Frederick D. Edwards

Diagnosis and Treatment of Lyme Disease

Lyme disease is the most common tick-borne disease in the United States. This review details the risk factors, clinical presentation, treatment, and prophylaxis for the disease. Information was obtained from a search of the PubMed and MEDLINE databases (keyword: Lyme disease) for articles published from August 31, 1997, through September 1, 2007. Approximately 20,000 cases of Lyme disease are reported annually. Residents of the coastal Northeast, northwest California, and the Great Lakes region are at highest risk. Children and those spending extended time outdoors in wooded areas are also at increased risk. The disease is transmitted to humans through the bite of the Ixodes tick (Ixodes scapularis and Ixodes pacificus). Typically, the tick must feed for at least 36 hours for transmission of the causative bacterium, Borrelia burgdorferi, to occur. Each of the 3 stages of the disease is associated with specific clinical features: early localized infection, with erythema migrans, fever, malaise, fatigue, headache, myalgias, and arthralgias; early disseminated infection (occurring days to weeks later), with neurologic, musculoskeletal, or cardiovascular symptoms and multiple erythema migrans lesions; and late disseminated infection, with intermittent swelling and pain of 1 or more joints (especially knees). Neurologic manifestations (neuropathy or encephalopathy) may occur. Diagnosis is usually made clinically. Treatment is accomplished with doxycycline or amoxicillin; cefuroxime axetil or erythromycin can be used as an alternative. Late or severe disease requires intravenous ceftriaxone or penicillin G. Single-dose doxycycline (200 mg orally) can be used as prophylaxis in selected patients. Preventive measures should be emphasized to patients to help reduce risk.

The 'Collaborative Care' curriculum: an educational model addressing key ACGME core competencies in primary care residency training.

Aim  The ‘Collaborative Care’ curriculum is a 12‐month senior resident class project in which one evidence‐based clinical guideline is designed, implemented and evaluated in our residency practice. This curriculum specifically addresses three of the six Accreditation Council for Graduate Medical Education (ACGME) core competencies: Practice‐Based Learning and Improvement, Interpersonal and Communication Skills and System‐Based Practices. Additionally, the project enhances the quality of patient care within the model family practice centre in a family practice residency.

Assessing adherence to evidence-based guidelines for the diagnosis and management of uncomplicated urinary tract infection.

OBJECTIVE To assess adherence to evidence-based guidelines for the diagnosis and management of uncomplicated urinary tract infection (UTI) in a family medicine residency clinic setting. PATIENTS AND METHODS We retrospectively reviewed the medical records of female patients seen in 2005 at the Mayo Clinic Family Medicine Center in Scottsdale, Ariz, who were identified by International Classification of Diseases, Ninth Revision code 599.0 (UTI). We assessed documentation rates, use of diagnostic studies, and antibiotic treatments. Antibiotic sensitivity patterns from outpatient urine culture and sensitivity analyses were determined. RESULTS Of 228 patients, 68 (30%) had uncomplicated UTI. Our physicians recorded essential history and examination findings for most patients. Documentation of the risk of sexually transmitted disease differed between residents and attending physicians and was affected by patient age. Urine dipstick and urine culture and sensitivity analyses were ordered in 57 (84%) and 52 (76%) patients, respectively. Eighty percent of patients with positive results on urine dipstick analyses also had urine culture and sensitivity analyses. Sulfamethoxazole-trimethoprim (SMX-TMP) was used as initial therapy in 26 patients (38%). Sixty-one percent of SMX-TMP and ciprofloxacin prescriptions were appropriately provided for 3 days. Escherichia coil was sensitive to SMX-TMP in 33 (94%) of 35 cultures. Treatment was not changed in any patient with an uncomplicated UTI because of results of urine culture and sensitivity analyses. Antibiotic sensitivity patterns for outpatients were significantly different from those for inpatients. CONCLUSION Only 30% of our patients had uncomplicated UTI, making their management within clinical guidelines appropriate. However, of those patients with uncomplicated UTI, less than 25% received empirical treatment as suggested. Urine culture and sensitivity analyses were performed frequently, even in patients who already had positive results on a urine dip-stick analysis. Although SMX-TMP is effective, it is underused. On the basis of these findings, we hope to provide interventions to increase SMX-TMP prescription, decrease use of urine culture and sensitivity analyses, and increase the frequency of 3-day antibiotic treatments at our institution.

Urinary Tract Infection in Women Over the Age of 65: Is Age Alone a Marker of Complication?

Background: We were interested to know if our older female patients with urinary tract infections (UTIs) might have differing pathogens or rates of Escherichia coli antibiotic sensitivity and if our physicians managed them in a manner similar or dissimilar to the care provided to younger patients with no complications. Methods: This was a secondary analysis from patients excluded from a previous retrospective study regarding uncomplicated UTIs. Results: Twenty-six percent of total patients with UTIs were older than 65 and otherwise medically uncomplicated whereas 21% were older patients who did have complicating factors. E. coli was a pathogen in 81% of uncomplicated elders’ and 54% of complicated elders’ cultures. E. coli sensitivity rate to sulfamethoxazole-trimethoprim (SMX/TMP) in both groups was 86%. Physicians were significantly less likely to prescribe SMX/TMP for complicated older patients with complications than for young patients with an uncomplicated UTI (P = .017); there was a significant trend of physicians to be less likely to prescribe SMX/TMP with advancing age in a patient and complications across all 3 groups (P = .011). Antibiotics rarely needed to be changed after cultures. Conclusions: The presence of E. coli on culture in patients with a UTI changes based on medical complications, not age. Being medically complex did not result in reduced sensitivity of E. coli to SMX/TMP but was associated with increased rates of the presence of other pathogens. In our setting, treatment employed with SMX/TMP and without the use of culture and sensitivity may be effective for appropriately selected older women. Prospective studies are needed to determine the optimal approach to management.

