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6.  Receipt of High Risk Medications among Elderly Enrollees in Medicare Advantage Plans 
Since 2005, the Centers for Medicare and Medicaid Services (CMS) has required all Medicare Advantage (MA) plans to report prescribing rates of high risk medications (HRM).
To determine predictors of receipt of HRMs, as defined by the National Committee for Quality Assurance’s “Drugs to Avoid in the Elderly” quality indicator, in a national sample of MA enrollees.
Retrospective analysis of Healthcare Effectiveness Data and Information Set (HEDIS) data for 6,204,824 enrollees, aged 65 years or older, enrolled in 415 MA plans in 2009. To identify predictors of HRM use, we fit generalized linear models and modeled outcomes on the risk-difference scale.
Receipt or non-receipt of one or two HRMs.
Approximately 21 % of MA enrollees received at least one HRM and 4.8 % received at least two. In fully adjusted models, females had a 10.6 (95 % CI: 10.0–11.2) higher percentage point rate of receipt than males, and residence in any of the Southern United States divisions was associated with a greater than 10 percentage point higher rate, as compared with the reference New England division. Higher rates were also observed among enrollees with low personal income (6.5 percentage points, 95 % CI: 5.5–7.5), relative to those without low income and those residing in areas in the lowest quintile of socioeconomic status (2.7 points, 95 % CI: 1.9–3.4) relative to persons residing in the highest quintile. Enrollees ≥ 85 years old, black enrollees, and other minority groups were less likely to receive these medications. Over 38 % of MA enrollees residing in the hospital referral region of Albany, Georgia received at least one HRM, a rate four times higher than the referral region with the lowest rate (Mason City, Iowa).
Use of HRMs among MA enrollees varies widely by geographic region. Persons living in the Southern region of the U.S., whites, women, and persons of low personal income and socioeconomic status are more likely to receive HRMs.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-012-2244-9) contains supplementary material, which is available to authorized users.
PMCID: PMC3599014  PMID: 23129159
high risk medications; geriatric prescribing; potentially inappropriate medication; quality prescribing; disparities
7.  Retail Clinic Visits and Receipt of Primary Care 
An increasing number of patients are visiting retail clinics for simple acute conditions. Physicians worry that visits to retail clinics will interfere with primary care relationships. No prior study has evaluated the impact of retail clinics on receipt of primary care.
To assess the association between retail clinic use and receipt of key primary care functions.
We performed a retrospective cohort analysis using commercial insurance claims from 2007 to 2009.
We identified patients who had a visit for a simple acute condition in 2008, the “index visit”. We divided these 127,358 patients into two cohorts according to the location of that index visit: primary care provider (PCP) versus retail clinic.
We evaluated three functions of primary care: (1) where patients first sought care for subsequent simple acute conditions; (2) continuity of care using the Bice–Boxerman index; and (3) preventive care and diabetes management. Using a difference-in-differences approach, we compared care received in the 365 days following the index visit to care received in the 365 days prior, using propensity score weights to account for selection bias.
Visiting a retail clinic instead of a PCP for the index visit was associated with a 27.7 visits per 100 patients differential reduction (p < 0 .001) in subsequent PCP visits for new simple acute conditions. Visiting a retail clinic instead of a PCP was also associated with decreased subsequent continuity of care (10.9 percentage-point differential reduction in Bice–Boxerman index, p < 0 .001). There was no differential change between the cohorts in receipt of preventive care or diabetes management.
Retail clinics may disrupt two aspects of primary care: whether patients go to a PCP first for new conditions and continuity of care. However, they do not negatively impact preventive care or diabetes management.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-012-2243-x) contains supplementary material, which is available to authorized users.
PMCID: PMC3599015  PMID: 23070656
primary health care; continuity of patient care; acute diseases; health services accessibility
8.  Learning by Doing: Effectively Incorporating Ethics Education into Residency Training 
Medical ethics is a critical component of the curriculum for clinical trainees. Educational initiatives should adapt content to participants’ experience in order to ensure relevance and retain their interest.
