Search

Medical error reporting systems are important information sources for designing strategies to improve the safety of health care. Applied Strategies for Improving Patient Safety (ASIPS) is a multi-institutional, practice-based research project that collects and analyzes data on primary care medical errors and develops interventions to reduce error. The voluntary ASIPS Patient Safety Reporting System captures anonymous and confidential reports of medical errors. Confidential reports, which are quickly de-identified, provide better detail than do anonymous reports; however, concerns exist about the confidentiality of those reports should the database be subject to legal discovery or other security breaches. Standard database elements, for example, serial ID numbers, date/time stamps, and backups, could enable an outsider to link an ASIPS report to a specific medical error. The authors present the design and implementation of a database and administrative system that reduce this risk, facilitate research, and maintain near anonymity of the events, practices, and clinicians. [ABSTRACT FROM AUTHOR]

BACKGROUND: Many medical errors occur during the laboratory testing process, including lost test results. Patient inquiry concerning results often represents the final safety net for locating lost results. This qualitative study sought to identify, from a patient perspective, specific preferences and factors that influence the process of communicating normal (negative) laboratory test results to patients. METHODS: We conducted 30-minute guided interviews with 20 adult patients. Patients were recruited from two practice-based research networks in Colorado that were participating in a medical errors study. A semi-structured interview elicited the participant's experience with and preference for laboratory test result notification. Quantitative descriptive statistics were generated for demographic and preference data. Qualitative results were analyzed by a team of experienced qualitative researchers using multiple styles of qualitative analyses, including a template approach and an editing approach. RESULTS: Ninety percent of participants wanted to be notified of all tests results. Important issues related to notification included privacy, responsive and interactive feedback, convenience, timeliness, and provision of details. Telephone notification was preferred, followed by regular mail. Electronic notification was perceived as uncomfortable because it was not secure. While 65% preferred being notified by a provider, participants acknowledge that this may be impractical; thus, they wanted to be notified by someone knowledgeable enough to answer questions. Participants do not normally discuss their preferences for test result notification with their providers. CONCLUSION: Privacy, responsive and interactive feedback, convenience, and timeliness with detailed information may be critical for patient satisfaction and for improving patient safety, and are features that may be incorporated into emerging communication channels. [ABSTRACT FROM AUTHOR]

Background: Continuous glucose monitoring (CGM) for patients with type 1 and type 2 diabetes is associated with improved clinical, behavioral, and psychosocial patient health outcomes and is part of the American Diabetes Association's Standards of Medical Care. CGM prescription often takes place in endocrinology practices, yet 50% of adults with type 1 diabetes and 90% of all people with type 2 diabetes receive their diabetes care in primary care settings. This study examined primary care clinicians' perceptions of barriers and resources needed to support CGM use in primary care., Methods: This qualitative study used semistructured interviews with primary care clinicians to understand barriers to CGM and resources needed to prescribe. Participants were recruited through practice-based research networks. Rapid qualitative analysis was used to summarize themes from interview findings., Results: We conducted interviews with 55 primary care clinicians across 21 states. Participants described CGM benefits for patients with varying levels of diabetes self-management and engagement. Major barriers to prescribing included lack of insurance coverage for CGM costs to patients, and time constraints. Participants identified resources needed to foster CGM prescribing, for example, clinician education, support staff, and EHR compatibility., Conclusion: Primary care clinicians face several challenges to prescribing CGM, but they are interested in learning more to help them offer it to their patients. This study reinforces the ongoing need for improved clinician education on CGM technology and continued expansion of insurance coverage for people with both type 1 and type 2 diabetes., Competing Interests: Conflict of interest: Drs. T. Oser and S. Oser have received Advisory Board Consulting fees (through the University of Colorado) from Dexcom, Ascensia, and Blue Circle Health and research grants (through the University of Colorado) from NINR, NIDDK, the Helmsley Charitable Trust, Abbott Diabetes, Dexcom, and Insulet. They report no conflicting or competing interests in connection with these collaborations. They do not own stocks in any device or pharmaceutical company. All other authors report no conflicts of interest., (© Copyright by the American Board of Family Medicine.)

Background: Opioid misuse is a significant public health crisis. The aim sought to identify potential gaps in opioid care in primary care practices., Methods: American Academy of Family Physicians (AAFP) offered a monthly online educational series to seven U.S. practices. Practices were asked to complete up to 50 chart reviews for visits during two periods: February-April, 2019, and February-April, 2022. Each chart had to have an ICD-10 diagnosis of opioid misuse, opioid dependence, or opioid use. Chart reviews consisted of 14 questions derived from an American Academy of Addiction Psychiatry (AAAP) Performance in Practice activity, and then, scored based on practices' responses. Descriptive statistics and binary logistic and multinomial regressions were used., Results: Both periods had 173 chart reviews (total: 346) from the six practices. Most chart reviews were for patients with a diagnosis of opioid dependence (2019: 90.2%; 2022: 83.2%). Three questions for assessing OUD treatment behaviors had high levels of documentation across both time periods (>85%): other drug use, treatment readiness, and treatment discussion., Discussion: Results show a gap in the treatment of patients with OUD in primary care across several clinical practice recommendations., Conclusions: Expanding OUD treatment integration to primary care remains the most promising effort to combat the opioid crisis.

Background: Clinician-patient miscommunication contributes to worse asthma outcomes. What patients call their asthma inhalers and its relationship with asthma morbidity are unknown., Methods: Inhaler names were ascertained from Black and Latinx adults with moderate-severe asthma and categorized as "standard" if based on brand/generic name or inhaler type (i.e., controller vs. rescue) or "non-standard" for other terms (i.e., color, device type, e.g., "puffer," or unique names). Clinical characteristics and asthma morbidity measures were evaluated at baseline: self-reported asthma exacerbations one year before enrollment (i.e., systemic corticosteroid bursts, emergency department (ED)/urgent care (UC) visits, or hospitalizations), and asthma control and quality of life. Multivariable regression models tested the relationship between non-standard names and asthma morbidity measures, with adjustments., Results: Forty-four percent (502/1150) of participants used non-standard inhaler names. These participants were more likely to be Black (p=0.006), from the Southeast (p<0.001), and have fewer years with asthma (p=0.012) relative to those who used standard names. Non-standard inhaler names was associated with an incidence rate ratio (IRR) of 1.29 (95% confidence interval [CI], 1.11-1.50, p=0.001; 1.8 vs. 1.5 events) for corticosteroid bursts for asthma, an IRR=1.43 (95% CI, 1.21-1.69, p<0.001; 1.9 vs. 1.4 events) for ED/UC visits for asthma, and an odds ratio=1.57 (95% CI, 1.12-2.18, p=0.008; 0.5 vs. 0.3 events) for asthma hospitalizations after adjustment., Conclusions: Patients who use non-standard names for asthma inhalers experience increased asthma morbidity. Ascertaining what patients call their inhalers may be a quick method to identify those at higher risk of poor outcomes., Competing Interests: Conflict of interest: Ms. Forth reports receiving honoraria from Takeda for work in advisory boards for Alpha 1 antitrypsin and severe COPD. Dr. Cardet reports receiving honoraria from AstraZeneca, Genentech, and GSK for work in advisory boards and educational lectures on asthma. Dr. Fuhlbrigge is an unpaid consultant to AstraZeneca for the development of outcome measures for asthma and COPD clinical trials and a consultant to Novartis on epidemiologic analyses related to asthma control. Dr. Pace has received research grants from and is a consultant for Boehringer Ingelheim and a research grant from AstraZeneca. Dr. Phipatanakul received grants from Genentech, Regeneron, Novartis, Sanofi, Merck, and GSK; consulting fees from Regeneron, Sanofi, GSK, Genentech, and Novartis; and honoraria for educational events from Genentech, Sanofi, Regeneron, and GSK. Dr. Mosnaim received research grant support from AstraZeneca, Alk-Abello and Genentech and receives research grant support from GlaxoSmithKline, Novartis, Sanofi-Regeneron, and TEVA. Dr. Israel received in-kind medications or devices for NIH or PCORI-sponsored studies from Teva, Circassia, royalties from UpToDate, and consulting fees from AB Science, Allergy and Asthma Network, Amgen, Arrowhead Pharmaceuticals, AstraZeneca, Avillion, Biometry, Equillium, Genentech, GlaxoSmithKline, Merck, NHLBI, Novartis, Pneuma Respiratory, PPS Health, Regeneron, Sanofi Genzyme, Sienna Biopharmaceuticals, TEVA, and Cowen. The other authors have no conflicts of interest to disclose., (© Copyright by the American Board of Family Medicine.)

