Timely News and Notes for Primary Care Providers From the American Diabetes Association
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ABSTRACT:
SUBMITTER: Bingham M
PROVIDER: S-EPMC7839611 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:BACKGROUND:Glucose control is monitored primarily through ordering HbA1c levels, which is problematic in patients with glycemic variability. Herein, we report on the management of these patients by board-certified primary care providers (PCPs) in the United States. METHODS:We measured provider practice in a representative sample of 156 PCPs. All providers cared for simulated patients with diabetes presenting with symptoms of glycemic variability. Provider responses were reviewed by trained clinicians against evidence-based care standards and accepted standard of care protocols. RESULTS:Care varied widely-overall quality of care averaged 51.3%±10.6%-with providers performing just over half the evidence-based practices necessary for their cases. More worryingly, provider identified the underlying etiology of the poor glycemic control only 36.3% of the time. HbA1c was routinely ordered in 91.3% of all cases but often (59.5%) inappropriately. Ordering other tests of glycemic control (done in 15% of cases) led to significant increases in identifying the etiology of the hyperglycemia. Correctly modifying their patient's treatment was more likely to occur if doctors first identified the underlying etiology (65.9% vs 49.0%, P<0.001). We conservatively estimated a US $65/patient/visit in unnecessary testing and US $389 annually in additional care costs when the etiology was missed, translating potentially into millions of dollars of wasteful spending. CONCLUSION:Despite established evidence that HbA1c misses short-term changes in diabetes, we found PCPs consistently ordered HbA1c, rarely using other available blood tests. However, if the factors leading to poor glycemic control were recognized, PCPs were more likely to correctly alter their patient's hypoglycemic therapy.
| S-EPMC7189162 | biostudies-literature
Project description:Background The 2013 American College of Cardiology/American Heart Association Cholesterol Treatment Guideline increased the number of primary prevention patients eligible for statin therapy, yet uptake of these guidelines has been modest. Little is known of how primary care provider ( PCP ) beliefs influence statin prescription. Methods and Results We surveyed 164 PCP s from a community-based North Carolina network in 2017 about statin therapy. We evaluated statin initiation among the PCP s' statin-eligible patients between 2014 and 2015 without a previous prescription. Seventy-two PCP s (43.9%) completed the survey. The median estimate of the relative risk reduction for high-intensity statins was 45% (interquartile range, 25%-50%). A minority of providers (27.8%) believed statins caused diabetes mellitus, and only 16.7% reported always/very often discussing this with patients. Most PCPs (97.2%) believed that statins cause myopathy, and 72.3% reported always/very often discussing this with patients. Most (77.7%) reported always/very often using the 10-year atherosclerotic cardiovascular disease risk calculator, although many reported that in most cases other risk factors or patient preferences influenced prescribing (59.8% and 43.1%, respectively). Of 6172 statin-eligible patients, 22.3% received a prescription for a moderate- or high-intensity statin at follow-up. Providers reporting greater reliance on risk factors beyond atherosclerotic cardiovascular disease risk were less likely to prescribe statins. Conclusions Although beliefs and approaches to statin discussions vary among community PCP s, new prescription rates are low and minimally associated with those beliefs. These results highlight the complexity of increasing statin prescriptions for primary prevention and suggest that strategies to facilitate standardized discussions and to address external influences on patient beliefs warrant future study.
| S-EPMC6405576 | biostudies-literature
Project description:People with type 1 diabetes may receive a significant portion of their care from primary care providers (PCPs). To understand the involvement of PCPs in delivering type 1 diabetes care, we performed surveys in California and Florida, two of the most populous and diverse states in the United States. PCPs fill insulin prescriptions but report low confidence in providing type 1 diabetes care and difficulty accessing specialty referrals to endocrinologists.
