Joseph W. Furst

Impact of retail walk-in care on early return visits by adult primary care patients: evaluation via triangulation.

Background Retail medicine clinics have become widely available. However, few studies have been published reporting on the outcomes of care from these clinics. The purpose of this study was to assess the risk of early return visits for patients using a retail walk-in clinic. Design Medical records of patients seen in a large group practice in Minnesota in the first 2 months of 2008 were analyzed for this study. Three groups of patients were studied: those using the retail walk-in clinic (n = 300), a comparison group using regular office care in the previous year (n = 373), and a same-day acute care clinic in a medical office (n = 204). The dependent variable was a return office visit within 2 weeks. Multiple logistic regression analysis was used to adjust for case-mix differences between groups. Results The percentage of office visits within 2 weeks for these groups was 31.7 for retail walk-in patients, 38.9 for office visit patients, and 37.1 for same-day acute care clinic patients, respectively (P = .13). The corresponding percentages of return office visits within 2 weeks for the same reasons were 14.0, 24.4, and 20.6 (P < .01). After adjustment for age, sex, marital status, acuity, and number of office visits in the previous 6 months, no significant differences in risk of early return visits were found among clinic types. Conclusion Our retail walk-in clinic appeared to increase access without increasing early return visits.

Provider satisfaction with virtual specialist consultations in a family medicine department.

Virtual consultations (VCs) are being ordered by primary care physicians in 1 large multispecialty clinic, replacing face-to-face visits with specialists. Virtual consultations involve electronic communication between physicians, including exchanging medical information. The purpose of this study was to assess provider satisfaction with VCs via e-mail survey. Although approximately 30% of the 56 family medicine providers had not tried the VC system after it had been in place for over a year or said that they often forgot that VCs were an option, most of the providers surveyed (73%) felt that VCs provided good medical care. A majority felt that VCs are a cost-effective and efficient tool for our department (65%). Most specialists (81%) reported that VCs were an efficient use of their time, and 67% said that VCs were less disruptive than contacts by telephone or pager. Only 5% felt that VCs do not provide good medical care. Although several of our primary care providers have been enthusiastic about VCs, others have been reluctant to adopt this innovation. Specialists providing VCs tended to be supportive. This illustrates both the difficulty of incorporating e-health innovations in primary care practice and the potential for increased efficiency.

Impact of open-access scheduling on realized access

Open-access or advanced-access scheduling, which opens the clinic calendar to patients without requiring them to schedule far in advance of the visit, is being introduced in primary care for the purpose of improving access. None of the evaluations reported to date have measured differences in actual visits that might be associated with different scheduling systems. The purpose of this study was to compare utilization of visits to primary care providers for patients served by an open-access clinic with utilization patterns of patients served at clinics not using open-access scheduling. We hypothesized that the odds that a continuing patient received more than one primary care visit would be greater in the clinic where open-access scheduling was in use than in comparison clinics. Our study provides mixed support for the hypotheses. After adjustment for case mix, stable chronic patients treated in open-access clinics may sometimes have greater odds of receiving two or more preventive care visits. However, these effects do not occur in all clinics, suggesting that other clinic characteristics may overcome the effects of open-access scheduling.

Obesity and pre-hypertension in family medicine: Implications for quality improvement

Background.Prevention of pre-hypertension is an important goal for primary care patients. Obesity is a risk factor for hypertension, but has not been addressed for pre-hypertension in primary care populations. The objective of this study was to assess the degree to which obesity independently is associated with risk for pre-hypertension in family medicine patients.Methods.This study was a retrospective analysis of information abstracted from medical records of 707 adult patients. Multivariable logistic regression was used to test the relationship between body mass index (BMI) and pre-hypertension, after adjustment for comorbidity and demographic characteristics. Pre-hypertension was defined as systolic pressure between 120 and 139 mm Hg or diastolic pressure between 80 and 89 mm Hg.Results.In our sample, 42.9% of patients were pre-hypertensive. Logistic regression analysis revealed that, in comparison to patients with normal body mass, patients with BMI > 35 had higher adjusted odds of being pre-hypertensive (OR = 4.5, CI 2.55–8.11, p < .01). BMI between 30 and 35 also was significant (OR = 2.7, CI 1.61–4.63, p < 0.01) as was overweight (OR = 1.8, CI 1.14–2.92, p = 0.01).Conclusion.In our sample of family medicine patients, elevated BMI is a risk factor for pre-hypertension, especially BMI > 35. This relationship appears to be independent of age, gender, marital status and comorbidity. Weight loss intervention for obese patients, including patient education or referral to weight loss programs, might be effective for prevention of pre-hypertension and thus should be considered as a potential quality indicator.