Purpose: A community teaching hospital serving a rural population established an intensive "hospital at home" program for patients with COVID-19 utilizing disease risk stratification and pulse oximeter readings to dictate nurse and clinician contact. Herein, we report patient outcomes and provider experiences resulting from this "virtual" approach to triaging pandemic care., Methods: COVID-19-positive patients appropriate for outpatient management were enrolled in our COVID Virtual Hospital (CVH). Patients received pulse oximeters and instructions for home monitoring of vital signs. CVH nurses contacted the patient within 12-48 hours. The primary care provider was alerted of the patient's diagnosis and held a virtual visit with patient within 2-3 days. Nurses completed a triage form during each patient call; the resulting risk score determined timing of subsequent calls. CVH-relevant patient outcomes included emergency department (ED) visits, mortality, and disease-related hospitalization. Additionally, a survey of providers was conducted to assess CVH experience., Results: From April 22, 2020, to December 21, 2020, 1916 patients were enrolled in the CVH, of which 195 (10.2%) had subsequent visits to the ED. Among those 195 ED visits, 102 (52.3%) were nurse-directed while 93 (47.7%) were patient self-directed; 88 (86.3%) nurse-directed ED visits were subsequently admitted to inpatient care and 14 were discharged home. Of the 93 self-directed ED visits, 3 (3.2%) were admitted. A total of 91 CVH patients (4.7%) were ultimately admitted to inpatient care. Seven deaths occurred among CVH patients, 5 of whom had been admitted for inpatient care. Among 71 providers (23%) who responded to the survey, 94% and 93% agreed that the CVH was beneficial to providers and patients, respectively., Conclusions: Proactive in-home triage of patients with COVID-19 utilizing a virtual hospital model minimized unnecessary presentations to ED and likely prevented our rural hospital from becoming overwhelmed during year one of the pandemic., Competing Interests: Conflicts of Interest None., (© 2023 Advocate Aurora Health, Inc.)

During the COVID-19 pandemic, providers and patients explored the use of telehealth on a wide and rapid scale. Reflecting on how prenatal providers and pregnant patients used telehealth during the pandemic and afterward, we review existing and new lessons learned from the pandemic. This article summarizes international and national guidelines on prenatal care, presents practice examples on how telehealth and remote patient monitoring were used during the COVID-19 pandemic, and offers lessons learned and suggestions for future care., Competing Interests: Disclosure None of the authors report any disclosures., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background and Objectives: While advance care planning (ACP) is critical for ensuring optimal end-of-life outcomes among individuals with mild cognitive impairment (MCI), many individuals who may benefit from ACP have not initiated this process. This article aims to describe the iterative design of an MCI group visit-based intervention and evaluate the feasibility and acceptability of the intervention., Research Design and Methods: We used human-centered design, rapid-cycle prototyping, and multiple methods to adapt an ENgaging in Advance Care planning Talks (ENACT) Group Visits intervention. We convened an advisory panel of persons with MCI and care partners (n = 6 dyads) to refine the intervention and conducted a single-arm pilot of 4 MCI ENACT intervention prototypes (n = 13 dyads). We used surveys and interviews to assess outcomes from multiple perspectives., Results: The advisory panel affirmed that ACP is a priority for individuals with MCI, described the need for ACP in a group setting, and suggested refinements to ACP resources for the MCI ENACT intervention. Feasibility of recruitment was limited. MCI ENACT intervention participants strongly agreed that group discussions provided useful information and recommended the intervention. Themes supporting acceptability included (a) feedback on acceptability of the intervention, (b) previous experiences with ACP, and (c) reasons for participation, including desire for discussions about MCI and how it relates to ACP., Discussion and Implications: Despite stakeholders' positive ratings of acceptability of the MCI ENACT intervention, future work is needed to enhance the feasibility of recruitment to support implementation into clinical settings., (Published by Oxford University Press on behalf of The Gerontological Society of America 2021.)

Introduction: Health systems undertook a rapid transition to increase the use of telemedicine in the wake of the COVID-19 pandemic. A continued need for telemedicine services in the coming years is likely. This article examines telemedicine from multiple stakeholders' perspectives considering reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) outcomes., Methods: Semistructured interviews were conducted with primary care practice team members and patients. Rapid qualitative analysis was used to identify themes in experiences and perceptions related to telemedicine implementation. The RE-AIM implementation framework was applied to thematic findings to understand influences on implementation outcomes., Results: Twenty-four practice members and 17 patients across 5 clinics participated. All stakeholder groups reported that technological capabilities influenced patients' access to telemedicine and that certain patients and reasons for visits were not appropriate for telemedicine. All groups felt that telemedicine was a good option for some patients some of the time but not all patients all of the time., Discussion: Telemedicine works well if it is used for the appropriate visits and patient types and with needed technological elements. Older age may limit the feasibility of telehealth for some patients. Added administrative work and associated costs support systematic screening to determine visit appropriateness for telemedicine., Competing Interests: Conflict of interest: The authors declare no conflicting or competing interests to report., (© Copyright 2022 by the American Board of Family Medicine.)

Objective: Stimulant medications are used to treat attention-deficit/hyperactivity disorder (ADHD) in adults. However, stimulants are among the most frequently prescribed medications that have a potential to be used nonmedically. We sought to define types of errors associated with treatment of ADHD in adults and to describe a classification rubric for stimulant-related prescribing faults., Methods: An expert panel conducted a scoping review of the literature and rubric development. The literature search including relevant English language publications indexed in Medline (1990-present, human) and Embase (1990-present, human). In addition, we reviewed relevant documentation such as medication labels and guides containing information related to medications used for the treatment of adult ADHD. The initial version draft rubric was developed by adapting an existing framework for prescribing errors. The expert panel further defined a classification rubric and developed error subcategories, classifications, and descriptions., Results: Two error categories were identified. Category 1 errors are errors resulting from prescribing faults, which further included errors in decision making/judgment; errors related to monitoring for potential harm of stimulants; possible errors: events that should generally be avoided or be used with caution; and suboptimal prescribing. Category 2 errors result from prescription writing, further defined as failure to communicate essential information and transcription errors., Conclusions: This study provides a comprehensive description of medication errors associated with stimulant and related medications. Our findings have the potential to assist decision making and to tailor delivery programs, recommendations, guidelines, and clinical decision support health information technology on stimulant prescribing and monitoring., Competing Interests: The authors disclose no conflict of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Primary care clinicians need to recognize and diagnose Adult ADHD (AADHD). We tested the feasibility and outcomes of a two-step screening process for AADHD in primary care. Methods: Seven practices screened patients using computerized surveys. Patients screening positive completed the AADHD Quality of Life (AAQoL). We explored the impact of screening on workflow and the acceptability to patients, and identified key barriers/opportunities to continuing screening. Results: Of the 711 participating adults, 188 (26.4%) screened positive, of which 32 (17.0%) had scores at least one standard deviation below means on two or more domains on the AAQoL (average 23.6 ± 7.3). These 32 individuals represented 4.5% of all participants. Clinicians were willing to screen, diagnose, and treat AADHD, but need additional resources. The screening process and technology was acceptable to patients and staff. Conclusions: A two-step screening method shows promise for routine screening for AADHD.