To develop and evaluate an experiential educational program for physicians.
Academic medical center.
Senior internal medicine residents (n = 40).
A case-based didactic program was designed in which each resident shared a difficult ethics case from their clinical experience. We created a curriculum around these cases involving formal didactics as well as open-ended discussion and summarized the ethical issues most relevant to the participants. A course survey was administered based upon the validated Students’ Evaluation of Educational Quality (SEEQ).
Common issues raised included surrogate decision-making (18 %), refusal of treatment (14 %), capacity/informed consent (10 %), and medical futility (10 %). Mean SEEQ subscale scores for learning value, organization/clarity, group interaction, breadth of coverage, and assignments/readings were 4.5 (maximum possible score 5). Residents unanimously rated the course overall as good/very good, and all agreed or strongly agreed that the course was useful and its structure effective.
An experiential case-based didactic program in medical ethics engaged adult learners and facilitated a comprehensive and clinically relevant educational initiative.
PMCID: PMC3599016  PMID: 23179971
medical ethics; experiential learning; resident education
9.  Continuity in a Changing Health Care Environment 
PMCID: PMC3599017  PMID: 23288374
10.  Open Access in the Patient-Centered Medical Home: Lessons from the Veterans Health Administration 
The Veterans Health Administration (VHA) has undertaken a 5-year initiative to transform to a patient-centered medical home model. An early focus of implementation was on creating open access, defined as continuity and capacity in primary care.
We describe the impact of readiness for implementation on efforts of pilot teams to make changes to improve access and identify successful strategies used by early adopters to overcome barriers to change.
A qualitative, formative evaluation of the first 18 months of implementation in one Veterans Integrated Service Network (VISN) spread across six states.
Members of local implementation teams including administrators, primary care providers, and staff from primary care clinics located at 10 medical centers and 45 outpatient clinics.
We conducted site visits during the first 6 months of implementation, observations at Learning Collaboratives, semi-structured interviews, and review of internal organizational documents. All data collection took place between April 2010 and December 2011.
Key Results
Early adopters employed various strategies to enhance access, with a focus on decreasing demand for face-to-face care, increasing supply of different types of primary care encounters, and improving clinic efficiencies. Our interviews with key contacts revealed three important areas where readiness for implementation (or lack thereof) had an impact on interventions to improve access: leadership engagement, staffing resources, and access to information and knowledge.
Key factors related to readiness for implementation had an impact on which interventions pilot teams could put into place, as well as the viability and sustainability of access gains. Wide variations in interventions to improve access occurring across sites situated within one organization have important implications for efforts to measure the impact of enhanced access on patient outcomes, costs, and other systems-level indicators of the Medical Home.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-012-2279-y) contains supplementary material, which is available to authorized users.
PMCID: PMC3599018  PMID: 23192447
patient-centered access; primary care; continuity of care; veterans health; qualitative evaluation
11.  A Systematic Review of Communication Quality Improvement Interventions for Patients with Advanced and Serious Illness 
Effective communication is an interaction between two or more people that produces a desired effect and is a key element of quality of care for patients with advanced and serious illness and their family members. Suboptimal provider-patient/family communication is common, with negative effects on patient/family-centered outcomes.
To systematically review the evidence for effectiveness of communication-related quality improvement interventions for patients with advanced and serious illness and to explore the effectiveness of consultative and integrative interventions.
Data Sources
MEDLINE, CINAHL, PsycINFO, Cochrane, and DARE from 2000 through December 2011 and reference list of eligible articles and reviews.
Study Eligibility Criteria, Participants And Interventions
Prospective, controlled quality improvement studies in populations with life-limiting or severe life-threatening illness with a primary intervention focus of improving communication with patients and/or families.
Study Appraisal and Synthesis Methods
Two investigators independently screened and abstracted data on patient/family-centered outcomes.