Family Medicine Patients Who Use Retail Clinics Have Lower Continuity of Care

Purpose: The purpose of this study was to compare continuity of care for family medicine patients using retail medicine clinics to continuity for patients not using retail clinics. Retail medicine clinics have become popular in some markets. However, their impact on continuity of care has not been studied. Methods: Electronic medical records of adult primary care patients seen in a large group practice in Minnesota in 2011 were analyzed for this study. Two randomly chosen groups of patients were selected (N = 400): those using 1 of 3 retail walk-in clinics staffed by nurse practitioners in addition to standard office care and a comparison group that only used standard office care. Continuity was measured as the percentage of visits that involved the primary care provider. We also compared patients who made zero visits to their primary care providers with those who made some visits to their primary care providers. Results: Continuity of care was lower for patients who used retail clinics than for patients who did not use retail clinics (0.17 vs 0.44, mean difference 0.27). The percentage of patients who made zero visits to their primary care providers was 54.5 for users of retail clinics versus 31.0 for those who did not use retail clinics. Conclusions: Continuity of care should be monitored as retail medicine continues to expand.

Obesity and Medical Visits in Family Medicine: A Retrospective Analysis of Medical Records

BackgroundControlling the number of medical visits consumed by primary care patients is essential to cost containment; therefore, identification of patients likely to be frequent users of medical visits is required. Obesity has not often been used as a marker for selecting patients for disease management efforts.MethodsThis study was a retrospective analysis of information abstracted from the medical records of 1405 adult patients who were treated in family medicine practices in Rochester, Minnesota, USA, and referred to specialists. Patients were sorted into two groups — frequent visitors and others — with patients in the highest quartile of use being classified as frequent visitors. Multiple logistic regression analysis was used to test the relationship between body mass index (BMI) and frequency of visits, after adjustment for co-morbidities and demographic characteristics.ResultsMultiple logistic regression analysis revealed that, in comparison with patients with a BMI of 0–24.9 kg/m2, patients with a BMI ≥35 kg/m2 had greater odds of being frequent visitors, after adjusting for co-morbidity, age, marital status, and gender (adjusted odds ratio [AOR] = 1.51; 95% CI 1.01, 2.26; p = 0.04). AORs for being a frequent visitor were also significantly greater for subjects with Charlson co-morbidity scores of 1 (AOR = 2.10; 95% CI 1.50,2.95; p < 0.01) and ≥2 (AOR = 4.45; 95% CI 3.17, 6.25; p < 0.01) than for those with no co-morbid diseases and were lower for married patients than those who were unmarried (AOR = 0.71; 95% CI 0.52, 0.96; p = 0.03). The BMI categories of 25-29.9 kg/m2 and 30-34.9 kg/m2 were not independently related to the frequency of medical visits.ConclusionsIn our sample of patients who attended family medicine practices and were referred to specialists, having a BMI ≥35 kg/m2 was an independent risk factor for frequent utilization of medical visits. Referral to weight management programs might be an effective utilization management strategy.

Equal Performance of Self-Collected and Health Care Worker-Collected Pharyngeal Swabs for Group A Streptococcus Testing by PCR

ABSTRACT A process employing patient- or parent-collected pharyngeal swabs for group A Streptococcus (GAS) testing would expedite diagnosis and treatment, reduce patient exposure to the health care setting, and decrease health care costs. Our aim was to determine the concordance between patient- or parent-collected (self-collected) and health care worker (HCW)-collected pharyngeal swabs for detection of GAS by PCR. From 9 October 2012 to 21 March 2013, patients presenting with a sore throat meeting criteria for GAS testing and not meeting criteria for severe disease were offered the opportunity to collect their own pharyngeal swab. The HCW also collected a swab. Paired swabs were tested by GAS real-time PCR, allowing semiquantitative comparisons between positive results. Of the 402 participants, 206 had a swab collected by the patient and 196 a swab collected by the parent. The percent positivity results were 33.3% for HCW-collected swabs and 34.3% for self-collected swabs (P = 0.41). The overall concordance between the two collection strategies was 94.0% (95% confidence interval [CI], 91.3 to 96.0). Twenty-four of the paired swabs had discordant results, with 10 and 14 positives detected only with the HCW- and self-collected swabs, respectively (P = 0.41). The person collecting the swab in the self-collected arm, the order of collection, and prior swab collection training did not influence results. Among the 124 specimens that were positive by both collection methods, the amount of GAS DNA was higher in the self-collected versus the HCW-collected swabs (P = 0.008). Self-collected pharyngeal swabs provide a reliable alternative to HCW collection for detection of GAS and offer a strategy for improved health care delivery.