Introduction: Our university hospital-based primary care practices transitioned a budding interest in telehealth to a largely telehealth-based approach in the face of the COVID-19 pandemic., Initial Work: Implementation of telehealth began in 2017. Health system barriers, provider and patient reluctance, and inadequate reimbursement prevented widespread adoption at the time. COVID-19 served as the catalyst to accelerate telehealth efforts., Implementation: COVID-19 resulted in the need for patient care with "social distancing." In addition, due to the pandemic, the Centers for Medicare and Medicaid Services and other insurers began expanded reimbursement for telehealth. More than 2000 providers received virtual health training in less than 2 weeks. In March 2020, we provided 2376 virtual visits, and in April 5293, which was more than 75 times the number provided in February; 73% of all visits in April were virtual (up from 0.5% in October 2019). As COVID-19 cases receded in May, June, and July, patient demand for virtual visits decreased, but 28% of visits in July were still virtual., Lessons Learned: Several key lessons are important for future efforts regarding clinical implementation: (1) prepare for innovation, (2) cultivate an innovation mindset, (3) standardize (but not too much), (4) technological innovation is necessary but not sufficient, and (5) communicate widely and often., Competing Interests: Conflict of interest: None., (© Copyright 2021 by the American Board of Family Medicine.)

Background: Advance care planning is the process of discussing health care treatment preferences based on patients' personal values, and it often involves the completion of advance directives. In the first months of 2020, a novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), began circulating widely in the American state of Colorado, leading to widespread diagnosis of coronavirus disease (COVID-19), hospitalizations, and deaths. In this context, the importance of technology-based, non-face-to-face methods to conduct advance care planning via patient portals has increased., Objective: The aim of this study was to determine the rates of use of a web-based advance care planning tool through a health system-based electronic patient portal both before and in the early months of the COVID-19 pandemic., Methods: In 2017, we implemented web-based tools through the patient portal of UCHealth's electronic health record (EHR) for patients to learn about advance care planning and complete an electronically signed medical durable power of attorney (MDPOA) to legally appoint a medical decision maker. Patients accessing the portal can complete and submit a legally valid MDPOA, which becomes part of their medical record. We collected data on the patients' date of MDPOA completion, use of advance care planning messaging, age, sex, and geographic location during the early phase of the COVID-19 pandemic (December 29, 2019, to May 30, 2020)., Results: Over a 5-month period that includes the early phase of the COVID-19 pandemic in Colorado, total monthly use of the advance care planning portal tool increased from 418 users in January to 1037 users in April and then decreased slightly to 815 users in May. The number of MDPOA forms submitted per week increased 2.4-fold after the stay-at-home order was issued in Colorado on March 26, 2020 (P<.001). The mean age of the advance care planning portal users was 47.7 years (SD 16.1), and 2206/3292 (67.0%) were female. Women were more likely than men to complete an MDPOA, particularly in younger age groups (P<.001). The primary use of the advance care planning portal tools was the completion of an MDPOA (3138/3292, 95.3%), compared to sending an electronic message (148/3292, 4.5%). Over 50% of patients who completed an MDPOA did not have a prior agent in the EHR., Conclusions: Use of a web-based patient portal to complete an MDPOA increased substantially during the first months of the COVID-19 pandemic in Colorado. There was an increase in advance care planning that corresponded with state government shelter-in-place orders as well as public health reports of increased numbers of COVID-19 cases and deaths. Patient portals are an important tool for providing advance care planning resources and documenting medical decision makers during the pandemic to ensure that medical treatment aligns with patient goals and values., (©Jennifer D Portz, Adreanne Brungardt, Prajakta Shanbhag, Elizabeth W Staton, Seuli Bose-Brill, Chen-Tan Lin, Jean S Kutner, Hillary D Lum. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 11.08.2020.)

Background: Adult immunization rates are below Healthy People 2020 targets. Our objective was to evaluate the effectiveness of a multicomponent intervention to improve adult immunization rates., Methods: This prospective interventional before-and-after non-randomized study was conducted through the American Academy of Family Physicians National Research Network with 43 primary care physicians from a large multi-specialty healthcare organization (multicomponent intervention group n = 23; comparator group n = 20) in the United States. The multicomponent intervention included provider reminders, quarterly provider-level performance reports, provider education, patient visual aid materials, and standing orders on adult pneumococcal, influenza, and zoster immunizations. We assessed individual and comparative provider-level vaccination rates and missed opportunities detailing concordance with targets established by Healthy People 2020 for pneumococcal, influenza, and zoster immunizations., Results: Vaccination rates increased after 12 months in intervention and comparator groups respectively for: a). influenza from 44.4 ± 16.7 to 51.3% ± 12.9% (by 6.9 percentage points, p = 0.001) and from 35.1 ± 19.1 to 41.3% ± 14.2%, (by 6.2 percentage points, p = 0.01); b). pneumococcal vaccinations in older adults from 62.8 ± 17.6 to 81.4% ± 16.6% (by 18.6 percentage points, for p < 0.0001) and from 55.9 ± 20.0 to 72.7% ± 18.4% (by 16.7 percentage points, p < 0.0001); and c). zoster from 37.1 ± 13.4 to 41.9% ± 13.1% (by 4.8 percentage points, p < 0.0001) and from 35.0 ± 18.7 to 42.3% ± 20.9% (7.3 percentage points, p = 0.001). Pneumococcal vaccinations in adults at risk did not change from baseline in intervention group (35.7 ± 19.6 to 34.5% ± 19.0%, p = 0.3) and improved slightly in comparator group (24.3 ± 20.1 to 28.2% ± 20.0%, p = 0.003). Missed opportunities reduced after 12 months, most noticeably, for: a). for influenza from 57.7 to 48.6% (by 9.1 percentage points, p < 0.0001) and from 69.7 to 59.6% (by 10.1 percentage points, p < 0.0001); b). pneumococcal vaccinations in older adults from 18.1 to 11.5% (by 6.6 percentage points p < 0.0001) and from 24.6 to 20.4% (by 4.3 percentage points, p < 0.0001) in intervention and comparator groups respectively., Conclusions: Multicomponent interventions show promise in improving vaccination rates and reducing missed opportunities in older adults for pneumococcal and zoster vaccines and vaccination against influenza. Provider reminders remain the most effective strategy when delivered either as a component of these interventions or alone.

Background: The role of family physicians (FPs) and college health professionals (CHPs) in stimulant treatment and nonmedical use of stimulants is not clear., Objective: To investigate the current practices, concerns, needs, beliefs, barriers, and facilitators to appropriate pharmacological treatment of teens and young adults with attention deficit hyperactivity disorder (ADHD) and prevention of nonmedical use and diversion., Methods: A cross-sectional survey developed by the project team and experts in the field, delivered to national sample of FPs and CHPs., Results: A total of 794 completed surveys were analyzed. The average age of respondents was 51.6 ± 10.3 years; 50.6% of the respondents were female. The majority of CHPs (80.6%) reported they spend 75% to 100% of their time with patients age 17 to 24 years and 74.0% of FPs reported they spend less than 25% of their time with this age group. The majority (91.7%) of the respondents indicated that untreated ADHD affects quality of life, and 76.4% indicated untreated ADHD is often associated with risky behaviors. More CHPs than FPs always refer out for ADHD diagnosis (70.7% vs 52.1%; P < .001). Most respondents (81.2%) were concerned with ADHD medication diversion, and 84.2% believed that diversion or abuse is a problem overall. Respondents indicated they are unprepared to provide patient education on decisions about pharmacotherapy or behavioral therapy choices for adult ADHD., Conclusion: There is an opportunity to enhance safety and effectiveness of ADHD management in young adults. Additional resources and interventions are needed to improve medication management, reduce misuse, and ensure safe and appropriate use of stimulants., Competing Interests: Conflict of interest: none declared., (© Copyright 2020 by the American Board of Family Medicine.)

