusions: One in 5 patients presenting to a primary care clinic for a methicillin-resistant S. aureus SSTI will likely require additional interventions at an associated cost of almost $2,000 per patient. Baseline risk stratification and new treatment approaches are needed to reduce treatment failures and costs in the primary care setting.

Background: Practice facilitation (PF) is an implementation strategy now commonly used in primary care settings for improvement initiatives. PF occurs when a trained external facilitator engages and supports the practice in its change efforts. The purpose of this group-randomized trial is to assess PF as an intervention to improve the delivery of chronic illness care in primary care., Methods: A randomized trial of 40 small primary care practices who were randomized to an initial or a delayed intervention (control) group. Trained practice facilitators worked with each practice for one year to implement tailored changes to improve delivery of diabetes care within the Chronic Care Model framework. The Assessment of Chronic Illness Care (ACIC) survey was administered at baseline and at one-year intervals to clinicians and staff in both groups of practices. Repeated-measures analyses of variance were used to assess the main effects (mean differences between groups) and the within-group change over time., Results: There was significant improvement in ACIC scores (p < 0.05) within initial intervention practices, from 5.58 (SD 1.89) to 6.33 (SD 1.50), compared to the delayed intervention (control) practices where there was a small decline, from 5.56 (SD 1.54) to 5.27 (SD 1.62). The increase in ACIC scores was sustained one year after withdrawal of the PF intervention in the initial intervention group, from 6.33 (SD 1.50) to 6.60 (SD 1.94), and improved in the delayed intervention (control) practices during their one year of PF intervention, from 5.27 (SD 1.62) to 5.99 (SD 1.75)., Conclusions: Practice facilitation resulted in a significant and sustained improvement in delivery of care consistent with the CCM as reported by those involved in direct patient care in small primary care practices. The impact of the observed change on clinical outcomes remains uncertain., Trial Registration: This protocol followed the CONSORT guidelines and is registered per ICMJE guidelines:, Clinical Trial Registration Number: NCT00482768.

Purpose: Practice facilitation is widely recognized as a promising method for achieving large-scale practice redesign. Little is known, however, about the cost of providing practice facilitation to small primary practices from the prospective of an organization providing facilitation activities., Methods: We report practice facilitation costs on 19 practices in South Texas that were randomized to receive facilitation activities. The study design assured that each practice received at least 6 practice facilitation visits during the intervention year. We examined only the variable cost associated with practice facilitation activities. Fixed or administrative costs of providing facilitation actives were not captured. All facilitator activities (time, mileage, and materials) were self-reported by the practice facilitators and recorded in spreadsheets., Results: The median total variable cost of all practice facilitation activities from start-up through monitoring, including travel and food, was $9,670 per practice (ranging from $8,050 to $15,682). Median travel and food costs were an additional $2,054 but varied by clinic. Approximately 50% of the total cost is attributable to practice assessment and start-up activities, with another 31% attributable to practice facilitation visits. Sensitivity analysis suggests that a 24-visit practice facilitation protocol increased estimated median total variable costs of all practice facilitation activities only by $5,428, for a total of $15,098., Conclusions: We found that, depending on the facilitators wages and the intensity of the intervention, the cost of practice facilitation ranges between $9,670 and $15,098 per practice per year and have the potential to be cost-neutral from a societal prospective if practice facilitation results in 2 fewer hospitalizations per practice per year.

