Browsing by Subject "Primary care"
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Item A Patient-Centered Nurse-Supported Primary care-based Collaborative Care Program to Treat Opioid Use Disorder and Depression: Design and Protocol for the MI-CARE Randomized Controlled Trial(Elsevier, 2023) DeBar, Lynn L.; Bushey, Michael A.; Kroenke, Kurt; Bobb, Jennifer F.; Schoenbaum, Michael; Thompson, Ella E.; Justice, Morgan; Zatzick, Douglas; Hamilton, Leah K.; McMullen, Carmit K.; Hallgren, Kevin A.; Benes, Lindsay L.; Forman, David P.; Caldeiro, Ryan M.; Brown, Ryan P.; Campbell, Noll L.; Anderson, Melissa L.; Son, Sungtaek; Haggstrom, David A.; Whiteside, Lauren; Schleyer, Titus K. L.; Bradley, Katharine A.; Psychiatry, School of MedicineBackground: Opioid use disorder (OUD) contributes to rising morbidity and mortality. Life-saving OUD treatments can be provided in primary care but most patients with OUD don't receive treatment. Comorbid depression and other conditions complicate OUD management, especially in primary care. The MI-CARE trial is a pragmatic randomized encouragement (Zelen) trial testing whether offering collaborative care (CC) to patients with OUD and clinically-significant depressive symptoms increases OUD medication treatment with buprenorphine and improves depression outcomes compared to usual care. Methods: Adult primary care patients with OUD and depressive symptoms (n ≥ 800) from two statewide health systems: Kaiser Permanente Washington and Indiana University Health are identified with computer algorithms from electronic Health record (EHR) data and automatically enrolled. A random sub-sample (50%) of eligible patients is offered the MI-CARE intervention: a 12-month nurse-driven CC intervention that includes motivational interviewing and behavioral activation. The remaining 50% of the study cohort comprise the usual care comparison group and is never contacted. The primary outcome is days of buprenorphine treatment provided during the intervention period. The powered secondary outcome is change in Patient Health Questionnaire (PHQ)-9 depression scores. Both outcomes are obtained from secondary electronic healthcare sources and compared in "intent-to-treat" analyses. Conclusion: MI-CARE addresses the need for rigorous encouragement trials to evaluate benefits of offering CC to generalizable samples of patients with OUD and mental health conditions identified from EHRs, as they would be in practice, and comparing outcomes to usual primary care. We describe the design and implementation of the trial, currently underway.Item A practical guide to recognize, assess, treat and evaluate (RATE) primary care patients with chronic pain(Taylor & Francis, 2023) Gebke, Kevin B.; McCarberg, Bill; Shaw, Erik; Turk, Dennis C.; Wright, Wendy L.; Semel, David; Medicine, School of MedicineThe management of patients with chronic pain is one of the most important issues In medicine and public health. Chronic pain conditions cause substantial suffering for patients, their significant others and society over years and even decades and increases healthcare utilization resources including the cost of medical care, loss of productivity and provision of disability services. Primary care providers are at the frontline in the identification and management of patients with chronic pain, as the majority of patients enter the healthcare system through primary care and are managed by primary care providers. Due to the complexity of chronic pain and the range of issues involved, the accurate diagnosis of the causes of pain and the formulation of effective treatment plans presents significant challenges in the primary care setting. In this review, we use the classification of pain types based on pathophysiology as the template to guide the assessment, treatment, and monitoring of patients with chronic pain conditions. We outline key methods that can be used to efficiently and accurately diagnose the putative pathophysiological mechanisms underlying chronic pain conditions and describe how this information should be used to tailor the treatment plan to meet the patient's needs. We discuss methods to evaluate patients and the impact of treatment plans over a series of consultations, with a particular focus on strategies to improve the patient's ability to self-manage their pain and related symptoms and perform daily functions despite persistent pain. Finally, we introduce the mnemonic RATE (Recognize, Assess, Treat, and Evaluate) as a general strategy that healthcare providers can use to aid their management of patients presenting with chronic pain.Item A randomized controlled trial of an online health tool about Down syndrome(Elsevier, 2021) Chung, Jeanhee; Donelan, Karen; Macklin, Eric A.; Schwartz, Alison; Elsharkawi, Ibrahim; Torres, Amy; Hsieh, Yichuan Grace; Parker, Holly; Lorenz, Stephen; Patsiogiannis, Vasiliki; Santoro, Stephanie L.; Wylie, Mark; Clarke, Lloyd; Estey, Greg; Baker, Sandra; Bauer, Patricia