Introduction: Care teams partnering with patients are integral to quality primary care. Effective patient-team partnership recognizes patients' contributions in decision-making and respecting patients' goals and social context. We report practice characteristics associated with greater patient-team partnership scores., Methods: EvidenceNOW Southwest was a multistate initiative to improve cardiovascular care in primary care practices through guideline-concordant aspirin use, blood pressure control, cholesterol management, and smoking cessation. EvidenceNOW Southwest provided 9 months of practice facilitation and information technology support through regular meetings and training to 211 Colorado and New Mexico primary care practices from 2015 to 2017. We analyzed surveys from 97% of participating practices regarding patient-team partnership activities of self-management support, social need assessment, resource linkages, and patient input. We used linear and mixed effects regression modeling to examine relationships between patient-team partnership and practice characteristics., Results: Practice characteristics significantly associated with greater patient-team partnership were using patient registries, medically underserved area designation, multispecialty mix, and using clinical cardiovascular disease management guidelines. Our findings suggest that patient-team partnership implementation in small primary care practices is moderate, with mean practice- and member-level scores of 52 of 100 (range, 0-100) and 71 of 100 (range, 10-100), respectively., Conclusion: Practices can improve efforts to partner with patients to assess social needs, gather meaningful input on practice improvement and patient experience, and offer resource connections. Our findings supplement recent evidence that patient registries and evidence-based guidelines may effectively prevent and manage cardiovascular disease. These strategies may also promote primary care patient-team partnership., Competing Interests: Conflict of interest: none declared., (© Copyright 2019 by the American Board of Family Medicine.)

Background: The same trauma that produces concussion may also produce neck injury. The signs of concussion and neck injury are similar, and symptoms after acceleration-deceleration trauma to the head-neck complex do not accurately discriminate between them. Research on the epidemiology of neck injury among sport-concussed youth is sparse., Purpose: The purpose of this study was to investigate the epidemiology of diagnosed neck injury in non-sport-related concussion (Non-SRC) versus sport-related concussion (SRC) in youth by age, sex, and sport., Study Design: Cross-sectional epidemiologic study., Methods: De-identified data from community-based electronic health records over 13 years were extracted to analyze rates and characteristics of neck injuries among non-SRCs and SRCs in youth aged five to 21. Neck injury diagnosis prevalence rates and odds ratios were calculated to estimate risk of neck injury among concussed youth, comparing non-SRCs to SRCs by age and sex., Results: Sixteen thousand, eight hundred eighty-five concussion records were extracted, of which 3,040 SRCs and 2,775 non-SRCs in youth aged five to 21 were identified by cross-filtering sport-related keywords (e.g., football, basketball, soccer, running, swimming, batting, horseback riding, skiing, etc.) with all ICD-9 and ICD-10 concussion codes. The prevalence of neck injuries diagnosed among SRCs (7.2%) was significantly different than the prevalence of neck injuries diagnosed among non-SRCs (12.1%, p < 0.000). Neck injury diagnoses were significantly more prevalent in females overall (p < 0.000) and among non-SRCs (p < 0.000). The prevalence of neck injury diagnoses was not significantly higher in concussed females versus concussed males with SRC (p = 0.164).Among youth aged five to 21 exposed to concussions, non-SRCs were more likely to be accompanied by a neck injury diagnosis than SRCs (OR 1.66; 95% CI 1.39 to 1.98; p < 0.000). Similarly, female-to-male neck injury proportion ratios were significantly higher in females in non-SRCs compared to SRCs (IPR 1.90, 95% CI 1.60 to 2.25, p < 0.000).Sports with highest prevalence of concussion differ from sports with highest prevalence of concussion-related neck injury in both sexes., Conclusions: The overall prevalence of diagnosed neck injuries in youth was higher in non-SRCs compared to SRCs (12.1 vs. 7.2%, p < 0.001), with the highest prevalence at age 14 in both sexes. The risk of neck injury diagnosis accompanying concussion was significantly higher in females compared to males (6.1% difference; p < 0.000)., (© 2019 by the Sports Physical Therapy Section.)

Purpose: The purpose of this project was to evaluate the real-world usability and usefulness of a revised version of the published Agency for Healthcare Research and Quality "Improving Your Office Testing Process" toolkit, designed to help primary care practices standardize and systematize laboratory testing processes., Method: We used a multiple case study approach to evaluate toolkit implementation in 2 primary care practices with existing quality improvement (QI) infrastructure. We collected qualitative data at baseline, midpoint (3 to 4 weeks), and follow-up (7 to 8 weeks postimplementation). Data included key informant interviews and practice site observations. Nineteen clinicians and staff participated in the interviews. Thematic analysis was used to summarize (1) how practices used the toolkit for guiding lab testing process improvement (usefulness), and (2) ease of use and practice experience with using the toolkit (usability)., Results: The toolkit was perceived as easy to use and easy to follow step by step. Two components of the toolkit were particularly useful: guidance on data gathering to inform quality improvement and tools for effective practice-patient communication. The toolkit's practice and patient assessments facilitated practice-specific insights into the lab processes considered most harmful to patients and informed improvement activities., Conclusion: The usability and usefulness of the toolkit were related to the characteristics of the toolkit itself (adaptability, simplicity, and design quality and packaging, and guidance in planning) and practice processes (presence of practice champions and implementation teams). In a set of 2 practices in which laboratory testing process improvement was a high priority and where well-established QI infrastructure exists, the toolkit was easy to use with little technical assistance., Competing Interests: Conflict of interest: none declared., (© Copyright 2019 by the American Board of Family Medicine.)

Importance: Information is needed about optimal strategies to improve evidence-based treatment of chronic kidney disease (CKD) in primary care., Objective: To determine whether a multimodal intervention delays annualized loss of estimated glomerular filtration rate (eGFR) in stages 3 and 4 CKD., Design, Setting, and Participants: This pragmatic cluster randomized clinical trial enrolled 42 primary care practices located in nonhospital settings with electronic health record systems. Practices were recruited through the American Academy of Family Physicians National Research Network. The study was conducted January 2013 through January 2016., Interventions: Practices were randomized at the organization level to either the clinical decision support (CDS) plus practice facilitation (PF) group (n = 25) or CDS group (n = 17) using covariate constrained randomization. Both groups received point-of-care CDS to prompt screening, diagnosis, and treatment of CKD; the intervention group also received PF based on the 9-point TRANSLATE model (target, use point-of-care reminder systems, get administrative buy-in, network information systems using registries, site coordination, local physician champion, audit and feedback, team approach, and education)., Main Outcomes and Measures: The primary outcome measure was eGFR over time. Secondary outcome measures were systolic blood pressure over time, change in hemoglobin A1c (HbA1c) over time, avoidance of nonsteroidal anti-inflammatory medications, use of angiotensin converting enzyme inhibitor or angiotensin-renin blocker medication, early recognition and diagnosis of CKD, blood pressure control, and smoking cessation., Results: In this cluster randomized trial of 30 primary care practices comprising 6699 patients, there were 1685 patients in the control group (10 practices) and 5014 patients in the intervention group (20 practices). The final sample of practices differed from the original set of randomized practices owing to dropout. Patients in the practices were similar at baseline for age (mean [SD], 71.3 [9.6] years), sex (2716 male [40.5%]), and eGFR. There was a significant difference in eGFR slopes for patients in the intervention vs control group practices. The mean (SE) annualized loss of eGFR was 0.95 (0.19) in the control group in propensity-adjusted longitudinal analyses and 0.01 (0.12) in the intervention group (mean [SE] difference in slopes, 0.93 [0.23]; P < .001). Among patients with HbA1c measures, slopes differed significantly for patients in intervention vs control practices, with a mean (SE) annualized increase of 0.14 (0.03) in HbA1c for patients in control practices and a mean (SE) decline of 0.009 (0.02) for patients in intervention practices. There was a significant difference in HbA1c slopes for patients in the intervention compared with control group practices (control vs intervention, -0.14; P < .001), but no difference in the other secondary outcomes., Conclusions and Relevance: A multimodal intervention in primary care, based on the TRANSLATE model, slowed annualized loss of eGFR. This study had several important strengths, weaknesses, and lessons learned regarding the implementation of pragmatic interventions in primary care to improve CKD outcomes., Trial Registration: ClinicalTrials.gov Identifier: NCT01767883.