Background: Recent research from a complexity theory perspective suggests that implementation of complex models of care, such as the Chronic Care Model (CCM), requires strong relationships and learning capacities among primary care teams., Purposes: Our primary aim was to assess the extent to which practice member perceptions of relational coordination and reciprocal learning were associated with the presence of CCM elements in community-based primary care practices., Methodology/approach: We used baseline measures from a cluster randomized controlled trial testing a practice facilitation intervention to implement the CCM and improve risk factor control for patients with Type 2 diabetes in small primary care practices. Practice members (i.e., physicians, nonphysician providers, and staff) completed baseline assessments, which included the Relational Coordination Scale, Reciprocal Learning Scale, and the Assessment of Chronic Illness Care (ACIC) survey, along with items assessing individual and clinic characteristics. To assess the association between Relational Coordination, Reciprocal Learning, and ACIC, we used a series of hierarchical linear regression models accounting for clustering of individual practice members within clinics and controlling for individual- and practice-level characteristics and tested for mediation effects., Findings: A total of 283 practice members from 39 clinics completed baseline measures. Relational Coordination scores were significantly and positively associated with ACIC scores (Model 1). When Reciprocal Learning was added, Relational Coordination remained a significant yet notably attenuated predictor of ACIC (Model 2). The mediation effect was significant (z = 9.3, p < .01); 24% of the association between Relational Coordination and ACIC scores was explained by Reciprocal Learning. Of the individual- and practice-level covariates included in Model 3, only the presence of an electronic medical record was significant; Relational Coordination and Reciprocal Learning remained significant independent predictors of ACIC., Practice Implications: Efforts to implement complex models of care should incorporate strategies to strengthen relational coordination and reciprocal learning among team members.

Aims: Cost burdens represent a significant barrier to medication adherence among chronically ill patients, yet financial pressures may be mitigated by clinical or organizational factors, such as treatment aligned with the Chronic Care Model (CCM). This study examines how perceptions of chronic illness care attenuate the relationship between adherence and cost burden., Methods: Surveys were administered to patients at 40 small community-based primary care practices. Medication adherence was assessed using the 4-item Morisky scale, while five cost-related items documented recent pharmacy restrictions. CCM experiences were assessed via the 20-item Patient Assessment of Chronic Illness Care (PACIC). Nested random effects models determined if chronic care perceptions modified the association between medication adherence and cost-related burden., Results: Of 1823 respondents reporting diabetes and other chronic diseases, one-quarter endorsed intrapersonal adherence barriers, while 23% restricted medication due of cost. Controlling for age and health status, the relationship between medication cost and CCM with adherence was significant; including PACIC scores attenuated cost-related problems patients with adequate or problematic adherence behavior., Conclusions: Patients experiencing treatment more consistent with the CCM reported better adherence and lower cost-related burden. Fostering highly activated patients and shared clinical decision making may help alleviate medication cost pressures and improve adherence., (Published by Elsevier Ltd.)

Objectives: Quantify the prevalence, measure the severity, and describe treatment patterns in patients who present to medical clinics in Texas with community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) skin and soft-tissue infections (SSTI)., Methods: Ten primary care clinics participated in this prospective, community-based study. Clinicians consented patients and collected clinical information, pictures, and wound swabs; data were processed centrally. MRSASelect™ was used for identification. Susceptibilities were determined via Etest®., Results: Overall, 73 of 119 (61%) patients presenting with SSTIs meeting eligibility requirements had CA-MRSA. Among these, 49% were male, 79% were Hispanic, and 30% had diabetes. Half (56%) of the lesions were ≥ 5 cm in diameter. Most patients had abscesses (82%) and many reported pain scores of ≥ 7 of 10 (67%). Many presented with erythema (85%) or drainage (56%). Most received incision and drainage plus an antibiotic (64%). Antibiotic monotherapy was frequently prescribed: trimethoprim-sulfamethoxazole (TMP-SMX) (78%), clindamycin (4%), doxycycline (2%), and mupirocin (2%). The rest received TMP-SMX in combination with other antibiotics. TMP-SMX was frequently administered as one double-strength tablet twice daily. Isolates were 93% susceptible to clindamycin and 100% susceptible to TMP-SMX, doxycycline, vancomycin, and linezolid., Conclusions: We report a predominance of CA-MRSA SSTIs, favorable antibiotic susceptibilities, and frequent use of TMP-SMX in primary care clinics.

