Niharika Khanna

Comparison of patient visits to emergency departments, physician offices, and dental offices for dental problems and injuries

OBJECTIVES Our understanding of the use of emergency departments (EDs) and physician offices for the management of dental problems is limited. We undertook this study to examine whether there are differences in their use by low-income White and minority adults as compared with higher-income adults. METHODS Participantsincluded White, Black, and Hispanic adults who had experi enced a dental problem during the previous 12 months and who visited a physician, ED, or dentist for treatment. We selected a stratified random sample of 27,002 Maryland households with listed telephones to screen for eligibility. We identified 1,387 households with an eligible adult, selected 423 for interviews, and completed interviews with 401 (94.8%). RESULTS To restore correct proportionality to the sample, and to adjust for nonresponse and the distribution of demographic characteristics, weights were created for use in the analyses. Only 7.1 percent of respondents contacted an ED, while 14.3 percent contacted a physician and 90.2 percent a dentist. The vast majority of respondents who contacted an ED (96.0%) or a physician (92.2%) also contacted a dentist. Lower-income respondents were more likely to seek care from an ED, while higher-income respondents were more likely to seek care from a dentist. Over whelmingly, respondents visiting EDs (89.4%) and physicians (51.7%) were instructed to see a dentist or given prescriptions/samples. Treatment provided by EDs, physicians, and dentists was not associated with the respondents income or race/ethnicity. CONCLUSIONS Respondents visiting EDs and physicians typically did not receive definitive care and subsequently visited a dentist for treatment.

The Baltimore Partnership to Educate and Achieve Control of Hypertension (The BPTEACH Trial): a randomized trial of the effect of education on improving blood pressure control in a largely African American population.

J Clin Hypertens (Greenwich). 2011;13:563–570. ©2011 Wiley Periodicals, Inc.

Phase I Clinical Trial of Repeat Dose Terameprocol Vaginal Ointment in Healthy Female Volunteers

Objectives: This safety study of terameprocol (also called M4N, EM-1421) daily vaginal application in healthy women explores its potential application as a microbicide in interrupting human immunodeficiency virus sexual transmission and additional interruption of human papillomavirus and herpes simplex virus transmission. Methods: A double-blind placebo controlled phase I repeat dose tolerability and pharmacokinetic, crossover study of 90 mg terameprocol (2% w/w ointment) administered intravaginally for 7 consecutive days in healthy female subjects. The pharmacokinetics after administration was examined on days 1 and 7 of dosing. Subjects underwent vaginal examination following the 6-hour pharmacokinetic sample on day 7 of each study period. Results: Recruitment started January 2006 and ended May 2006, and 14 subjects completed the study. Median age was 24 years. No treatment-related serious adverse events were reported, and there were a total of 17 treatment-emergent adverse events (AE) reported by 11 participants. The most common AE was headache. Terameprocol was not detectable in serum in pharmacokinetic samples. Conclusions: Terameprocol was well tolerated at a 90 mg dose (2% wt/wt) administered vaginally daily for 7 days. No serious adverse events occurred and any AEs were mild. The excellent safety profile supports future clinical trial to evaluate the application of intravaginal terameprocol in women.

Impact of Case Mix Severity on Quality Improvement in a Patient-centered Medical Home (PCMH) in the Maryland Multi-Payor Program