E.; Bull, Marilyn; Chicoine, Brian; Cullen, Sarah; Frey-Vogel, Ariel; Gallagher, Maureen; Hasan, Reem; Lamb, Ashley; Majewski, Lisa; Mast, Jawanda; Riddell, Travis; Sepucha, Karen; Skavlem, Melissa; Skotko, Brian G.; Pediatrics, School of MedicinePurpose: We sought to determine if a novel online health tool, called Down Syndrome Clinic to You (DSC2U), could improve adherence to national Down syndrome (DS) guidelines. We also sought to determine if primary care providers (PCPs) and caregivers are satisfied with this personalized online health tool. Methods: In a national, randomized controlled trial of 230 caregivers who had children or dependents with DS without access to a DS specialist, 117 were randomized to receive DSC2U and 113 to receive usual care. The primary outcome was adherence to five health evaluations indicated by national guidelines for DS. DSC2U is completed electronically, in all mobile settings, by caregivers at home. The outputs-personalized checklists-are used during annual wellness visits with the patient's PCP. Results: A total of 213 participants completed a 7-month follow-up evaluation. In the intention-to-treat analysis, the intervention group had a 1.6-fold increase in the number of indicated evaluations that were recommended by the primary care provider or completed compared with controls. Both caregivers and PCPs reported high levels of satisfaction with DSC2U. Conclusions: DSC2U improved adherence to the national DS health-care guidelines with a novel modality that was highly valued by both caregivers and PCPs.Item Acceptability and Results of Dementia Screening Among Older Adults in the United States(Bentham Science, 2018) Harrawood, Amanda; Fowler, Nicole R.; Perkins, Anthony J.; LaMantia, Michael A.; Boustani, Malaz A.; Medicine, School of MedicineOBJECTIVES: To measure older adults acceptability of dementia screening and assess screening test results of a racially diverse sample of older primary care patients in the United States. DESIGN: Cross-sectional study of primary care patients aged 65 and older. SETTING: Urban and suburban primary care clinics in Indianapolis, Indiana, in 2008 to 2009. PARTICIPANTS: Nine hundred fifty-four primary care patients without a documented diagnosis of dementia. MEASUREMENTS: Community Screening Instrument for Dementia, the Mini-Mental State Examination, and the Telephone Instrument for Cognitive Screening. RESULTS: Of the 954 study participants who consented to participate, 748 agreed to be screened for dementia and 206 refused screening. The overall response rate was 78.4%. The positive screen rate of the sample who agreed to screening was 10.2%. After adjusting for demographic differences the following characteristics were still associated with increased likelihood of screening positive for dementia: age, male sex, and lower education. Patients who believed that they had more memory problems than other people of their age were also more likely to screen positive for dementia. CONCLUSION: Age and perceived problems with memory are associated with screening positive for dementia in primary care.Item Addressing Food Insecurity: Lessons Learned from Co-Locating a Food Pantry with a Federally Qualified Health Center(Ubiquity Press, 2022-09-30) Reinoso, Deanna; Haut, Dawn; Claffey, Stephen; Hahn Keiner, Kathy; Chavez, Alejandra; Nace, Nicole; Carter, Amy; Pediatrics, School of MedicineIntroduction: Social determinants of health, such as food insecurity, contribute to chronic health conditions, decreased quality of life, and health disparities. Increasingly, healthcare systems seek to address social determinants of health by integrating medical and social care. Description: Eskenazi Health Center Pecar is a Federally Qualified Health Center providing comprehensive primary care to vulnerable patients in Indianapolis, IN, USA. This health center, in coalition with community partners, established and continually developed an integrated food pantry model to address food insecurity, improve nutrition education, and support patient access to healthy food. Discussion: Food insecurity and poor nutrition are common in primary care and contribute to the incidence and outcomes of chronic conditions such as obesity, hypertension, and diabetes. Long-term management of food assistance and nutrition programs requires substantial resources, partnerships, and leadership. We describe lessons learned in food pantry partnership, funding, logistics, and sustainability in a collaborative food access model integrated into healthcare. These lessons learned can be utilized by other health systems to scale up and accelerate strategies to better address food security and nutrition education. This paper articulates best practices for integrating a food pantry model within primary care with the goal of long-term sustainability and direct impact on patient health outcomes.Item Adolescent suicide assessment and management in primary care(BMC, 