We included 20 studies; 13 (65 %) were in intensive care. We found four intervention types: (1) family meetings with the usual team (11 studies, 77 % found improvement in healthcare utilization), (2) palliative care teams (5 studies, 50 % found improvement in healthcare utilization), (3) ethics consultation (2 studies, 100 % found improvement in healthcare utilization), and (4) physician-patient communication (2 studies, no significant improvement in healthcare utilization). Among studies addressing the outcomes of patient/family satisfaction, 22 % found improvement; among studies addressing healthcare utilization (e.g., length of stay), 73 % found improvement. Results suggest that consultative interventions, as opposed to integrative ones, may be more effective, but more research is needed.
Study heterogeneity did not allow quantitative synthesis.
Conclusions and Implications of Key Findings
Communication in the care of patients with advanced and serious illness can be improved using quality improvement interventions, particularly for healthcare utilization as an outcome. Interventions may be more effective using a consultative approach.
PMCID: PMC3599019  PMID: 23099799
communication; seriously ill patients; patients with advanced diseases; quality improvement interventions
12.  Unintentional Prescription Opioid-Related Overdose Deaths: Description of Decedents by Next of Kin or Best Contact, Utah, 2008–2009 
Little is known about the characteristics that may predispose an individual to being at risk for fatal overdose from prescription opioids.
To identify characteristics related to unintentional prescription opioid overdose deaths in Utah.
Interviews were conducted (October 2008–October 2009) with a relative or friend most knowledgeable about the decedent’s life.
Analyses involved 254 decedents aged 18 or older, where cause of death included overdose on at least one prescription opioid.
Decedents were more likely to be middle-aged, Caucasian, non-Hispanic/Latino, less educated, not married, or reside in rural areas than the general adult population in Utah. In the year prior to death, 87.4 % were prescribed prescription pain medication. Reported potential misuse prescription pain medication in the year prior to their death was high (e.g., taken more often than prescribed [52.9 %], obtained from more than one doctor during the previous year [31.6 %], and used for reasons other than treating pain [29.8 %, almost half of which “to get high”]). Compared with the general population, decedents were more likely to experience financial problems, unemployment, physical disability, mental illness (primarily depression), and to smoke cigarettes, drink alcohol, and use illicit drugs. The primary source of prescription pain medication was from a healthcare provider (91.8 %), but other sources (not mutually exclusive) included: for free from a friend or relative (24 %); from someone without their knowledge (18.2 %); purchase from a friend, relative, or acquaintance (16.4 %); and purchase from a dealer (not a pharmacy) (11.6 %).
The large majority of decedents were prescribed opioids for management of chronic pain and many exhibited behaviors indicative of prescribed medication misuse. Financial problems, unemployment, physical disability, depression, and substance use (including illegal drugs) were also common.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-012-2225-z) contains supplementary material, which is available to authorized users.
PMCID: PMC3599020  PMID: 23070654
chronic pain; illicit drug use; mental illness; opioids; overdose; overprescribed; prescription pain medication
15.  Capsule Commentaries 
PMCID: PMC3599024  PMID: 23423457
16.  Does Patient Gender Impact Resident Physicians’ Approach to the Cardiac Exam? 
Physical examination remains an important part of the initial evaluation of patients presenting with chest pain but little is known about the effect of patient gender on physician performance of the cardiovascular exam.
To determine if resident physicians are less likely to perform five key components of the cardiovascular exam on female versus male standardized patients (SPs) presenting with acute chest pain.
Videotape review of SP encounters during Objective Structured Clinical Examinations (OSCEs) administered by the Emory University Internal Medicine Residency Program in 2006 and 2007. Encounters were reviewed to assess residents’ performance of five cardiac exam skills: auscultation of the aortic, pulmonic, tricuspid, and mitral valve areas and palpation for the apical impulse.
One hundred forty-nine incoming residents.
Main Measures
Residents’ performance for each skill was classified as correct, incorrect, or unknown.