The asthma ePrompt: a novel electronic solution for chronic disease management.

Objective. This study tested the ability of an electronic prompt to promote an asthma assessment during primary care visits. Methods. We performed a prospective study of all eligible adult patients with previously diagnosed asthma in three geographically distinct ambulatory family medicine clinics within a 4-month period. The usual clinic visit process was performed at two geographically distinct control sites (n = 75 and n = 55 patients, respectively). The intervention group site (n = 64) had an electronic flag embedded in the Patient Check-in Locator field which prompted the distribution of a self-administered Asthma Management Questionnaire (AMQ) in the waiting room. The primary outcome measure was a documented asthma severity assessment. Results. The front desk distributed the AMQ successfully in 100% of possible opportunities and the AMQ was completed by 84% of patients. Providers in the intervention group were significantly more likely than providers in the two non-intervention groups to document asthma severity in the medical record during a non-asthma ambulatory clinic visit (63.3% vs. 18.7% vs. 3.6%; p < .001). Conclusion. The provision of standardized asthma information triggered by an electronic prompt at the time of check-in effectively initiates an asthma assessment during the primary care visits.

Avoidable after-hours calls to physicians in family medicine.

Objectives: To assess avoidability in after-hours telephone calls. Identification of predictors of avoidable calls is necessary so that system changes can be implemented in the interest of efficiency in patient care. Background: A new after-hours family physician call service was established in a large group practice to replace some of the resident call shifts and meet patient expectations. Data Source: Call logs completed by physicians who were on call. Sample: A total of 131 completed after-hours calls. Avoidable Call: An after-hours call to a physician that could have been effectively handled by another person, by a communication mechanism, or at another time. Assessment Result: Call defined as avoidable or not avoidable as assessed by the physician on call. Survey Results: Less than half (41.9%) of calls were avoidable. Run charts failed tests for shifts and runs. Patient age, time of day, and day of the week were not related to being avoidable, but avoidability varied by physician (P = .003). Conclusion: The after-hours call service experienced high rates of avoidable calls. Avoidability was associated with the physician on call. Reducing avoidable after-hours calls to physicians will require building clinical consensus on which types of calls should be considered avoidable and how avoidable calls should be redirected.

Low-density lipoprotein-cholesterol (LDL-C) greater than 100 mg/dL as a quality indicator: locating risk in person, place and time

RATIONALE, AIMS AND OBJECTIVES Achieving control over elevated lipid parameters, particularly low-density lipoprotein (LDL)-cholesterol, is an acknowledged quality indicator in primary care. The Centers for Disease Control and Prevention (CDC)s model for investigation of outbreaks (person-place-time) can be applied to the analysis of quality indicators. METHODS A sample of 322 family medicine patients for whom lipid levels were ordered was extracted. LDL > 100 mg/dL was cross-tabulated by personal characteristics [age group, gender, body mass index (BMI), diagnoses], month (time) and ordering department (place). RESULTS Age (except one age category), gender, time and location were not related to LDL > 100 mg/dL after adjustment for covariates. All levels of BMI above normal elevated the risk of LDL > 100 mg/dL [BMI 25-29.9: odds ratio (OR) = 3.41, confidence interval (CI) = 1.61-7.23, P = 0.0014; BMI 30-34.9: OR = 2.93, CI = 1.28-6.70, P = 0.0109; BMI ≥ 35: OR = 2.75, CI = 1.19-6.37, P = 0.0181]. Patients with coronary artery disease (CAD) and diabetes mellitus (DM) were at reduced risk for LDL > 100 mg/dL (CAD: OR = 0.47, CI = 0.24-0.91, P = 0.0254; DM: OR = 0.28, CI = 0.14-0.55, P = 0.0002). CONCLUSION An outbreak investigation model is useful for analysing variations in this quality indicator. Patients with higher BMI and those not diagnosed with CAD or DM type I/II may be considered for intensified lipid lowering using quality improvement efforts. These might include counselling for lifestyle changes or medication therapy depending upon their calculated cardiac risk.