Background: Patient portals may improve communication between families of children with asthma and their primary care providers and improve outcomes. However, the feasibility of using portals to collect patient-reported outcomes from families and the barriers and facilitators of portal implementation across diverse pediatric primary care settings have not been established., Objective: We evaluated the feasibility of using a patient portal for pediatric asthma in primary care, its impact on management, and barriers and facilitators of implementation success., Methods: We conducted a mixed-methods implementation study in 20 practices (11 states). Using the portal, parents of children with asthma aged 6-12 years completed monthly surveys to communicate treatment concerns, treatment goals, symptom control, medication use, and side effects. We used logistic regression to evaluate the association of portal use with child characteristics and changes to asthma management. Ten clinician focus groups and 22 semistructured parent interviews explored barriers and facilitators of use in the context of an evidence-based implementation framework., Results: We invited 9133 families to enroll and 237 (2.59%) used the portal (range by practice, 0.6%-13.6%). Children of parents or guardians who used the portal were significantly more likely than nonusers to be aged 6-9 years (vs 10-12, P=.02), have mild or moderate/severe persistent asthma (P=.009 and P=.04), have a prescription of a controller medication (P<.001), and have private insurance (P=.002). Portal users with uncontrolled asthma had significantly more medication changes and primary care asthma visits after using the portal relative to the year earlier (increases of 14% and 16%, respectively). Qualitative results revealed the importance of practice organization (coordinated workflows) as well as family (asthma severity) and innovation (facilitated communication and ease of use) characteristics for implementation success., Conclusions: Although use was associated with higher treatment engagement, our results suggest that achieving widespread portal adoption is unlikely in the short term. Implementation efforts should include workflow redesign and prioritize enrollment of symptomatic children., Clinicaltrial: Clinicaltrials.gov NCT01966068; https://clinicaltrials.gov/ct2/show/NCT01966068 (Archived by WebCite at http://www.webcitation.org/6i9iSQkm3).

Prevention plays an important role in achieving the triple aim of decreasing per capita health care costs, improving the health of populations, and bettering the patient experience. Primary care is uniquely positioned to provide preventive services. External forces are aligning to support the transition of primary care from traditional models focused on disease-specific, acute episodes of care to new ways of organizing that are more patient centered, team based, and quality driven. By aligning leadership, building change capacity, and selectively choosing relevant processes to change, those practicing primary care can successfully organize their practice environment to deliver preventive services., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Purpose: Given the increasing age of the US population, understanding how primary care is delivered surrounding dementia and physicians' perceived barriers and needs associated with this care is essential., Methods: A 29-item questionnaire was developed by project investigators and family physician consultants and mailed to a random sample of 1500 US members of the American Academy of Family Physicians in 2008; 2 follow-up mailings were sent to nonrespondents. Physicians were queried about sociodemographic characteristics, practice patterns, and beliefs (including challenges, barriers, and needs) about care processes focusing on dementia among older patients., Results: The response rate was 60%, with respondents statistically comparable (P > .05) to the American Academy of Family Physicians physician population. Among physicians, 93% screen and/or conduct diagnostic evaluations for dementia in older patients, whereas 91% provide ongoing primary care for patients with dementia whether or not they screen for or diagnose dementia. Forty percent of physicians refer some patients with suspected dementia to other providers (primarily neurologists) to verify diagnosis, for comanagement, or both. Factors affecting the diagnosis of dementia and the delivery of dementia care included patient behavior challenges (aggressiveness, restlessness, paranoia, wandering); comorbidities (falls, delirium, adverse medication reactions, urinary incontinence); caregiver challenges (fatigue, planning for patient's institutional placement, anger); and structural barriers (clinician time, time required for screening, limited treatment options). Tools needed to provide enhanced dementia care included better assessment tools, community resources, and diagnostic and screening tools., Conclusion: Family physicians are highly involved in the assessment and routine care of patients with suspected dementia or diagnosed with dementia, although a relative few are not. This is despite the recognized challenges physicians encounter in the assessment and care processes.

Patient-reported health data are critical components of patient-centered health care. However, barriers related to acquisition, implementation, and data use have not been well characterized. We conducted a systematic review of literature about health assessments in ambulatory and primary care covering 2 domains: (1) best practices in health assessments in primary care and (2) integration of health assessments into electronic health records. Our review found that training and standardization of practice workflows improves implementation of health assessments; however, gaps remain on identification and selection of health assessments, integration with electronic health records, and optimal intervals of health assessments administration.

Purpose: The purpose of this article was to test whether physical activity, healthy eating, and emotional well-being would improve if patients received feedback about biomarkers that have been shown to be responsive to changes in weight and fitness., Methods: Patients were randomized to limited feedback (weight, body mass index [BMI], and blood pressure at 4 and 10 months) or enhanced feedback (weight, BMI, blood pressure, homeostatic insulin resistance, and nuclear magnetic resonance lipoprotein profiles at 2, 4, 7, and 10 months). Repeated measures mixed effects multivariate regression models were used to determine whether BMI, fitness, diet, and quality of life changed over time., Results: Major parameters were similar in both groups at baseline. BMI, measures of fitness, healthy eating, quality of life, and health state improved in both patient groups, but there was no difference between patient groups at 4 or 10 months. Systolic blood pressure improved in the enhanced feedback group, and there was a difference between the enhanced and limited feedback groups at 10 months (95% confidence interval, -6.011 to -0.5113)., Conclusions: Providing patients with enhanced feedback did not dramatically change outcomes. However, across groups, many patients maintained or lost weight, suggesting the need for more study of nondiet interventions.

Objective: The objective of this study was to examine the relationship between physicians' completion of American Board of Family Medicine (ABFM) Maintenance of Certification (MOC) modules and the quality of medical care delivered., Methods: Physicians from the Electronic National Quality Improvement and Research Network (eNQUIRENet) were enrolled. Data from their electronic health records were compared before and after they completed one or more MOC modules for family physicians (Self-Assessment Module [Part II MOC] and Performance in Practice Module [Part IV MOC]; SAM/PPM). Process data and other quantitative clinical measures for all adult patients with a diagnosis of type 2 diabetes were gathered from each study physician. General linear mixed effects models were used to analyze data before and after the MOC modules, adjusting for clustering of patients within physicians., Results: Physicians participating in SAM/PPM activities demonstrated greater improvements over time in 11 of 24 measures in process and intermediate outcome measures related to type 2 diabetes care compared with non-SAM/PPM participants. All groups demonstrated improvements over time., Conclusion: Participation in SAM/PPM activities is associated with greater improvements in care, but the association between activity undertaken and specific improvements is difficult to demonstrate.