Improving service quality in primary care.

A framework for improving health care service quality was implemented at a 12-provider family medicine practice in 2010. A national patient satisfaction research vendor conducted weekly telephone surveys of 840 patients served by that practice: 280 patients served in 2009, and 560 served during 2010 and 2011. After the framework was implemented, the proportion of “excellent” ratings of provider service (the highest rating on a 5-point scale) increased by 5% to 9%, most notably thoroughness (P = .04), listening (P = .04), and explaining (P = .04). Other improvements included prompt test result notification and telephone staff courtesy (each by 10%, P = .02), as well as teamwork (by 8%, P = .04). Overall quality increased by 10% (P = .01), moving the practice from the 68th to the 91st percentile of medical practices in the research vendor’s database. Improvements in patient satisfaction suggest that this framework may be useful in value-based payment models.

When traditionally inseparable services are separated by technology: the case of patient portal features offered by primary care providers

Health-care services have traditionally been provided and consumed simultaneously, as exemplified by in-person patient visits to primary care providers (PCPs), where clinical assessment and treatment are provided and consumed face-to-face. Technological intermediation is changing this traditional assumption, however, as patient-centric technologies, such as patient portals, are creating service separation opportunities. While service separation facilitated by patient portals may bring welcome changes to access, efficiency, and clinical outcomes, usage of patient portals by health-care consumers remains low. Suboptimal demand-side usage of patient portals, especially at the primary care level, could have significant negative implications for patient-centered policy initiatives predicated on patient empowerment and engagement. This paper contributes to this important policy context by reporting findings from a study designed to assess patient perceptions associated with hypothetical patient portal features offered by PCPs and potential subsequent impacts to PCP loyalty and switching propensity. We find that patient portal features focused on back-office (clinical) self-service capabilities (such viewing health records or summaries from prior visits) are perceived positively by consumers, but, interestingly, clinical digital communication and collaboration features (such as online video consultations with physicians) do not have significant perception impacts. These findings suggest that patient portals may act as a complement to health-care service delivery, while substitution for clinical in-person interactions may not be viewed positively.

Use of FRAX as a Determinant for Risk-Based Osteoporosis Screening May Decrease Unnecessary Testing While Improving the Odds of Identifying Treatment Candidates

PURPOSE We have assessed the hypothetical impact of guideline-concordant osteoporosis screening on baseline behaviors utilizing two different guidelines and determined the relative ability of each to identify osteoporosis treatment candidates. METHODS We conducted secondary analyses from the Fracture Risk Perception Study, which enrolled patients aged 50 to 75 years to complete questionnaires about their bone health. We determined our baseline screening rates and detection of treatment candidates and then assessed the hypothetical impact of adherence to U.S. Preventive Services Task Force (USPSTF) and National Osteoporosis Foundation (NOF) criteria, particularly for women aged 50 to 64. RESULTS Of 144 women aged 50 to 64 years screened, 14 (9.7%) were treatment candidates. Screening based on identification of one or more risks (NOF) would lead to testing of 102 of the 144 patients (71%) to identify 12 of 14 treatment candidates (86%). Applying USPSTF criteria (9.3% FRAX threshold) would test 45 of the same 144 women (31%) to identify 11 of 14 treatment candidates (79%). NOF risk-based criteria would result in a moderate absolute screening rate reduction (16%, p = .0011; 95% CI, 7%-25%), but only marginal improvement in identifying treatment candidates (odds ratio, 2.67; 95% CI, 0.57-12.47). Applying the more selective USPSTF criteria greatly reduced unnecessary testing (56% absolute screening rate reduction; p < .0001; 95% CI, 47%-64%) while further improving the odds of identifying treatment candidates (odds ratio, 10.35; 95% CI, 2.72-39.35). CONCLUSIONS When contemplating screening younger patients, systematic calculation of FRAX and ordering only when the 9.3% fracture risk threshold is reached may decrease unnecessary screening for many women while still identifying appropriate osteoporosis treatment candidates.

Improving hypertension control in diabetes: a multisite quality improvement project that applies a 3-step care bundle to a chronic disease care model for diabetes with hypertension.

Hypertension in diabetes patients leads to significant morbidity and mortality. Nonetheless blood pressure (BP) control in patients with diabetes remains disappointing. The authors applied a care bundle to decrease the proportion of patients with BP exceeding 130/80. Teams from 4 sites in 3 states (Minnesota, Florida, and Arizona) developed a bundle consisting of a standardized BP process, an order set, and a patient goal. Baseline data were collected in the first 12 weeks, followed by 6 weeks of implementing changes. The final 16 weeks represented the intervention. There was a statistically significant decrease in the proportion of patients with uncontrolled BP in 3 of 4 sites (P < .0001 in all 3 sites demonstrating improvement). There was a statistically significant improvement in the satisfaction survey (P = .0011). Implementing an evidence-based care bundle for hypertension in diabetes mellitus can improve BP outcomes.