| S-EPMC7164993 | biostudies-literature
Project description:Patients admitted to general medicine inpatient services are increasingly cared for by hospital-based physicians rather than their primary care providers (PCPs). This separation of hospital and ambulatory care may result in important care discontinuities after discharge. We sought to determine whether communication between hospital-based physicians and PCPs influences patient outcomes.We approached consecutive patients admitted to general medicine services at six US academic centers from July 2001 to June 2003. A random sample of the PCPs for consented patients was contacted 2 weeks after patient discharge and surveyed about communication with the hospital medical team. Responses were linked with the 30-day composite patient outcomes of mortality, hospital readmission, and emergency department (ED) visits obtained through follow-up telephone survey and National Death Index search. We used hierarchical multi-variable logistic regression to model whether communication with the patient's PCP was associated with the 30-day composite outcome.A total of 1,772 PCPs for 2,336 patients were surveyed with 908 PCPs responses and complete patient follow-up available for 1,078 patients. The PCPs for 834 patients (77%) were aware that their patient had been admitted to the hospital. Of these, direct communication between PCPs and inpatient physicians took place for 194 patients (23%), and a discharge summary was available within 2 weeks of discharge for 347 patients (42%). Within 30 days of discharge, 233 (22%) patients died, were readmitted to the hospital, or visited an ED. In adjusted analyses, no relationship was seen between the composite outcome and direct physician communication (adjusted odds ratio 0.87, 95% confidence interval 0.56 - 1.34), the presence of a discharge summary (0.84, 95% CI 0.57-1.22), or PCP awareness of the index hospitalization (1.08, 95% CI 0.73-1.59).Analysis of communication between PCPs and inpatient medical teams revealed much room for improvement. Although communication during handoffs of care is important, we were not able to find a relationship between several aspects of communication and associated adverse clinical outcomes in this multi-center patient sample.
| S-EPMC2642573 | biostudies-other
Project description:Advanced diabetes technologies have produced increasingly favorable outcomes compared to older treatments. Disparities in practice resources have led to a treatment disparity by clinical setting, where endocrinologists typically prescribe far more such technologies than primary care providers (PCPs). Fully automated artificial pancreas systems (APS), which combine technologies to deliver and adjust insulin dosing continuously in response to automatic and continuous glucose monitoring, may be more straightforward for PCPs to prescribe and manage, therefore extending their benefit to more patients. We aimed to assess willingness of PCPs to prescribe advanced diabetes technologies through a cross-sectional survey of PCPs from 4 geographically diverse centers. While respondents were uncomfortable initiating (63 of 72, 88%) or adjusting (64 of 72, 89%) traditional insulin pumps, their views on APS were quite different: 71 of 76 (93%) saw advantages to prescribing APS by PCPs rather than only endocrinologists. Most would consider prescribing APS for type 1 diabetes (58 of 76, 76%) and type 2 diabetes (52 of 76, 68%). No differences were seen among attendings, residents, or nurse practitioners. APS were much more acceptable than traditional insulin pumps among this primary care sample. If successful, primary care management of closed-loop APS would greatly increase access to such therapies and reduce disparities among those patients who face more difficulty accessing subspecialty care than they do primary care.
| S-EPMC8297491 | biostudies-literature
Project description:BackgroundVideoconference interviews (VCIs) are increasingly being used in the selection process of residency program candidates across a number of medical specialties, but nevertheless remain an underutilized approach, particularly in the field of primary care.ObjectiveThis retrospective data review with cost analysis explores financial and acceptability outcomes of VCI implementation over a 9-year period.MethodsVCIs were incorporated into the recruitment process at a community-based academic family medicine residency program in 2011, whereby suitable candidates were selected for VCIs after Electronic Residency Application Service (ERAS) application review. Based on the outcome of VCI, candidates were invited via a structured interview tool for a subsequent in-person interviews to determine final rank decisions. Costs of the interview process were tracked, as well as perceptions of VCIs.ResultsVCI implementation over 9 years demonstrated a median 48% reduction of in-person interviews-or 95 applicants eliminated out of a total 195 VCIs performed. This represents a mean annual direct cost savings estimated at $9,154, equating to a 55% reduction in allocated program costs, in addition to indirect cost savings to both applicants and the program.ConclusionsCompared to exclusively in-person interviewing, the utilization of VCIs is potentially more cost-effective for residency programs and candidates, while creating a more personal experience for applicants early in the recruitment process. Limited data of acceptability among faculty and candidates is generally favorable but remains mixed.
| S-EPMC7771615 | biostudies-literature
Project description:Anorectal conditions are one of the most common problems evaluated by primary care physicians. Most patients present with rectal pain, rectal bleeding, or purulent drainage per rectum. Colorectal conditions have overlapping symptoms. Thorough history and careful anorectal examination can differentiate common anorectal conditions like hemorrhoids, anorectal abscesses, anal fistula, anal fissure, and anal condyloma. Most of these conditions can be diagnosed and treated without imaging.