Evaluating effective growth and development of a practice-based research network (PBRN) can be challenging. The purpose of this article is to describe the development of a logic model and how the framework has been used for planning and evaluation in a primary care PBRN. An evaluation team was formed consisting of the PBRN directors, staff, and its board members. After the mission and the target audience were determined, facilitated meetings and discussions were held with stakeholders to identify the assumptions, inputs, activities, outputs, outcomes, and outcome indicators. The long-term outcomes outlined in the final logic model are 2-fold: (1) improved health outcomes of patients served by PBRN community clinicians and (2) community clinicians are recognized leaders of quality research projects. The logic model proved useful in identifying stakeholder interests and dissemination activities as an area that required more attention in the PBRN. The logic model approach is a useful planning tool and project management resource that increases the probability that the PBRN mission will be successfully implemented.

Background: Implementing improvement programmes to enhance quality of care in primary care clinics is complex. Understanding how improvement strategies can be implemented in primary care is timely given the recent national movement towards transforming primary care into patient centred medical homes (PCMH). This study examined practice members' perceptions of the opportunities and challenges associated with implementing changes in their practice., Methods: Semi-structured interviews were conducted with a sample of 56 individuals working in 16 small, community based primary care practices. The interviews consisted of open-ended questions focused on participants' perceptions of: (1) practice vision, (2) perceived need for practice improvement and (3) barriers that hinder practice improvement. The interviews were conducted at the participating clinics and were tape-recorded, transcribed, and content analysed., Results: Content analysis identified two main domains for practice improvement related to: (1) the process of care, and (2) patients' involvement in their disease management. Examples of desired process of care changes included improvement in patient tracking and follow-up, standardisation of processes of care and overall clinic documentation. Changes related to patients' involvement in their care included improving (a) health education, and (b) self-care management. Among the internal barriers were: staff readiness for change, poor communication and relationship difficulties among team members. External barriers were insurance regulations, finances and patient health literacy., Conclusions: Transforming practices to more patient-centred models of care will be a priority for primary care providers. Identifying opportunities and challenges associated with implementing change is critical for successful improvement programmes. Successful strategies for enhancing the adoption and uptake of PCMH elements should leverage areas of concordance between practice members' perceived needs and planned improvement efforts.

Background: discussing self-care activities like exercise is challenging with the many competing demands during primary care encounters. Our objective was to study the relationship between the Chronic Care Model (CCM) score in the clinic and time spent by the physicians discussing exercise during encounters with diabetic patients., Methods: consecutive patients with diabetes across 20 primary care clinics in South Texas were included. Time spent discussing exercise was determined using the Davis Observation Code on audio recordings of the visits. Clinicians completed the Assessment of Chronic Illness Care survey, a validated measure of the extent to which care delivered is consistent with the CCM. Data were analyzed using hierarchical linear models., Results: a total of 162 transcribed recordings were analyzed. Age, the number of problems addressed, stage of change (SOC), and overall length of the visit were associated with time spent discussing exercise. There was a significant relationship between clinic CCM score and time spent by physicians advising about exercise, independent of SOC for exercise (P < .01). Also, a discussion about exercise was more likely to occur with patients who were in the contemplation SOC for exercise., Conclusions: discussions of exercise may be 18 to 33 seconds longer in clinics with full implementation of the CCM compared with those with basic implementation. Facilitating more complete CCM implementation in clinics with a basic level of CCM that serve a population of patients who are sedentary may realize the most benefit.