Purpose: Colon cancer is the second leading cause of cancer death in the United States. Despite tests that can detect and enable removal of precancerous polyps, effectively preventing this disease, screening for colon cancer lags behind other cancer screening. The purpose of this study was to develop and test a community-based participatory approach to increase colon cancer screening., Methods: Using a community-based participatory research approach, the High Plains Research Network and their Community Advisory Council developed a multicomponent intervention-Testing to Prevent Colon Cancer-to increase colon cancer screening. A controlled trial compared 9 intervention counties in northeast Colorado with 7 control counties in southeast Colorado. We performed a baseline and postintervention random digit-dial telephone survey and conducted both intent-to-treat and on-treatment analyses., Results: In all, 1,050 community members completed a preintervention questionnaire and 1,048 completed a postintervention questionnaire. During the study period, there was a 5% absolute increase in the proportion of respondents who reported ever having had any test in the intervention region (from 76% to 81%) compared with no increase in the control region (77% at both time points) (P = .22). No significant differences between these groups were found in terms of being up to date generally or on specific tests. The extent of exposure to intervention materials was associated with a significant and cumulative increase in screening., Conclusions: This community-based multicomponent intervention engaged hundreds of community members in wide dissemination aimed at increasing colorectal cancer screening. Although we did not find any statistically significant differences, the findings are consistent with an intervention-related increase in screening and provide preliminary evidence on the effectiveness of such interventions to improve colon cancer screening.

Purpose: An increasing number of Americans are putting their health at risk from being overweight. We undertook a study to compare patient-level outcomes of 2 methods of implementing the Americans In Motion-Healthy Interventions (AIM-HI) approach to promoting physical activity, healthy eating, and emotional well-being., Methods: We conducted a randomized trial in which 24 family medicine practices were randomized to (1) an enhanced practice approach in which clinicians and office staff used AIM-HI tools to make personal changes and created a healthy environment, or (2) a traditional practice approach in which physicians and staff were trained and asked to use the tools with patients. Of the 610 patients enrolled, 331 were in healthy practices, and 279 were in traditional practices. At 0, 4, and 10 months we assessed blood pressure, body mass index, fasting blood glucose and insulin levels, nuclear magnetic resonance lipoprotein profiles, fitness, dietary intake, physical activity, and emotional well-being. Outcome data were analyzed using linear, mixed-effects multivariate models, adjusting for practices as a random effect., Results: Regardless of patient group, 16.2% of patients who completed a 10-month visit (n = 378 patients, 62% of enrollees) and 10% of all patients enrolled lost 5% or more of their body weight; 16.7% of patients who completed a 10-month visit (10.3% of all enrollees) had a 2-point or greater increase in their fitness level; and 29.2% of 10-month completers (18.0% of all enrollees) lost 5% or more of their body weight and/or increased their fitness level by 2 or more points. There were no significant differences in these outcomes between groups., Conclusions: There was no difference between the 2 groups in the primary and most secondary outcomes. Both patient groups were able to show significant before-after improvements in selected patient-level outcomes.

Objective: To describe the development, implementation, and effects of collaborative effort to reduce diversion of prescription drugs in Caldwell County, NC., Design: Development and implementation of practice guideline, statewide opioid registry, and survey of all primary care providers., Setting: Rural Caldwell County, NC, has a population of 83,029, of which 89 percent are non-Hispanic White; 2009 median household income of $35,489., Patients, Participants: All primary care clinicians in the county (N = 35)., Interventions: A task force developed and implemented a practice guideline that encouraged the following: 1) signing of pain contracts; 2) requiring patients to undergo random urine drug testing; and 3) requiring random pill counts. North Carolina implemented a statewide registry in 2007 that contained information on virtually all opioid prescriptions filled by pharmacies., Main Outcome Measure(s): Opioid pill confiscations by the Caldwell County Narcotics Division 24 months prior to implementation of the guidelines, the first 12 months during guideline implementation, and 12 months after the guideline was fully implemented., Results: From 2005 to 2007, opioid pill confiscations decreased by 300 percent. Of the 35 physicians who were sent surveys, 27 responded (77 percent response rate). Ninety percent of respondents who prescribe opioids use the chronic pain guidelines. Sixty percent report an improvement in the overall management of patients with chronic pain; 65 percent reported having more confidence in treating patients with chronic pain; and 60 percent reported using the opioid registry., Conclusions: This county wide medical initiative appears to have resulted in a significant improvement in the abuse and diversion of medically derived opioids.

Background: Depression is a leading cause of morbidity worldwide. The majority of treatment for depression occurs in primary care, but effective care remains elusive. Clinical decision making and comparative studies of real-world antidepressant effectiveness are limited by the absence of clinical measures of severity of illness and suicidality., Methods: The Distributed Ambulatory Research in Therapeutics Network (DARTNet) was engaged to systematically collect data using the 9-item Patient Health Questionnaire (PHQ-9) at the point of care. We used electronic health records (EHRs) and the PHQ-9 to capture, describe, and compare data on both baseline severity of illness and suicidality and response and suicidality after diagnosis for depressed patients in participating DARTNet practices., Results: EHR data were obtained for 81,028 episodes of depression (61,464 patients) from 14 clinical organizations. Over 9 months, data for 4900 PHQ-9s were collected from 2969 patients in DARTNet practices (this included 1892 PHQ-9s for 1019 adults and adolescents who had at least one depression diagnosis). Only 8.3% of episodes identified in our depression cohort had severity of illness information available in the EHR. For these episodes, considerable variation existed in both severity of illness (32.05% with no depression, 26.89% with minimal, 19.54% with mild, 12.04% with moderate, and 9.47% with severe depression) and suicidality (69.43% with a score of 0, 22.58% with a score of 1, 4.97% with a score of 2, and 3.02% with a score of 3 on item 9 of the PHQ-9). Patients with an EHR diagnosis of depression and a PHQ-9 (n = 1019) had similar severity but slightly higher suicidality levels compared with all patients for which PHQ-9 data were available. The PHQ-9 showed higher sensitivity for identifying depression response and emergent (after diagnosis) severity and suicidality; 25% to 30% of subjects had some degree of suicidal thought at some point in time according to the PHQ-9., Conclusions: This study demonstrated the value of adding PHQ-9 data and prescription fulfillment data to EHRs to improve diagnosis and management of depression in primary care and to enable more robust comparative effectiveness research on antidepressants.

Background: Americans in Motion-Healthy Interventions (AIM-HI) is an initiative designed to assist family physicians with positioning fitness (physical activity, nutrition, and emotional well-being) as the treatment of choice for prevention and management of chronic disease. We investigated whether the concept of a culture of fitness would benefit office personnel and carry over to patient care., Methods: This randomized, controlled trial provided an intervention based on the AIM-HI curriculum to 12 enhanced offices with support for office activities, while 12 traditional offices received only AIM-HI tools with encouragement for use with patients. Before intervention, at 4 months, and at 14 months, we measured the practice personnel's dietary behavior (PrimeScreen), physical activity (International Physical Activity Questionnaire), self-determined (intrinsic) motivation (Treatment Self-Regulation Questionnaire [TSRQ]), perceived ability to carry out health behaviors (Perceived Competence Scale), and readiness to improve and/or maintain health behaviors (Stages of Change)., Results: From 24 practices we enrolled 470 subjects; 21 practices completed the study, and data from 341 patients were analyzed. Differential change from baseline between the enhanced and traditional offices was not evident for behavior changes. An overall decrease from baseline in self-reported total physical activity measured as metabolic equivalent-minutes for all surveyed groups occurred over the study time period (4-month β = -11.97; 14-month β = -9.01; P = .003). A statistically significant increase occurred at 4 months among participants from the enhanced practices for the TSRQ outcomes of Healthy Eating (baseline, 3.00 ± 0.12; 4 months, 3.26 ± 0.13; P = .013). Among clinicians, TSRQ Healthy Eating scores increased from 3.19 ± 0.13 at baseline to 3.52 ± 0.14 at 4 months (P = .005). However, increases in TSRQ Eating scores were not sustained by 14 months. Stages of Change scores decreased from baseline to 4 months in enhanced group offices. There was also a decrease in Stages of Change scores among staff from baseline to 14 months., Conclusions: Primary care clinicians and office staff are resistant to health behavior change. External motivation did not seem to help them change. The effect of this intervention on patient care is not yet known.

