Matthew E. Bernard

Impact of online primary care visits on standard costs: a pilot study.

As medical providers seek new ways to control costs, online visits have begun to receive serious consideration. The purpose of this study was to compare the odds of being a cost outlier during a 6-month period after either an online visit or a standard drop-in visit in a conventional medical office setting. Medical records of primary care patients (both adults and children) seen in a large group practice in Minnesota in 2008 were analyzed for this study. Two groups of patients were studied: those who had an online visit (N = 390) and a comparison group who had regular office care for same-day, acute visits (N = 376). Case types were classified as either complex or common, with common being defined as treatment for pinkeye, sore throat, viral illness, bronchitis, or cough. Outliers were defined as patients for whom standard costs exceeded the 75(th) percentile during a 6-month period after the index visit. Multiple logistic regression analysis was used to adjust for differences between groups. The percentage of online visitors who were cost outliers was 21.2 (versus 28.5 in the standard visit group). Median standard costs were

Primer on Medical Genomics Part II: Background Principles and Methods in Molecular Genetics

161 for online visits and

Impact of open-access scheduling on realized access

219 for same-day acute visits. The adjusted odds of being a cost outlier was lower for the online visit group than for the standard visit group (odds ratio [OR] 0.52, 95% confidence interval [95% CI] 0.35-0.77) after adjusting for number of visits in the previous 6 months, age, sex, and case type. Outpatient visits in the previous 6 months were positively related to outlier status (OR 1.23, 95% CI 1.17-1.29). Online visits appeared to reduce medical costs for patients during a 6-month period after the visit.

Use of a clinical decision support system to increase osteoporosis screening.

The nucleus of every human cell contains the full complement of the human genome, which consists of approximately 30,000 to 70,000 named and unnamed genes and many intergenic DNA sequences. The double-helical DNA molecule in a human cell, associated with special proteins, is highly compacted into 22 pairs of autosomal chromosomes and an additional pair of sex chromosomes. The entire cellular DNA consists of approximately 3 billion base pairs, of which only 1% is thought to encode a functional protein or a polypeptide. Genetic information is expressed and regulated through a complex system of DNA transcription, RNA processing, RNA translation, and posttranslational and cotranslational modification of proteins. Advances in molecular biology techniques have allowed accurate and rapid characterization of DNA sequences as well as identification and quantification of cellular RNA and protein. Global analytic methods and human genetic mapping are expected to accelerate the process of identification and localization of disease genes. In this second part of an educational series in medical genomics, selected principles and methods in molecular biology are recapped, with the intent to prepare the reader for forthcoming articles with a more direct focus on aspects of the subject matter.

Repeat retail clinic visits: impact of insurance coverage and age of patient.

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.

Physical symptoms that predict psychiatric disorders in rural primary care adults.

Background In 2002, the US Preventive Services Task Force recommended routine osteoporosis screening for women aged 65 years or older. However, studies have indicated that osteoporosis remains underdiagnosed, and various methods such as the use of health information technology have been tried to increase screening rates. We investigated whether we could boost the low rates of bone mineral density testing with implementation of a point-of-care clinical decision support system in our primary care practice. Methods We retrospectively reviewed the medical records of female patients eligible for osteoporosis screening who had no prior bone mineral density test who were seen at our primary care practice sites in 2007 or 2008 (before and after implementation of a point-of-care clinical decision support system). Results Overall, screening rates were 80.1% in 2007 and 84.1% in 2008 (P < 0.001). Of patients who did not have osteoporosis screening before the visit, 5.87% completed the screening after the visit in 2007, compared with 9.79% in 2008 (when the clinical support system was implemented), a 66.7% improvement (P = 0.025). Conclusion Clinical decision support for primary care doctors significantly improved osteoporosis screening rates among eligible women. Carefully designed clinical decision support systems can optimize care delivery, ensuring that important preventive services such as osteoporosis screening for patients at risk for fracture are performed while unnecessary testing is avoided.

Levothyroxine dosage is associated with stability of thyroid-stimulating hormone values.

As retail clinics provide a less costly alternative for health care, it would be reasonable to expect an increase in multiple (repeat) retail visits by those patients who may have expenses for receiving primary care. If costs were not a significant factor, then repeat visits should not be significantly different between these patients and those with coverage for primary care visits. The hypothesis for this study was that patients with the potential for out-of-pocket expenses would have a higher frequency of repeat retail clinic visits within 180 days compared to those with primary care coverage. A retrospective chart review was conducted of 5703 patients utilizing a retail clinic in Rochester, Minnesota from January 1, 2009 through June 30, 2009. The first visit to the retail clinic was considered the index visit and the chart was reviewed for repeat retail clinic visits within the next 180 days. Using a multiple logistic regression model, the odds of a pediatric patient (N=2344) having a repeat retail visit within 180 days of the index visit were not significantly impacted by insurance coverage (P=0.4209). Of the 3359 adult patients, those with unknown coverage had a 25.6% higher odds ratio of repeat retail clinic visits than those with insurance coverage (odds ratio 1.2557, confidence interval 1.0421-1.5131). This study suggested that when cost is an issue, the adult patient may favor retail clinics for episodic, low-acuity health care. In contrast, the pediatric population did not, suggesting that other factors, such as convenience, may play more of a role in the choice of episodic health care for this age group.

