Logan Stuck

Missed Opportunities for Pregnancy Prevention Among Insured Adolescents

IMPORTANCE Birth to a teenaged mother is associated with adverse health and social outcomes. Adolescents at risk for pregnancy may not receive needed reproductive health services at primary care visits. OBJECTIVE To review services provided at outpatient visits in the year prior to pregnancy among adolescents in a US Midwestern integrated health care delivery system. DESIGN, SETTING, AND PARTICIPANTS Retrospective medical record review of continuously insured adolescents aged 15 to 19 years experiencing pregnancy in a nonprofit Minnesota health care organization. MAIN OUTCOMES AND MEASURES Primary care visits in the year prior to pregnancy. RESULTS Adolescents experiencing a pregnancy with stable insurance coverage had an estimated average of 2.7 primary care visits in the 12 months prior to becoming pregnant. Medical record review revealed that 57% did not have documentation of sexual activity and 47% did not have documentation of reproductive health counseling. These rates varied by health care professional type and visit type. Only 35% had contraception prescribed within 12 months of becoming pregnant and only 1 had a long-acting contraceptive prescribed. CONCLUSIONS AND RELEVANCE Our data highlight the need for primary care professionals to review health behaviors and pregnancy risk at all adolescent encounters.

Organizational Factors and Change Strategies Associated With Medical Home Transformation

There is limited information about how to transform primary care practices into medical homes. The research team surveyed leaders of the first 132 primary care practices in Minnesota to achieve medical home certification. These surveys measured priority for transformation, the presence of medical home practice systems, and the presence of various organizational factors and change strategies. Survey response rates were 98% for the Change Process Capability Questionnaire survey and 92% for the Physician Practice Connections survey. They showed that 80% to 100% of these certified clinics had 15 of the 18 organizational factors important for improving care processes and that 60% to 90% had successfully used 16 improvement strategies. Higher priority for this change (P = .001) and use of more strategies (P = .05) were predictive of greater change in systems. Clinics contemplating medical home transformation should consider the factors and strategies identified here and should be sure that such a change is indeed a high priority for them.

Achieving a Safe Endotracheal Tube Cuff Pressure in the Prehospital Setting: Is It Time to Revise the Standard Cuff Inflation Practice?

ABSTRACT Numerous studies have reported unsafe endotracheal tube (ETT) cuff pressures (CP) in the prehospital environment. The purpose of this study was to identify an optimal cuff inflation volume (CIV) to achieve a safe CP (20–30 cmH2O). This observational study utilized 30 recently harvested ovine tracheae, which were warmed from refrigeration in a water bath at 85°F prior to testing. Each trachea was intubated with five different ETT sizes (6.0–8.0 mm), and each size tube was tested with six cuff inflation volumes (5–10 cc). The order of ETT size for each trachea and CIV for each size ETT was randomly pre-assigned. Data were descriptively summarized and categorized before mixed-effects logistic regression was used to determine optimal CIV. Only 113 CP measurements (12.6%, N = 900) were within the optimal range (M = 54.75 cmH2O, SD = 38.52), all of which resulted from a CIV 6 or 7 cc (61% and 39%, respectively). CIVs of 5 cc (n = 150) resulted in underinflation (<20 cmH2O) in all instances, while CIVs of 8, 9, or 10 cc (n = 150 each) resulted in overinflation (>30 cmH2O) in all instances, regardless of ETT size. The odds of achieving a safe CP were greater with CIV of 6 cc for tube sizes 6.0 (OR = 15.9, 95% CI = 3.85–65.58, p < 0.01) and 6.5 mm (OR = 3.16, 95% CI = 1.06–9.39, p = 0.039); however, there was no significant difference in the odds of achieving a safe CP between CIV of 6 and 7 cc for tube sizes 7.0, 7.5, or 8.0 mm. Neither trachea circumference (M = 7.11cm, SD = 0.40), nor tissue temperature (M = 81.32°F, SD = 0.93) were found to be significant predictors of CP (p = 0.20 and 0.81, respectively). Our study showed a high frequency of CP measurements outside of the desired norms. The CIV range of 6–7 cc resulted in the highest likelihood of achieving the desired cuff pressure range, while cuffs inflated with 8–10 cc resulted in dangerously high CPs in all instances. In the absence of a more ideal solution, the results of this study suggest that narrowing the recommended CIV from 5–10 cc to 6–7 cc might be a reasonable target for any tube size.

Outcomes from routine cognitive screening in a general neurology clinic

MiDD was 9.90% in NCD, 16.89% in MCI, and 19.51% in ADD. The frequency of NIMH-dAD was 26.23%, 33.56%, and 40.24%, respectively. While the frequency of MaDD did not show any significant difference among cognitive subgroups, those of MiDD and NIMH-dAD, i.e., relatively milder depression syndromes, had significant group difference with gradual increase from NCD to ADD. Conclusions: The current findings obtained from a large number of cognitively diverse elderly individuals who visited a memory clinic indicated that mild depressive conditions are highly prevalent in general and more common in individuals with poorer cognitive condition, while the frequency of severe depressive disorder like MaDD is not related to cognitive status.

D2-4: Failure on Cognitive Screening Predicts Increased Healthcare Utilization

Background/Aims Most physicians fail to diagnose dementia until the moderate-severe stages. Cognitive screening for dementia in the asymptomatic population is not routinely performed due to the absence of evidence showing improved health outcomes. HealthPartners has piloted the use of the Mini-Cog as a standardized screening tool for cognitive function in patients aged 65 and older in order to assess the impact of undetected cognitive impairment on chronic disease management and healthcare utilization. Methods Patients screened within specialty or primary care clinics were identified. Data from the 18 months prior to screening was collected from the electronic medical record and included the Mini-cog score (scored 0–5, fail is less than 4), demographics, presence of diagnosis for four chronic diseases (diabetes, hypertension, hyperlipidemia, heart disease), measures of chronic disease management (HbA1c, blood pressure, lipid panel, INR levels), and measures of healthcare utilization. Data analysis consisted of Poisson regression and normal mixed effects regression. Results The Mini-Cog was administered in 753 patients (average 77 yr, 58% female) and 33% failed screening. No significant differences in chronic disease management were identified in the 18 months prior to screening between the patients that passed and failed. However, patients failing the MiniCog had a significantly higher incidence rate of hospitalizations (24%), emergency room visits (58%), appointment no shows (76%), cancelled visits (23%), and phone encounters (11%). In a sub-analysis, patients failing screening in specialty care (193 of 554) had a higher incidence rate of appointment no shows (82%), but no difference in hospitalizations. In contrast, patients failing screening in primary care (56 of 199) showed a more profound effect on crisis driven care (a 134% and 411% increase in hospitalization and emergency room visit rates, respectively compared to those passing), but no difference in appointment no shows. Conclusions Standardized cognitive screening in older adults has the potential to not only diagnosis dementia at its earliest stages, but also to identify at-risk individuals with higher healthcare utilization. The next step is to examine post-screen data for any changes in chronic disease management or healthcare utilization.