Common "quality" metrics may represent the quality of care for large populations; however, they do not adequately represent quality in individual primary care settings, especially as stand-alone indices. Using discreet threshold values to measure quality in primary care may result in physicians focusing on managing patients by the numbers at the expense of making individualized and nuanced clinical decisions. Current performance measures may be misapplied as proxies for both cost savings and quality. We posit that developing and focusing measurement on high-leverage activities will yield better clinical outcomes and potentially lower cost. As a starting point for further work in this area, we suggest the development of metrics that track identification and management of depression; management of transitions of care; care coordination; team-based care; identification and support of socially frail/isolated individuals; pharmacologic management, including optimizing medication and dealing with adherence issues; and establishment of a therapeutic environment. These processes, or others like them, will require infrastructure that may be costly and time-consuming, and measuring these processes will require thought and effort. Nevertheless, we believe developing metrics based on high-leverage activities will yield greater clinical and economic returns than relying on the metrics currently in place.

Background: There are often disparities between current evidence and current practice. Decreasing the gap between desired practice outcomes and observed practice outcomes in the healthcare system is not always easy. Stopping previously recommended or variably recommended interventions may be even harder to achieve than increasing the use of a desired but under-performed activity. For over a decade, aspirin has been prescribed for primary prevention of cardiovascular disease and for patients with the coronary artery disease risk equivalents; yet, there is no substantial evidence of an appropriate risk-benefit ratio to support this practice. This paper describes the protocol of a randomized trial being conducted in six primary care practices in the Denver metropolitan area to examine the effectiveness of three interventional strategies to change physician behavior regarding prescription of low-dose aspirin., Methods: All practices received academic detailing, one arm received clinician reminders to reconsider aspirin, a second arm received both clinician and patient messages to reconsider aspirin. The intervention will run for 15 to 18 months. Data collected at baseline and for outcomes from an electronic health record will be used to assess pre- and post-interventional prescribing, as well as to explore any inappropriate decrease in aspirin use by patients with known cardiovascular disease., Discussion: This study was designed to investigate effective methods of changing physician behavior to decrease the use of aspirin for primary cardiovascular disease prevention. The results of this study will contribute to the small pool of knowledge currently available on the topic of ceasing previously supported practices., Trial Registration: ClinicalTrials.gov: NCT01247454.

Purpose: Observational studies that collect patient-level survey data at the point-of-care are often called card studies. Card studies have been used to describe clinical problems, management, and outcomes in primary care for more than 30 years. In this article we describe 2 types of card studies and the methods for conducting them., Methods: We undertook a descriptive review of card studies conducted in 3 Colorado practice-based research networks and several other networks throughout the United States. We summarized experiences of the State Networks of Colorado Ambulatory Practices and Partners (SNOCAP)., Results: Card studies can be designed to study specific conditions or care (clinicians complete a card when they encounter patients who meet inclusion criteria) and to determine trends and prevalence of conditions (clinicians complete a card on all patients seen during a period). Data can be collected from clinicians and patients and can be linked., Conclusions: Card studies provide cross-sectional descriptive data about clinical care, knowledge and behavior, perception of care, and prevalence of conditions. Card studies remain a robust method for describing primary care.

Purpose: The Ask Me 3 (AM3) health communication program encourages patients to ask specific questions during office visits with the intention of improving understanding of their health conditions and adherence to treatment recommendations. This study evaluated whether implementing AM3 improves patients' question-asking behavior and increases adherence to prescription medications and lifestyle recommendations., Methods: This randomized trial involved 20 practices from the American Academy of Family Physicians National Research Network that were assigned to an AM3 intervention group or a control group. Forty-one physicians in the practices were each asked to enroll at least 20 patients. The patients' visits were audio recorded, and recordings were reviewed to determine whether patients asked questions and which questions they asked. Patients were interviewed 1 to 3 weeks after the visit to assess their recall of physicians' recommendations, rates of prescription filling and taking, and attempts at complying with lifestyle recommendations., Results: The study enrolled 834 eligible patients in 20 practices. There were no significant difference between the AM3 and control patients in the rate of asking questions, but this rate was high (92%) in both groups. There also were no differences in rates of either filling or taking prescriptions, although rates of these outcomes were fairly high, too. Control patients were more likely to recall that their physician recommended a lifestyle change, however (68% vs 59%, P = .04)., Conclusions: In a patient population in which asking questions already occurs at a high rate and levels of adherence are fairly high, we found no evidence that the AM3 intervention results in patients asking specific questions or more questions in general, or in better adherence to prescription medications or lifestyle recommendations.

Purpose: We wanted to compare survey responses from members of a national practice-based research network (PBRN) with those of a larger sample of family physicians to assess the generalizability of findings from the PBRN to the larger physician population., Methods: The American Academy of Family Physicians National Research Network (AAFP NRN) conducted 3 separate national surveys among random samples of AAFP active members and physician members of the AAFP NRN. The surveys assessed self-reported clinical behaviors and beliefs related to hepatitis C, hyperlipidemia, and pharyngitis. Bivariate comparisons were conducted to detect statistical differences between the AAFP and AAFP NRN respondents on both demographic and clinically relevant survey items. Multivariate analyses of outcomes were found to be statistically significant at the bivariate level., Results: Response rates to the surveys ranged from 53% to 59% for AAFP members and 60% to 72% for AAFP NRN members. The most consistent differences (P <.05) in demographic comparisons were for percentage of time spent in patient care, practice location, practice type, and census region. Bivariate comparisons found the groups differed on 8 (12%) of 66 clinically relevant survey items, with the Bonferroni correction for multiple comparisons reducing these items to 4 (6%). These comparisons were followed by multivariate analyses of outcomes that were found statistically significant at bivariate level., Conclusions: The AAFP NRN and AAFP membership differed on several demographic characteristics, but network members were overall more representative than not of the AAFP active membership in their self-reported clinical behaviors and related beliefs.

The Distributed Ambulatory Research in Therapeutics Network (DARTNet) is a federated network of electronic health data from 8 organizations representing more than 500 clinicians and more than 400 000 patients. DARTNet was designed to increase knowledge of the comparative effectiveness of prescription medications and medical devices. Traditional observational comparative effectiveness research is conducted using large data sets, such as claims databases. Such databases do not provide important clinical information that is critical to understanding comparative effectiveness. By linking electronic health records, laboratory and imaging data, and administrative data from diverse and geographically disparate patients, DARTNet provides important new insight into the comparative effectiveness of oral diabetes medications, and it is ready for expansion to further enable effectiveness research.

Objectives: Little research has focused on preventing harm from errors that occur in primary care. We studied mitigation of patient harm by analysing error reports from family physicians' offices., Methods: The data for this analysis come from reports of testing process errors identified by family physicians and their office staff in eight practices in the American Academy of Family Physicians National Research Network. We determined how often reported error events were mitigated, described factors related to mitigation and assessed the effect of mitigation on the outcome of error events., Results: We identified mitigation in 123 (21%) of 597 testing process event reports. Of the identified mitigators, 79% were persons from inside the practice, and 7% were patients or patient's family. Older age was the only patient demographic attribute associated with increased likelihood of mitigation occurring (unadjusted OR 18-44 years compared with 65 years of age or older = 0.27; p = 0.007). Events that included testing implementation errors (11% of the events) had lower odds of mitigation (unadjusted OR = 0.40; p = 0.001), and events containing reporting errors (26% of the events) had higher odds of mitigation (unadjusted OR = 1.63; p = 0.021). As the number of errors reported in an event increased, the odds of that event being mitigated decreased (unadjusted OR = 0.58; p = 0.001). Multivariate logistic regression showed that an event had higher odds of being mitigated if it included an ordering error or if the patient was 65 years of age or older, and lower odds of being mitigated if the patient was between age 18 and 44, or if the event included an implementation error or involved more than one error. Mitigated events had lower odds of patient harm (unadjusted OR = 0.16; p<0.0001) and negative consequences (unadjusted OR = 0.28; p<0.0001). Mitigated events resulted in less severe and fewer detrimental outcomes compared with non-mitigated events., Conclusion: Nearly a quarter of testing process errors reported by family physicians and their staff had evidence of mitigation, and mitigated errors resulted in less frequent and less serious harm to patients. Vigilance throughout the testing process is likely to detect and correct errors, thereby preventing or reducing harm.