2022-07-02) Aalsma, M.; Keys, J.; Ferrin, S.; Shan, M.; Garbuz, T.; Scott, T.; Adams, Z.; Hulvershorn, L.; Downs, S.; Pediatrics, School of MedicineBackground: To understand how suicide management occurs within the primary care setting in terms of follow-up assessments and referral practices. Methods: At an initial primary care visit, adolescents (aged 12-20 years old) completed electronic screening. Data were focused on youth who endorsed a suicidal risk item while completing screening at two Midwestern primary care clinics. Data were collected through retrospective chart reviews to analyze actions taken by the primary care physician at the youth's initial visit and follow-up visit within the next 12 months. Results: At initial visits 200 adolescents endorsed a suicidal risk item and 39 (19.5%) were considered to be concerning by their primary care physician. The average age was 14.7 years old (SD ± 2.0). Seventy-two percent (n = 144) were female, and 65% (n = 129) identified as Black. At initial visits, significant differences between suicidal concern groups were found in reporting active suicidal ideation, past suicide attempts, those who were referred to behavioral health counseling, and those who had a diagnosis of depression. Interestingly, only 13% (n = 25) of all patients who endorsed the suicide item were asked whether or not there were weapons in their home and primary care providers asked only 7% (n = 13) of all patients whether they had a safety plan. Conclusions: There was inconsistent follow-up for adolescents with a history of suicide concerns. At this time, national guidelines do not exist regarding primary care follow-up of youth with suicide concerns. Guidelines are a necessary precursor for practice improvement.Item Agile implementation of alcohol screening in primary care(Springer Nature, 2024-07-11) Summanwar, Diana; Ropert, Chelan; Barton, James; Hiday, Rachael; Bishop, Dawn; Boustani, Malaz; Willis, Deanna; Medicine, School of MedicineBackground: Despite the United States Preventive Services Task Force recommendation to screen adults for unhealthy alcohol use, the implementation of alcohol screening in primary care remains suboptimal. Methods: A pre and post-implementation study design that used Agile implementation process to increase screening for unhealthy alcohol use in adult patients from October 2021 to June 2022 at a large primary care clinic serving minority and underprivileged adults in Indianapolis. Results: In comparison to a baseline screening rate of 0%, the agile implementation process increased and sustained screening rates above 80% for alcohol use using the Alcohol Use Disorders Identification Test - Consumption tool (AUDIT-C). Conclusions: Using the agile implementation process, we were able to successfully implement evidence-based recommendations to screen for unhealthy alcohol use in primary care.Item Assessing the use of a clinical decision support tool for pain management in primary care(Oxford University Press, 2022-09-15) Apathy, Nate C.; Sanner, Lindsey; Adams, Meredith C.B.; Mamlin, Burke W.; Grout, Randall W.; Fortin, Saura; Hillstrom, Jennifer; Saha, Amit; Teal, Evgenia; Vest, Joshua R.; Menachemi, Nir; Hurley, Robert W.; Harle, Christopher A.; Mazurenko, Olena; Health Policy and Management, School of Public HealthObjective: Given time constraints, poorly organized information, and complex patients, primary care providers (PCPs) can benefit from clinical decision support (CDS) tools that aggregate and synthesize problem-specific patient information. First, this article describes the design and functionality of a CDS tool for chronic noncancer pain in primary care. Second, we report on the retrospective analysis of real-world usage of the tool in the context of a pragmatic trial. Materials and methods: The tool known as OneSheet was developed using user-centered principles and built in the Epic electronic health record (EHR) of 2 health systems. For each relevant patient, OneSheet presents pertinent information in a single EHR view to assist PCPs in completing guideline-recommended opioid risk mitigation tasks, review previous and current patient treatments, view patient-reported pain, physical function, and pain-related goals. Results: Overall, 69 PCPs accessed OneSheet 2411 times (since November 2020). PCP use of OneSheet varied significantly by provider and was highly skewed (site 1: median accesses per provider: 17 [interquartile range (IQR) 9-32]; site 2: median: 8 [IQR 5-16]). Seven "power users" accounted for 70% of the overall access instances across both sites. OneSheet has been accessed an average of 20 times weekly between the 2 sites. Discussion: Modest OneSheet use was observed relative to the number of eligible patients seen with chronic pain. Conclusions: Organizations implementing CDS tools are likely to see considerable provider-level variation in usage, suggesting that CDS tools may vary in their utility across PCPs, even for the same condition, because of differences in provider and care team workflows.Item Caregiver