Richard Marshall

Neonatal necrotizing enterocolitis. Therapeutic decisions based upon clinical staging.

A method of clinical staging for infants with necrotizing enterocolitis (NEC) is proposed. On the basis of assigned stage at the time of diagnosis, 48 infants were treated with graded intervention. For Stage I infants, vigorous diagnostic and supportive measures are appropriate. Stage II infants are treated medically, including parenteral and gavage aminoglycoside antibiotic, and Stage III patients require operation. All Stage I patients survived, and 32 of 38 Stage II and III patients (85%) survived the acute episode of NEC. Bacteriologic evaluation of the gastrointestinal microflora in these neonates has revealed a wide range of enteric organisms including anaerobes. Enteric organisms were cultured from the blood of four infants dying of NEC. Sequential cultures of enteric organisms reveal an alteration of flora during gavage antibiotic therapy. These studies support the use of combination antimicrobial therapy in the treatment of infants with NEC.

Patient and physician reminders to promote colorectal cancer screening: a randomized controlled trial.

BACKGROUND Screening reduces colorectal cancer mortality, but effective screening tests remain underused. Systematic reminders to patients and physicians could increase screening rates METHODS We conducted a randomized controlled trial of patient and physician reminders in 11 ambulatory health care centers. Participants included 21 860 patients aged 50 to 80 years who were overdue for colorectal cancer screening and 110 primary care physicians. Patients were randomly assigned to receive mailings containing an educational pamphlet, fecal occult blood test kit, and instructions for direct scheduling of flexible sigmoidoscopy or colonoscopy. Physicians were randomly assigned to receive electronic reminders during office visits with patients overdue for screening. The primary outcome was receipt of fecal occult blood testing, flexible sigmoidoscopy, or colonoscopy over 15 months, and the secondary outcome was detection of colorectal adenomas. RESULTS Screening rates were higher for patients who received mailings compared with those who did not (44.0% vs 38.1%; P < .001). The effect increased with age: +3.7% for ages 50 to 59 years; +7.3% for ages 60 to 69 years; and +10.1% for ages 70 to 80 years (P = .01 for trend). Screening rates were similar among patients of physicians receiving electronic reminders and the control group (41.9% vs 40.2%; P = .47). However, electronic reminders tended to increase screening rates among patients with 3 or more primary care visits (59.5% vs 52.7%; P = .07). Detection of adenomas tended to increase with patient mailings (5.7% vs 5.2%; P = .10) and physician reminders (6.0% vs 4.9%; P = .09). CONCLUSIONS Mailed reminders to patients are an effective tool to promote colorectal cancer screening, and electronic reminders to physicians may increase screening among adults who have more frequent primary care visits.

Quality Monitoring of Physicians: Linking Patients’ Experiences of Care to Clinical Quality and Outcomes

BackgroundPhysicians are increasingly asked to improve the delivery of clinical services and patient experiences of care.ObjectiveWe evaluated the association between clinical performance and patient experiences in a statewide sample of physician practice sites and a sample of physicians within a large physician group.Design, Setting, ParticipantsWe separately identified 373 practice sites and 119 individual primary care physicians in Massachusetts.MeasurementsUsing Health Plan Employer Data and Information Set data, we produced two composites addressing processes of care (prevention, disease management) and one composite addressing outcomes. Using Ambulatory Care Experiences Survey data, we produced seven composite measures summarizing the quality of clinical interactions and organizational features of care. For each sample (practice site and individual physician), we calculated adjusted Spearman correlation coefficients to assess the relationship between the composites summarizing patient experiences of care and those summarizing clinical performance.ResultsAmong 42 possible correlations (21 correlations involving practice sites and 21 involving individual physicians), the majority were positive in site level (71%) and physician level (67%) analyses. For the 28 possible correlations involving patient experiences and clinical process composites, 8 (29%) were significant and positive, and only 2 (7%) were significant and negative. The magnitude of the significant positive correlations ranged from 0.13 to 0.19 at the site level and from 0.28 to 0.51 at the physician level. There were no significant correlations between patient experiences and the clinical outcome composite.ConclusionsThe modest correlations suggest that clinical quality and patient experience are distinct, but related domains that may require separate measurement and improvement initiatives.

