Douglas R. Smucker

The Outcomes and Costs of Care for Acute Low Back Pain among Patients Seen by Primary Care Practitioners, Chiropractors, and Orthopedic Surgeons

BACKGROUND Patients with back pain receive quite different care from different types of health care practitioners. We performed a prospective observational study to determine whether the outcomes of and charges for care differ among primary care practitioners, chiropractors, and orthopedic surgeons. METHODS Two hundred eight practitioners in North Carolina were randomly selected from six strata: urban primary care physicians (n = 39), rural primary care physicians (n = 48), urban chiropractors (n = 32), rural chiropractors (n = 32), orthopedic surgeons (n = 29), and primary care providers at a group-model health maintenance organization (HMO) (n = 28). The practitioners enrolled consecutive patients with acute low back pain. The patients were contacted by telephone periodically for up to 24 weeks to assess functional status, work status, use of health care services, and satisfaction with the care received. RESULTS The status at six months was ascertained for 1555 of the 1633 patients enrolled in the study (95 percent). The times to functional recovery, return to work, and complete recovery from low back pain were similar among patients seen by all six groups of practitioners, but there were marked differences in the use of health care services. The mean total estimated outpatient charges were highest for the patients seen by orthopedic surgeons and chiropractors and were lowest for the patients seen by HMO and primary care providers. Satisfaction was greatest among the patients who went to the chiropractors. CONCLUSIONS Among patients with acute low back pain, the outcomes are similar whether they receive care from primary care practitioners, chiropractors, or orthopedic surgeons. Primary care practitioners provide the least expensive care for acute low back pain.

Evidence of Thorough Reporting of Sexually Transmitted Diseases in a Southern Rural County

Background and Objectives Private physicians outside the South have been found to report half or fewer of the sexually transmitted diseases that they diagnose. The authors studied whether this is also true in a Southern rural county. Study Design Reports of gonorrhea and chlamydia infection from private physician practices in a rural North Carolina county were compared with laboratory records of positive test results. The proportions reported through 8 months of passive surveillance were compared with the proportion reported during 2 months of active weekly telephone surveillance. Results A total of 72% of all positive gonorrhea test results and 55% of all chlamydia test results were reported through passive surveillance. The proportions increased to 88% and 79%, respectively, with active surveillance. A separate system of multiple checks ensured complete reporting of syphilis that was not affected by surveillance type. Conclusions A relatively high proportion of sexually transmitted diseases diagnosed by private physicians was reported in this rural county. Potential reasons include physician awareness of reporting requirements, delegation of reporting to clinical staff, and personal acquaintance with the health department staff.

Partnering together? Relationships between faith-based community health centers and neighborhood congregations

Objective: The US Bureau of Primary Health Care has promoted collaboration between federally funded community health centers and neighborhood religious congregations, yet little is known about how such organizations currently interact in underserved neighborhoods. Methods: Semistructured interviews were conducted with leaders from five faith-based, urban community health centers and 23 neighborhood congregations. Transcripts were coded for prevalent concepts and themes regarding collaborations between the two types of organizations. Results: Collaborations between health centers and congregations are generally limited to modest sharing of resources and personnel and intermittent health promotion programs. Leaders of both types of organizations desire greater collaboration, but such desires appear to be frustrated by inadequate resources and differing priorities, visions, and philosophies. Conclusions: Increased collaboration between community health centers and neighborhood congregations will require efforts to overcome organizational differences, intercongregational tensions, and resource limitations. For the participants, comprehensive “faith partnerships” remain a desirable but elusive goal.

Patient Safety Incidents in Home Hospice Care: The Experiences of Hospice Interdisciplinary Team Members

BACKGROUND Hospice provides a full range of services for patients near the end of life, often in the patients own home. There are no published studies that describe patient safety incidents in home hospice care. OBJECTIVE The study objective was to explore the types and characteristics of patient safety incidents in home hospice care from the experiences of hospice interdisciplinary team members. METHODS The study design is qualitative and descriptive. From a convenience sample of 17 hospices in 13 states we identified 62 participants including hospice nurses, physicians, social workers, chaplains, and home health aides. We interviewed a separate sample of 19 experienced hospice leaders to assess the credibility of primary results. Semistructured telephone interviews were recorded and transcribed. Four researchers used an editing technique to identify common themes from the interviews. RESULTS Major themes suggested a definition of patient safety in home hospice that includes concern for unnecessary harm to family caregivers or unnecessary disruption of the natural dying process. The most commonly described categories of patient harm were injuries from falls and inadequate control of symptoms. The most commonly cited contributing factors were related to patients, family caregivers, or the home setting. Few participants recalled incidents or harm related to medical errors by hospice team members. CONCLUSIONS This is the first study to describe patient safety incidents from the experiences of hospice interdisciplinary team members. Compared with patient safety studies from other health care settings, participants recalled few incidents related to errors in evaluation, treatment, or communication by the hospice team.