Key Results
One hundred ten of 149 (74 %) of encounters were available for review. Residents were less likely to correctly perform each of the five skills on female versus male SPs. This difference was statistically significant for auscultation of the tricuspid (p = 0.004, RR = 0.62, 95 % CI 0.46–0.83) and mitral (p = 0.007, RR = 0.58, 95 % CI = 0.41–0.83) valve regions and palpation for the apical impulse (p < 0.001, RR = 0.27, 95 % CI = 0.16–0.47). Male residents were less likely than female residents to correctly perform each maneuver on female versus male SPs. The interaction of SP gender and resident gender was statistically significant for auscultation of the mitral valve region (p = 0.006) and palpation for the apical impulse (p = 0.01).
We observed significant differences in the performance of key elements of the cardiac exam for female versus male SPs presenting with chest pain. This observation represents a previously unidentified but potentially important source of gender bias in the evaluation of patients presenting with cardiovascular complaints.
PMCID: PMC3599025  PMID: 23138759
cardiovascular disease; clinical skills assessment; disparities; women’s health; medical student and residency education
17.  The Interconnections Project: Development and Evaluation of a Community-Based Depression Program for African American Violence Survivors 
Multi-faceted depression care programs based within the healthcare system have been found to be effective, but may not fully address the needs of African American Intimate Partner Violence (IPV) survivors, many of whom are not seeking depression care in healthcare settings.
To develop and evaluate a multifaceted, community-based depression care program (the Interconnections Project) for African American women with a history of IPV.
We used a community-based participatory research (CBPR) approach to develop, implement, and evaluate the intervention. Participants were African American women who had current depressive symptoms and a lifetime history of IPV. They participated in a 6-month intervention where a peer advocate provided education, skills training, and case management services, and used Motivational Interviewing to support self-management behaviors. We conducted pre-intervention and post-intervention assessments using quantitative and qualitative data.
Fifty-nine women participated, with 92 % attending any sessions and 51 % attending at least 6 h of intervention activities. Intervention changes made to better accommodate participants’ unpredictable schedules improved participation rates. Participants noted high levels of satisfaction with the program. There were significant improvements in depression severity (PHQ-9 13.9 to 7.9, p < 0.001), self-efficacy, self-management behaviors, and self-esteem (all p < 0.001), but no increase in use of antidepressants. Common themes related to why the program was helpful included that the program was by and for African American women, that it fostered trust, and that it taught self-management strategies with practical, lasting value.
Culturally specific, community-based interventions led by peer advocates may be a promising way to help African American IPV survivors effectively address depression.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-012-2270-7) contains supplementary material, which is available to authorized users.
PMCID: PMC3599026  PMID: 23150070
community-based participatory research; depression; intimate partner violence; African Americans; community interventions
18.  Electronic Health Record-Based Patient Identification and Individualized Mailed Outreach for Primary Cardiovascular Disease Prevention: A Cluster Randomized Trial 
Many individuals at higher risk for cardiovascular disease (CVD) do not receive recommended treatments. Prior interventions using personalized risk information to promote prevention did not test clinic-wide effectiveness.
To perform a 9-month cluster-randomized trial, comparing a strategy of electronic health record-based identification of patients with increased CVD risk and individualized mailed outreach to usual care.
Patients of participating physicians with a Framingham Risk Score of at least 5 %, low-density lipoprotein (LDL)-cholesterol level above guideline threshold for drug treatment, and not prescribed a lipid-lowering medication were included in the intention-to-treat analysis.
Patients of physicians randomized to the intervention group were mailed individualized CVD risk messages that described benefits of using a statin (and controlling hypertension or quitting smoking when relevant).
The primary outcome was occurrence of a LDL-cholesterol level, repeated in routine practice, that was at least 30 mg/dl lower than prior. A secondary outcome was lipid-lowering drug prescribing. identifier: NCT01286311.
Fourteen physicians with 218 patients were randomized to intervention, and 15 physicians with 217 patients to control. The mean patient age was 60.7 years and 77% were male. There was no difference in the primary outcome (11.0 % vs. 11.1 %, OR 0.99, 95 % CI 0.56–1.74, P = 0.96), but intervention group patients were twice as likely to receive a prescription for lipid-lowering medication (11.9 %, vs. 6.0 %, OR 2.13, 95 % CI 1.05–4.32, p = 0.038). In post hoc analysis with extended follow-up to 18 months, the primary outcome occurred more often in the intervention group (22.5 % vs. 16.1 %, OR 1.59, 95 % CI 1.05–2.41, P = 0.029).