Background: We present data on quality of care (QC) improvement in 35 of 45 National Quality Forum metrics reported annually by 52 primary care practices recognized as patient-centered medical homes (PCMHs) that participated in the Maryland Multi-Payor Program from 2011 to 2013. Methods: We assigned QC metrics to (1) chronic, (2) preventive, and (3) mental health care domains. The study used a panel data design with no control group. Using longitudinal fixed-effects regressions, we modeled QC and case mix severity in a PCMH. Results: Overall, 35 of 45 quality metrics reported by 52 PCMHs demonstrated improvement over 3 years, and case mix severity did not affect the achievement of quality improvement. From 2011 to 2012, QC increased by 0.14 (P < .01) for chronic, 0.15 (P < .01) for preventive, and 0.34 (P < .01) for mental health care domains; from 2012 to 2013 these domains increased by 0.03 (P = .06), 0.04 (P = .05), and 0.07 (P = .12), respectively. In univariate analyses, lower National Commission on Quality Assurance PCMH level was associated with higher QC for the mental health care domain, whereas case mix severity did not correlate with QC. In multivariate analyses, higher QC correlated with larger practices, greater proportion of older patients, and readmission visits. Rural practices had higher proportions of Medicaid patients, lower QC, and higher QC improvement in interaction analyses with time. Conclusions: The gains in QC in the chronic disease domain, the preventive care domain, and, most significantly, the mental health care domain were observed over time regardless of patient case mix severity. QC improvement was generally not modified by practice characteristics, except for rurality.

Dissemination and Adoption of the Advanced Primary Care Model in the Maryland Multi-Payer Patient Centered Medical Home Program

The Maryland Learning Collaborative together with the Maryland Multi-Payer Program transformed 52 medical practices into patient-centered medical homes (PCMH). The Maryland Learning Collaborative developed an Internet-based 14-question Likert scale survey to assess the impact of the PCMH model on practices and providers, concerning how this new method is affecting patient care and outcomes. The survey was sent to 339 practitioners and 52 care management teams at 18 months into the program. Sixty-seven survey results were received and analyzed. After 18 months of participation in the PCMH initiative, participants demonstrated a better understanding of the PCMH initiative, improved patient access to care, improved care coordination, and increased health information technology optimization (p > .001). The findings from the survey evaluation suggest that practice participation in the Maryland Multi-Payer Program has enhanced access to care, influenced patient outcomes, improved care coordination, and increased use of health information technology.

An Unsuspected Case of a Degenerating Leiomyoma

Uterine leiomyomata are the most common neoplasms of the female pelvis. They have been estimated to occur in 20% to 50% of women of reproductive age. ,2 Most leiomyomata are asymptomatic, and less than 50% of women will have symptoms directly attributed to this condition. It is necessary to be especially alert to diagnose asymptomatic leiomyomata that have unusual symptoms and signs, as shown by the following case.

Evaluation of PCMH Model Adoption on Teamwork and Impact on Patient Access and Safety

Purpose: Each of the participating patient-centered medical home (PCMH) received coaching and participated in learning collaborative for improving teamwork. The objective of the study was to assess the impact of trainings on patient-centered teamwork. Methods: The Teamwork Perception Questionnaire (TPQ) was administered once in spring 2014 and then in fall 2015. The TPQ consists of 35 questions across 5 domains: mutual support, situation monitoring, communication, team structure, and leadership. Based on our objective we compared the frequencies of strongly agree/agree by domain. The difference was tested using chi-square test. We compared the scores on each domain (strongly agree/agree = 1; maximum score = 7) via Wilcoxon rank sum test. Results: The response rate for this survey was n = 29 (80.6%) in spring 2014, and n = 31 (86.1%) in fall 2015. We found that the practice members significantly (P < .05) strongly agreed/agreed more in fall 2015 than spring 2014 for characteristics—“staff relay relevant information in a timely manner” (64.5% vs 83.9%) and “staff follow a standardized method of sharing information when handing off patients” (67.7% vs 90.3%) under communication domain and for characteristic—“staff within my practice share information that enables timely decision making” (74.2% vs 90.3%). However, there was no statistical significant difference observed in the scores for the overall TPQ at the 2 time points. Conclusion: Despite the statistical insignificance, the observations in PCMHs across the spectrum of practices participating in the Maryland Multi-Payer Program demonstrated enhanced teamwork specifically in communication and in leadership. This we believe will continue to result in enhanced patient access to care and safety.

Community Awareness of HPV Screening and Vaccination in Odisha.