MANAGEMENT OF HEART FAILURE

Heart failure imposes a major burden on society. Primary care physicians, who care for 70% of all heart-failure patients, have opportunities to reduce the economic and mortality impact of this disease by improved outpatient management. Management tasks for these patients are discussed. Successful completion of these tasks will lead to an improvement in functional capacity, fewer hospitalizations, and longer lives for heart-failure patients.

Urinary tract infections in elderly patients

PreviewUrinary tract infections are the most common cause of acute bacterial sepsis in patients older than 65 years. The potential for serious complications, a wide range of clinical syndromes, and often confusing clinical presentations pose real challenges to the physician who cares for elderly patients. Drs Zilkoski, Smucker, and Mayhew discuss these challenges and present an integrated, comprehensive approach to identifying disease and developing cost-effective management protocols.

“Flipping the Classroom” for Weekly Teaching Sessions: Create Your Own Low-Cost Website with Learning Resources for Fellows and IDTs (FR469-F)

Objectives Create a comprehensive list of 45 topics pertinent to both adult and pediatric HPM fellowship training, including topics applicable to geriatric fellowship training and interdisciplinary team members to encourage their attendance to small group discussions. Develop a website that ‘‘flips the classroom’’ for individual study of content prior to each session, followed by weekly small-group discussion of practical application to patient cases. Background. Creating a comprehensive set of engaging traditional PowerPoint lectures for a full year of fellowship training is a daunting task for a new program director. In a collaborative effort to combine and improve weekly classroom sessions for two small HPM fellowships (adult and pediatric), we ‘‘flipped the classroom’’ by creating a simple low-cost website to organize background materials for an annual series of 45 weekly small group HPM topic discussions. Methods. We created a list of 45 HPM topics from 32 lectures in the 2012 AAHPM Board Review Course and chapters from two core related to communication skills and pain management. We created a simple password-protected website using an online service and uploaded background lecture MP3 recordings and PDF articles organized by weekly topic. Each week one HPM faculty member or fellow facilitated group discussion of patient cases related to the background content. Paper handouts were often distributed, but not a single PowerPoint slide was projected during the year. Results. HPM fellows and faculty rated weekly sessions very highly and strongly encouraged continued use of the ‘‘flipped classroom’’ approach. Both the adult and pediatric fellows said the series was the single strongest teaching component of their fellowship year. They strongly endorsed the value of periodic attendance by geriatrics fellows and IDT members and suggested ways to increase their attendance. Discussion. A simple website with weekly background content and small-group discussions of 45 core HPM topics were highly rated by both adult and pediatric palliative care fellows and faculty. Now that the website content is established, it is low cost (

The Effect of an Inpatient Palliative Care Service On the Incidence and Survival Outcomes of Urgent Resuscitation Attempts for Hospitalized Patients (767)

18 per month) to maintain and improve in subsequent years. Conclusion. This approach to classroom teaching is an efficient and engaging way for fellowship programs to organize and present weekly teaching topics and could be easily adapted by interdisciplinary teams for regularly scheduled professional development sessions.

Patient Safety Incidents in Home Hospice Care: A Qualitative Study of Interdisciplinary Hospice Team Members (771)

to individuals with terminal or progressive and life-limiting conditions who express the desire to end life or request physician-assisted suicide or euthanasia. In such cases, palliative medicine implements interventions to relieve physical pain, emotional/psychological suffering, and psychosocial, spiritual, and existential distress. Growing evidence shows that relief of suffering decreases the desire for death, and that meaning-making interventions such as Dignity Therapy reduce depression among the terminally ill. Age-related declines can interact with psychosocial losses to engender suicidal crises of meaning and purpose. While literature documents the role of primary care, geriatrics, and psychiatry in identifying and treating older adults at risk of suicide, it does not articulate a systematic role for palliative care. As palliative medicine expands its services to reach a broader patient population, researchers, policymakers, and practitioners should consider palliative care modalities for providing holistic, multidisciplinary approaches to suicide interventions. This could include partnerships with institutional and community health care professionals to facilitate referrals for palliative care consults.

The Female Athlete Triad

Objectives 1. To describe the personal, emotional burden experienced by residents when learning to care for seriously ill and dying patients early in their residency training. 2. To describe the positive effects on residents’ sense of support and positive learning opportunities resulting from a new interdisciplinary palliative care consult service in their teaching hospital. 3. To generate discussion with conference attendees during poster sessions regarding additional potential educational benefits for resident physicians created by the presence of interdisciplinary palliative care teams.