| S-EPMC7144705 | biostudies-literature
Project description:BackgroundDespite efforts to improve access to Medications for Opioid Use Disorder (MOUD), such as buprenorphine, the number of opioid overdoses in the United States continues to rise. In April 2021, the Department of Health and Human Services removed the mandatory training requirement to obtain a buprenorphine waiver; the goal was to encourage more providers to prescribe buprenorphine, thus improving access. Little is known about the attitudes on buprenorphine prescribing after this policy change.ObjectiveThe primary objective was to assess attitudes among primary care providers toward the removal of the buprenorphine waiver training requirement. A secondary objective was to identify other barriers to prescribing buprenorphine.MethodsWe conducted a survey between September 15 and October 13, 2021 to assess the overall beliefs on the effectiveness of MOUD and attitudes toward the removal of the waiver training, current knowledge of buprenorphine, current practice styles related to screening for and treating OUD, and attitudes toward prescribing buprenorphine in the future. This survey was sent to 890 Mayo Clinic primary care providers in 5 US states.ResultsOne hundred twenty-three respondents (13.8%) completed the survey; 35.8% respondents agreed that the removal of the waiver training was a positive step. These respondents expressed a greater familiarity with the different formulations, pharmacology, and titration of buprenorphine. This group was also more likely to prescribe (or continue to prescribe) buprenorphine in the future. Approximately one-third (34.4%) of respondents reported perceived institutional support in prescribing buprenorphine. This group expressed greater confidence in diagnosing OUD, had greater familiarity with the different formulations, pharmacology, and titration of buprenorphine, and was more likely to prescribe (or continue to prescribe) buprenorphine in the future. Respondents who have been in practice for 11 to 20 years since completion of training were most likely to refer all OUD patients to specialists.ConclusionsResults of our survey suggests that simply removing the mandatory waiver training requirement is insufficient in positively changing attitudes toward buprenorphine prescribing. A key barrier is the perceived lack of institutional support. Future studies investigating effective ways to provide such support may help improve providers' willingness to prescribe buprenorphine.
| S-EPMC9284198 | biostudies-literature
Project description:ObjectiveTo develop a model for identifying clinic performance at fulfilling next-day and walk-in requests after adjusting for patient demographics and risk.Data sourceUsing Department of Veterans Affairs (VA) administrative data from 160 VA primary care clinics from 2014 to 2017.Study designUsing a retrospective cohort design, we applied Bayesian hierarchical regression models to predict provision of timely care, with clinic-level random intercept and slope while adjusting for patient demographics and risk status. Timely care was defined as the provision of an appointment within 48 hours of any patient requesting the clinic's next available appointment or walking in to receive care.Data collection/extraction methodsWe extracted 1 841 210 timely care requests from 613 263 patients.Principal findingsAcross 160 primary care clinics, requests for timely care were fulfilled 86 percent of the time (range 83 percent-88 percent). Our model of timely care fit the data well, with a Bayesian R2 of .8. Over the four years of observation, we identified 25 clinics (16 percent) that were either struggling or excelling at providing timely care.ConclusionStatistical models of timely care allow for identification of clinics in need of improvement after adjusting for patient demographics and risk status. VA primary care clinics fulfilled 86 percent of timely care requests.
| S-EPMC7080389 | biostudies-literature
Project description:BackgroundIt is unclear how patient-reported access to primary care differs by physician payment model and participation in team-based care. We examined the association between timely and after-hours access to primary care and physician payment model and participation in team-based care, and sought to assess how access varied by patient characteristics.MethodsWe conducted a cross-sectional analysis of adult (age ? 16 yr) Ontarians who responded to the Ontario Health Care Experience Survey between January 2013 and September 2015, reported having a primary care provider and agreed to have their responses linked to health administrative data. Access measures included the proportion of respondents who reported same-day or next-day access when sick, satisfaction with time to appointment when sick, telephone access and knowledge of an after-hours clinic. We tested the association between practice model and measures of access using logistic regression after stratifying for rurality.ResultsA total of 33 665 respondents met our inclusion criteria. In big cities, respondents in team and nonteam capitation models were less likely to report same-day or next-day access when sick than respondents in enhanced fee-for-service models (team capitation 43%, adjusted odds ratio [OR] 0.88, 95% confidence interval [CI] 0.79-0.98; nonteam capitation 39%, adjusted OR 0.78, 95% CI 0.70-0.87; enhanced fee-for-service 46% [reference]). Respondents in team and nonteam capitation models were more likely than those in enhanced fee-for-service models to report that their provider had an after-hours clinic (team capitation 59%, adjusted OR 2.59, 95% CI 2.39-2.81; nonteam capitation 51%, adjusted OR 1.90, 95% CI 1.76-2.04; enhanced fee-for service 34% [reference]). Patterns were similar for respondents in small towns. There was minimal to no difference by model for satisfaction with time to appointment or telephone access.InterpretationIn our setting, there was an association between some types of access to primary care and physician payment model and team-based care, but the direction was not consistent. Different measures of timely access are needed to understand health care system performance.
| S-EPMC7207031 | biostudies-literature