Introduction. A number of new technologies including cervical cancer screening and vaccination have introduced new tools in the fight against cervical cancer. Methods. This study was set in Odisha, India, at the Acharya Harihar Regional Cancer Center and study research infrastructure at the Asian Institute of Public Health. IRB approvals were obtained and a research assistant recruited 286 women aged 18–49 years, who provided informed consent and completed a survey tool. Data were entered into EpiData software and statistical analysis was conducted. Results. 76.3% women participants were married, 45.5% had sexual debut at age 21 or greater, 60.5% used contraception, 12.2% reported having a Pap smear in the past, and 4.9% reported having prior genital warts. Most, 68.8% had never heard of HPV and 11.9% were aware that HPV is the main cause of cervical cancer. 82.9% women thought that vaccinations prevent disease, and 74.8% said they make the decision to vaccinate their children. Conclusion. The Odisha community demonstrated a low level of knowledge about cervical cancer prevention, accepted vaccinations in the prevention of disease and screening, and identified mothers/guardians as the key family contacts.

Comparison of physician practice patterns for older adults compared to NHANES diabetes cohort on oral/other therapy

The American Diabetes Association and European Association for the Study of Diabetes issued a new patient-centered approach for the management of hyperglycemia in patients with Type 2 diabetes. With a focus on older adults and the elderly, the authors explored the alignment of elements of the suggested framework with patients’ reports of receiving combination or monotherapy using US national survey data (National Health and Nutrition Examination Survey 2001–2010) and a physician survey. Combination therapy was positively associated with age (range: 1.56–1.63; p = 0.04–0.07), obesity (odds ratio [OR]: 1.40; p = 0.01), HbA1c ≥7.0 (OR: 2.00; p < 0.01), number of years of living with diabetes (OR: 1.02 per year; p = 0.01) and hyperlipidemia (OR: 1.36; p = 0.02). An interaction term between years of living with diabetes and comorbidities >1 pointed to a trend of those with comorbidities >1 to be less probable to report combination therapy (OR: 0.98; p = 0.07) per additional year of diabetes history. Results suggest that sicker, older patients might benefit from more aggressive therapy, in the context of diabetes prevalence, this is expected to continue rising in that population.

Maryland multipayor patient-centered medical home program: A 4-year quasiexperimental evaluation of quality, utilization, patient satisfaction, and provider perceptions

Objective: To evaluate impact of the Maryland Multipayor Patient-centered Medical Home Program (MMPP) on: (1) quality, utilization, and costs of care; (2) beneficiaries’ experiences and satisfaction with care; and (3) perceptions of providers. Design: 4-year quasiexperimental design with a difference-in-differences analytic approach to compare changes in outcomes between MMPP practices and propensity score-matched comparisons; pre-post design for patient-reported outcomes among MMPP beneficiaries. Subjects: Beneficiaries (Medicaid-insured and privately insured) and providers in 52 MMPP practices and 104 matched comparisons in Maryland. Intervention: Participating practices received unconditional financial support and coaching to facilitate functioning as medical homes, membership in a learning collaborative to promote education and dissemination of best practices, and performance-based payments. Measures: Sixteen quality, 20 utilization, and 13 cost measures from administrative data; patient-reported outcomes on care delivery, trust in provider, access to care, and chronic illness management; and provider perceptions of team operation, team culture, satisfaction with care provided, and patient-centered medical home transformation. Results: The MMPP had mixed impact on site-level quality and utilization measures. Participation was significantly associated with lower inpatient and outpatient payments in the first year among privately insured beneficiaries, and for the entire duration among Medicaid beneficiaries. There was indication that MMPP practices shifted responsibility for certain administrative tasks from clinicians to medical assistants or care managers. The program had limited effect on measures of patient satisfaction (although response rates were low) and on provider perceptions. Conclusions: The MMPP demonstrated mixed results of its impact and indicated differential program effects for privately insured and Medicaid beneficiaries.