In this effectiveness trial, individualized mailed CVD risk messages increased the frequency of new lipid-lowering drug prescriptions, but we observed no difference in proportions lowering LDL-cholesterol after 9 months. With longer follow-up, the intervention’s effect on LDL-cholesterol levels was apparent.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-012-2268-1) contains supplementary material, which is available to authorized users.
PMCID: PMC3599027  PMID: 23143672
cholesterol; primary care; cardiovascular disease prevention; electronic health records; patient outreach
19.  Hiding Behind the Hippocratic Oath 
PMCID: PMC3599028  PMID: 22815063
20.  Lichen Sclerosus in a Breast Cancer Survivor on an Aromatase Inhibitor: A Case Report 
Lichen sclerosus is a commonly misdiagnosed disease that is characterized by thinned, hypopigmented, crinkled skin that often forms a figure-eight shape around the vaginal and anal openings. We present a case of advanced lichen sclerosus in a 53-year-old female patient prescribed a nonsteroidal aromatase inhibitor after the excision of a breast cancer tumor. We present a diagnostic approach to lichen sclerosus by recognizing its common figure-eight pattern, and we review the known causes and treatment of lichen sclerosus. Research has shown that lichen sclerosus is more common in low estrogen states, and thus it is logical that aromatase inhibitors could increase a patient’s risk for developing this disease. We therefore propose that all patients prescribed aromatase inhibitors undergo regular vulvo-vaginal exams to rule out lichen sclerosus and other hypoestrogen-related vulvo-vaginal problems.
PMCID: PMC3599029  PMID: 22956445
lichen sclerosus; aromatase inhibitor; complication; cancer survivorship; atrophic vulvovaginitis
24.  Patient Completion of Laboratory Tests to Monitor Medication Therapy: A Mixed-Methods Study 
Little is known about the contribution of patient behavior to incomplete laboratory monitoring, and the reasons for patient non-completion of ordered laboratory tests remain unclear.
To describe factors, including patient-reported reasons, associated with non-completion of ordered laboratory tests.
Mixed-Methods study including a quantitative assessment of the frequency of patient completion of ordered monitoring tests combined with qualitative, semi-structured, patient interviews.
Quantitative assessment included patients 18 years or older from a large multispecialty group practice, who were prescribed a medication requiring monitoring. Qualitative interviews included a subset of show and no-show patients prescribed a cardiovascular, anticonvulsant, or thyroid replacement medication.
Proportion of recommended monitoring tests for each medication not completed, factors associated with patient non-completion, and patient-reported reasons for non-completion.
Of 27,802 patients who were prescribed one of 34 medications, patient non-completion of ordered tests varied (range: 0–24 %, by drug-test pair). Factors associated with higher odds of test non-completion included: younger patient age (< 40 years vs. ≥ 80 years, adjusted odds ratio [AOR] 1.52, 95 % confidence interval [95 % CI] 1.27–1.83); lower medication burden (one medication vs. more than one drug, AOR for non-completion 1.26, 95 % CI 1.15–1.37), and lower visit frequency (0–5 visits/year vs. ≥ 19 visits/year, AOR 1.41, 95 % CI 1.25 to 1.59). Drug-test pairs with black box warning status were associated with greater odds of non-completion, compared to drugs without a black box warning or other guideline for testing (AOR 1.91, 95 % CI 1.66–2.19). Qualitative interviews, with 16 no-show and seven show patients, identified forgetting as the main cause of non-completion of ordered tests.
Patient non-completion contributed to missed opportunities to monitor medications, and was associated with younger patient age, lower medication burden and black box warning status. Interventions to improve laboratory monitoring should target patients as well as physicians.
PMCID: PMC3599033  PMID: 23229907
laboratory monitoring; patient completion; drug research
25.  The Essence of Morning 
PMCID: PMC3599035  PMID: 22948930

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