Purpose: To examine skin and soft tissue infections presenting at 4 primary care clinics and assess if historical risk factors and examination findings were associated with a positive methicillin-resistant Staphylococcus aureus (MRSA) culture., Methods: During the 10-month observational study (April 2007 through January 2008), physicians in 5 practices across South Texas collected history, physical examination findings, culture results, and antibiotic(s) prescribed for all patients presenting with a skin or soft tissue infection. Analyses were conducted to determine the relationship between historical indicators, location of lesions, and examination findings with a positive MRSA culture., Results: Across 4 practices, 164 cases of skin and soft tissue infections were collected during 10 months. Of the 94 with a culture, 63 (67%) were MRSA positive. Patients working in or exposed to a health care setting were more likely to have a culture positive for MRSA, as were those presenting with an abscess. MRSA-positive lesions were also significantly smaller in size., Conclusions: Because of the high prevalence of MRSA skin and soft tissue infections among patients presenting to family physicians, presumptive treatment for MRSA may be indicated. However, increasing levels of resistance to current antibiotics is concerning and warrants development of alternative management strategies.

Background: Patients with a chronic illness are likely to report difficulties in their encounters with the health care system. Although most patients with a chronic illness are managed by primary care clinicians, little is known about how the attributes of primary care might be related to health care system hassles., Objective: We sought to examine the relationship between attributes of primary care and health care system hassles among veterans with one or more chronic illnesses., Research Design: This was a cross-sectional mailed survey., Subjects: We included veterans with one or more chronic illnesses who were cared for in the South Texas Veteran's health care system., Measures: The Components of Primary Care Instrument was used to measure 4 attributes of primary care: accumulated knowledge of the patient by the clinician, coordination of care, communication, and preference for first contact with their primary care clinician. A 16-item health care systems hassles scale was constructed and demonstrated good face validity and reliability with a Cronbach's alpha of 0.94., Results: Of the 720 surveys administered by mail, 422 (59%) were returned. Patients with multiple chronic illnesses reported a higher level of hassles than patients with a single chronic illness. After controlling for patient characteristics, primary care communication and coordination of care were inversely associated with patient hassles score: as communication and coordination improved, the reported level of hassles decreased., Conclusions: Effective delivery of primary care to patients with one or more chronic illnesses may be important in decreasing the level of hassles they experience as they interact with the health care delivery system.

Purpose: The relationship between the self-monitoring of blood glucose (SMBG) and glycemic control in patients with type 2 diabetes mellitus in a Veterans Affairs (VA) medical center was studied., Methods: Laboratory, inpatient, outpatient, and demographic data for patients with type 2 diabetes mellitus who were seen for three years continuously or receiving their care regularly from a single Texas VA facility between October 1, 1999, and September 30, 2002, were obtained. Local pharmacy data were used to identify patients who received blood-glucosemonitoring strips. Patients were assigned to one of four mutually exclusive groups: those who did not receive monitoring strips at all, those who received strips in fiscal year (FY) 2002 only, those who received strips in FYs 2001 and 2002, and those who received strips during all three years (FYs 2000, 2001, and 2002). Frequency of monitoring and case-mix scores were measured. Nonparametric statistics were used to compare the demographic and clinical characteristics of the four groups. Robust regression was used to analyze the relationships between SMBG and glycemic control in FY 2002., Results: Of the 1185 patients who received oral hypoglycemic medications during all three fiscal years, 976 patients met the criteria for inclusion in one of the four groups. There were no significant differences among the four groups in baseline hemoglobin A1c (HbA1c) values, body mass index, or case-mix scores. The Kruskal-Wallis test found no significant difference among the four groups in the number of laboratory blood glucose tests conducted, but there were significant differences in the number of HbA1c tests conducted among the groups., Conclusion: SMBG was not associated with glycemic control in VA patients with type 2 diabetes mellitus managed on oral hypoglycemic medications.

In the United States, asthma now ranks as the most prevalent chronic disease among children. Within rural cotton-producing regions, a popular belief is that cotton production increases the prevalence of asthma. This case-control study was conducted to determine if the prevalence of asthma is higher in children living in rural cotton-producing countries than in children where cotton production is negligible. No evidence was found to support the belief that cotton production increases the rural childhood prevalence of asthma (P = .12). More importantly, this study did reveal a significantly higher prevalence of asthma among the fifth graders in rural West Texas than the prevalence predicted by the Centers for Disease Control and Prevention (P < .0001).