Predictors of osteoporosis screening completion rates in a primary care practice.

RATIONALE, AIMS AND OBJECTIVES There is a robust association between physical symptoms and mental distress, but recognition rates of psychiatric disorders by primary care doctors are low. We investigated patient-reported physical symptoms as predictors of concurrent psychiatric disorders in rural primary care adult outpatients. METHOD A convenience sample of 1092 patients were assessed with a two-stage diagnostic system consisting of a brief screening questionnaire and a clinician-administered semi-structured interview that linked common physical symptoms with the concurrent presence of psychiatric disorders. RESULTS Somatoform physical symptoms were highly predictive of the concurrent presence of a psychiatric disorder, with odds ratios ranging from 10.4 (fainting spells) to 54.6 (shortness of breath). Aggregate analysis of somatoform and non-somatoform symptoms relative to no physical symptom produced odds ratios of 3.0 or higher for headaches, chest pain, dizziness, sleep problem, shortness of breath, tired or low energy, and fainting spells. As the number of symptoms (especially somatoform) increased, the odds of a psychiatric disorder increased. CONCLUSION Although individual physical symptoms are valid triggers for suspecting a psychiatric disorder, the most powerful correlates are total number of physical complaints and somatoform symptom status.

Family Medicine Panel Size with Care Teams: Impact on Quality

OBJECTIVE In patients treated for hypothyroidism, the usual practice is to monitor thyroid-stimulating hormone values yearly once a therapeutic dosage of levothyroxine is determined. This study investigates whether there are any clinical predictors that could identify a subset of patients who might be monitored safely on a less frequent basis. METHODS With the use of a retrospective study design, 715 patients treated for hypothyroidism who had a normal (ie, therapeutic) thyroid-stimulating hormone value in 2006 while taking levothyroxine were identified. All thyroid-stimulating hormone values were then obtained through December 31, 2012. By using a Cox proportional hazard model, gender, age, body mass index, history of chronic autoimmune thyroiditis, initial thyroid-stimulating hormone level, and levothyroxine dose were analyzed for time to first abnormal thyroid-stimulating hormone value. RESULTS Age, gender, history of chronic autoimmune thyroiditis, and body mass index at the time of initial normal thyroid-stimulating hormone were not associated significantly with time to abnormal thyroid-stimulating hormone value. Levothyroxine dose >125 μg/day had an increased hazard ratio of 2.4 (95% confidence interval, 1.7-3.4; P < .0001) for time to first follow-up abnormal thyroid-stimulating hormone value, but dosages less than that did not increase the hazard ratio. One year after the initial normal thyroid-stimulating hormone value, 91.1% of patients taking ≤ 125 μg/day had a continued normal thyroid-stimulating hormone, whereas only 73.3% of patients taking >125 μg/day did. Transformed thyroid-stimulating hormone value (which represents a measure of how far the initial thyroid-stimulating hormone was from the midpoint of the normal range) also had an increased hazard ratio of 1.14 (95% confidence interval, 1.1-1.2; P < .0001) for time to first abnormal thyroid-stimulating hormone value. CONCLUSIONS For patients receiving ≤ 125 μg/day of levothyroxine, we propose that a testing interval up to 2 years may be acceptable if their thyroid-stimulating hormone is well within the normal range.

Prolonged Care Management for Depression A Case-Controlled Study of Those Enrolled for More Than One Year

The United States Preventive Services Task Force and the National Osteoporosis Foundation recommend routine osteoporosis screening for women aged 65 years or older. Previous studies have shown that the use of a clinical decision-support tool significantly improves screening rates. In a recently published study, a statistically significant improvement was found in the screening rates for eligible women with use of the tool. To evaluate whether a clinical decision-support tool independently predicts completion of osteoporosis screening tests and to identify predictors of screening completion, we examined the records of 2462 female patients who were eligible for osteoporosis screening but had no prior baseline screening and who were seen in our primary care practices in 2007 and 2008. Patient and provider characteristics and clinic visit type were identified, and their association with screening test completion was statistically analyzed using both univariate and multivariate models. Screening completion rates increased significantly from 2007 to 2008. Factors associated with increased likelihood of screening completion included race, marital status, residence, presence of comorbidity (cancer, rheumatologic disease), and the year and type of visit. Screening was less likely for women aged 80 years or older. The use of a point-of-care decision-support tool not only improved osteoporosis screening rates significantly but appeared to be an independent predictor of screening completion. It potentially can facilitate the systematic and effective delivery of preventive health services to patients in the primary care setting.