Comfort in Adolescents Independently Completing Screening Tablet-Based Questionnaires at Primary Care Visits(Elsevier, 2019-09-12) Ferrin, Stephanie N.; Grout, Randall W.; Gilbert, Amy Lewis; Wilkinson, Tracey A.; Cheng, Erika R.; Downs, Stephen M.; Aalsma, Matthew C.; Pediatrics, School of MedicineObjectives The objective of this study was to assess caregiver comfort regarding adolescent completion of computerized health screening questionnaires created for adolescents. Design We conducted a mixed method, cross-sectional survey of caregivers of adolescent patients (n=104) ages 12–18 years that had a medical visit between June and August of 2017. Topics assessed included who completed the questionnaire, caregiver comfort and concern regarding questionnaire data, and caregiver reasons for involvement in completing the questionnaire. A one-way ANOVA was used to compare age of the adolescent and caregiver involvement in the questionnaire. Results The majority of adolescents (64%) reported independent completion of the questionnaire. Thirteen percent of caregivers completed the questionnaire with no involvement of the adolescent and 23% reported that caregivers and adolescents completed the questionnaire in tandem. The majority of caregivers (84%) were comfortable with adolescents completing the questionnaire. A variety of reasons were identified for caregivers completing the questionnaire (time constraints, 22%; adolescent requested caregiver help, 19%; caregiver desired to answer questions, 14%; caregiver did not realize that the questionnaire was intended for the adolescent, 11%; caregiver believed that the adolescent was too young to respond alone, 11%. Caregiver comfort with adolescent completing the questionnaire increase with age. Conclusion We found the reason most caregivers gave for completing the questionnaires were related to clinic processes (e.g. time constraints) Caregivers were more likely to complete the questionnaire with younger adolescents. Thus, pediatricians should consider how to best prepare families for initial questionnaires in primary care.Item Clinician Attitudes and Confidence on the Detection and Management of Cognitive Impairment: Results from the Davos Alzheimer’s Collaborative Early Detection Program(Wiley, 2025-01-09) Barkman Ferrell, Phyllis; Murray, James F.; Ball, Daniel E.; dos Santos Filho, Otelo Corrêa; de Sá Paiva Lima, Marcilea Dias; Govia, Ishtar; Robinson, Janelle; Kowa, Hisatomo; López-Ortega, Mariana; McKean, Alison; Chambers, Wendy; Baksh, Magda R.; Baldivieso, Valeria; Willis, Deanna R.; Fowler, Nicole R.; Selzler, Katherine J.; Medicine, School of MedicineBackground: Early symptoms of cognitive impairment are frequently undetected. The Davos Alzheimer’s Collaborative System Preparedness (DAC‐SP) Early Detection program implemented a digital cognitive assessment (DCA) in primary care and other non‐specialty settings to increase the rate of detection of cognitive impairment. Methods: The DAC‐SP Early Detection program was initiated in 2021 in seven healthcare systems across six countries. Clinicians were trained on a DCA, including positive tests for cognitive impairment and diagnostic assessment. Prior to training or naïve to implementing a DCA in clinical practice, clinicians’ attitudes and confidence in diagnosis and managing dementia were assessed using the validated General Practitioners Attitude and Confidence Scale for Dementia (GPACS‐D), which is comprised of 15 items in three subscales: Confidence in Clinical Abilities, Attitude towards Care, and Engagement. Each item is measured on a 5‐point Likert scale (1 = strongly disagree; 5 = strongly agree), and subscale scores are standardized. A total of 265 pre‐training surveys were completed across the 7 sites. The GPACS‐D results were calculated by averaging individual physician results per the validated scoring algorithm. The cross‐site results were calculated by taking an equally weighted average across the seven sites. Results: The GPACS‐D results across the seven sites are presented in Table 1. Across all sites, baseline attitude towards care was the highest of the three subscales. For most sites, confidence in clinical abilities received the lowest scores, with engagement scores only modestly higher. The total and subscale scores were consistent across sites, supported by the relatively low standard deviation. Conclusion: The findings from the GPACS‐D total and subscale scores suggest that prior to receiving training on using a digital cognitive assessment for their patient populations, clinicians’ attitudes towards the diagnosis and management of cognitive impairment were similar across the seven sites, and independent of the country in which they practice. Despite positive attitudes toward care, the results suggest that education or training focused more on engagement and confidence may improve early detection and care of patients with cognitive impairment, particularly as new diagnostic and therapeutic options emerge.