Research conducted in a practice-based research network (PBRN) differs from other multisite research and presents particular planning challenges. The American Academy of Family Physicians National Research Network (AAFP NRN) has developed a number of procedures used for planning and implementing studies, which address the challenges of national PBRN studies. In this study, we highlight challenges common to PBRN research and describe the methods used by the AAFP NRN to address those challenges. The following tasks were identified as important to implementing PBRN research studies: (1) selecting fundable, feasible studies that interest members and have the potential to improve quality of care; (2) creating a practical budget that covers the costs of the study; (3) composing study teams and securing written agreements between team members; (4) recruiting and selecting study sites; and (5) training practice staff and physicians. Striking the balance of scientific rigor with practical application of PBRN studies must be addressed throughout these tasks. Proper planning for PBRN studies significantly affects the success of study implementation. Although developed by a national PBRN, the planning procedures described in this study may be adapted for state or regional PBRNs.

Objective: To explore patient perceptions of patient-provider communication after an actual adverse medical event because prior patient error studies are rarely based on real situations., Design: We conducted four patient focus groups using a semi-structured guide. We analyzed transcripts using an editing approach to identify themes., Setting: Three sites in Colorado., Study Participants: participants were recruited from statewide post-injury program. Purposeful sampling began with patients in a geographic location; we contacted every other patient (up to 50). Twenty-two patients initially agreed to participate; 16 adults participated, representing 13 cases., Results: Complex issues and processes were involved in resolution attempts. Effective communication was an important factor in whether professional relationships continued after an adverse event. The communication nature and quality influenced whether patients defined event as 'honest mistake' or 'error'. Two types of trauma (physical and emotional) were expected and found. A third (financial) uncovered and proved in some cases the most salient factor influencing patients' subsequent actions. Caring, honest, quick, personal, and repeated provider responses were linked to patient satisfaction., Conclusions: Provider communication timeliness and quality were important influences on patients' responses to adverse events. Confronting an adverse medical event collaboratively helped both patients and providers with patients' emotional, physical, and financial trauma and minimized the anger and frustration commonly experienced. Health organizations, providers, investigators, and policymakers should consider the patient experience when developing provider training or evaluating processes in patient resolution.

Purpose: We wanted to describe the potential benefits and problems associated with selected electronic methods of collecting data within practice-based research networks (PBRNs)., Methods: We considered a literature review, discussions with PBRN researchers, industry information, and personal experience. This article presents examples of selected PBRNs' use of electronic data collection., Results: Collecting research data in the geographically dispersed PBRN environment requires considerable coordination to ensure completeness, accuracy, and timely transmission of the data, as well as a limited burden on the participants. Electronic data collection, particularly at the point of care, offers some potential solutions. Electronic systems allow use of transparent decision algorithms and improved data entry and data integrity. These systems may improve data transfer to the central office as well as tracking systems for monitoring study progress. PBRNs have available to them a wide variety of electronic data collection options, including notebook computers, tablet PCs, personal digital assistants (PDAs), and browser-based systems that operate independent of or over the Internet. Tablet PCs appear particularly advantageous for direct patient data collection in an office environment. PDAs work well for collecting defined data elements at the point of care. Internet-based systems work well for data collection that can be completed after the patient visit, as most primary care offices do not support Internet connectivity in examination rooms., Conclusions: When planning to collect data electronically, it is important to match the electronic data collection method to the study design. Focusing an inappropriate electronic data collection method onto users can interfere with accurate data gathering and may also anger PBRN members.

Purpose: We wanted to explore potential effects of the Health Insurance Portability and Accountability Act (HIPAA) on research activities of practice-based research networks (PBRNs)., Methods: To understand the approaches PBRNs are using to advance their research while adhering to HIPAA standards, we combined a literature review, our experiences, and discussions with local HIPAA officers, PBRN researchers in the United States, and individuals involved in drafting HIPAA., Results: HIPAA requires researchers to pay special attention to how they handle patients' protected health information (PHI). For researchers working within PBRNs, which collect information from patients and health care professionals in multiple institutions, the HIPAA Privacy Rule presents additional challenges. PBRN researchers can obtain patient authorization to use PHI, but this process is difficult and may taint the findings of some research studies. Some institutions may allow patients to provide a blanket authorization for study recruitment. PBRNs additionally can collect only "de-identified" data (data with identifying information removed) or, with a data use agreement, can work with a limited data set. PBRNs that blend quality improvement and research can work with PHI, but the researcher and practices must enter into a business agreement. PBRN researchers may need to play active, educational roles in institutional privacy boards to facilitate their research., Conclusions: There are a number of ways for PBRN researchers to comply with HIPAA short of obtaining patient consent and authorization for every study. Careful planning and consideration of HIPAA issues during study design can go a long way toward reducing frustration later.

Context: Medical errors and patient safety have gained increasing attention throughout all areas of medical care. Understanding patient safety in rural settings is crucial for improving care in rural communities., Purpose: To describe a system to decrease medical errors and improve care in rural and frontier primary care offices., Methods: Applied Strategies for Improving Patient Safety (ASIPS) was a demonstration project designed to collect and analyze medical error reports and use these reports to develop and implement interventions aimed at decreasing errors. ASIPS participants were clinicians and staff in 2 practice-based research networks: the Colorado Research Network (CaReNet) and the High Plains Research Network (HPRN). This paper describes ASIPS in HPRN., Findings: Fourteen HPRN practices with a total of 150 clinicians and staff have participated in ASIPS. Participants have submitted 128 reports. Diagnostic tests were involved in 26% of events; medication errors appeared in 20% of events. Communication errors were reported in 72%. Two learning groups developed "Principles for Process Improvement" for medication errors and diagnostic testing errors. Several safety "alerts" were issued to improve care, and 2 interventions were implemented to decrease errors., Conclusions: A safe and secure reporting system that relies on voluntary reporting from clinicians and staff can be successfully implemented in rural primary care settings. Information from reports can be used to identify processes that can be improved.

Background: Practice-based research networks (PBRNs) replicating the National Ambulatory Medical Care Survey (NAMCS) must sample more than 1 year to account for presumed seasonal variation in illnesses. This study evaluated the effects of seasonality on diagnoses within NAMCS family physician data., Methods: Using combined data from the 1995-1998 NAMCS, diagnostic clusters that accounted for more than 1% of total visits were analyzed for seasonality. Seasons were coded categorically as dummy variables with summer as the reference category. A logistic regression was performed with each diagnosis as an outcome on the full data. To examine the ability of alternative sampling strategies to replicate the full year of data, a simulation study was carried out drawing 50 samples of 1,000 visits each for winter-summer and spring-fall sampling periods., Results: We found 23 diagnostic clusters that had a frequency more than 1%, of which 10 had seasonal variations (P < or = .001), primarily between winter and summer. If sampling were restricted to spring, the diagnostic clusters of pregnancy and coronary artery disease would account for less than 1% of visits. All other diagnostic clusters, though changing rank order, would account for more than 1% if sampled in a single quarter. In the simulated sampling strategy, visit prevalence dropped below 1% for at least 1 diagnosis in 24 of 50 samples in spring-fall compared with 20 of 50 samples for winter-summer (P > .20)., Conclusions: There is little seasonal variation in the 23 diagnoses that occur in more than 1% of visits to family physicians. There is, however, important seasonal variation in the rank order of these diagnoses. A sampling strategy that uses any quarter of the year but spring (March, April, May) could be used to understand what diagnoses are frequently seen within a PBRN.