Cultural Competency Training and Performance Reports to Improve Diabetes Care for Black Patients: A Cluster Randomized, Controlled Trial

BACKGROUND Increasing clinician awareness of racial disparities and improving communication may enhance diabetes care among black patients. OBJECTIVE To evaluate the effect of cultural competency training and performance feedback for primary care clinicians on diabetes care for black patients. DESIGN Cluster randomized, controlled trial conducted between June 2007 and May 2008. (ClinicalTrials.gov registration number: NCT00436176) SETTING: 8 ambulatory health centers in eastern Massachusetts. PARTICIPANTS 124 primary care clinicians caring for 2699 (36%) black and 4858 (64%) white diabetic patients. INTERVENTION INTERVENTION clinicians received cultural competency training and monthly race-stratified performance reports that highlighted racial differences in control of hemoglobin A(1c) (HbA(1c)) and low-density lipoprotein (LDL) cholesterol levels and blood pressure. MEASUREMENTS Clinician awareness of racial differences in diabetes care and rates of achieving clinical control targets among black patients at 12 months. RESULTS White and black patients differed significantly in baseline rates of achieving an HbA(1c) level less than 7% (46% vs. 40%), an LDL cholesterol level less than 2.59 mmol/L (<100 mg/dL) (55% vs. 43%), and blood pressure less than 130/80 mm Hg (32% vs. 24%) (all P < 0.050). At study completion, intervention clinicians were significantly more likely than control clinicians to acknowledge the presence of racial disparities in the 8 health centers as a whole (82% vs. 59%; P = 0.003), within their local health center (70% vs. 51%; P = 0.020), and among their own patients (63% vs. 43%; P = 0.037). Black patients of clinicians in the intervention and control groups did not differ at 12 months in rates of controlling HbA(1c) level (48% vs. 45%; P = 0.24), LDL cholesterol level (48% vs. 49%; P = 0.40), or blood pressure (23% vs. 25%; P = 0.47). LIMITATION 11% of primary care teams did not attend cultural competency training sessions. CONCLUSION The combination of cultural competency training and race-stratified performance reports increased clinician awareness of racial disparities in diabetes care but did not improve clinical outcomes among black patients.

Multidisciplinary primary care teams: effects on the quality of clinician-patient interactions and organizational features of care.

Background:Multidisciplinary teams may hold promise for improving primary care quality. This study examined the influence of multidisciplinary teams on patients’ assessments of primary care, including access, integration, and clinician–patient interaction quality. Methods:From January 2004 through March 2005, a large multispecialty practice in Massachusetts obtained data monthly from patients of 145 primary care physicians using a well-validated patient questionnaire. The analytic sample included respondents with at least 2 primary care visits over the study period (n = 14,835). For each respondent, administrative data were used to compute visit continuity over the study period and to classify each primary care visit as PCP, on-team, or off-team. Multivariate regression modeled the relationship of visit continuity to each primary care measure. Results:Approximately one-third of patients (35%) saw only their PCP; 15% had only PCP and “on-team” visits; 9% had a mix of PCP, on-, and off-team visits; and 41% had only “off-team” visits when not seeing their PCP. Greater PCP continuity was associated with more favorable scores on nearly all measures (P < 0.001). An exception was patients’ assessments of teams, which were better when on- versus off-team visits occurred (P < 0.01). For other measures, the decrements associated with discontinuity were the same irrespective of whether discontinuities involved on- or off-team visits. Conclusions:The finding that PCP visit discontinuities are associated with more negative care experiences, irrespective of whether discontinuities involve on- or off-team visits, highlights the challenges of incorporating teams into primary care in ways that patients experience as value-added rather than disruptive to primary care relationships.

Leveraging Text Messaging and Mobile Technology to Support Pediatric Obesity-Related Behavior Change: A Qualitative Study Using Parent Focus Groups and Interviews

Background Text messaging (short message service, SMS) is a widely accessible and potentially cost-effective medium for encouraging behavior change. Few studies have examined text messaging interventions to influence child health behaviors or explored parental perceptions of mobile technologies to support behavior change among children. Objective Our aim was to examine parental acceptability and preferences for text messaging to support pediatric obesity-related behavior change. Methods We conducted focus groups and follow-up interviews with parents of overweight and obese children, aged 6-12 years, seen for “well-child” care in eastern Massachusetts. A professional moderator used a semistructured discussion guide and sample text messages to catalyze group discussions. Seven participants then received 3 weeks of text messages before a follow-up one-on-one telephone interview. All focus groups and interviews were recorded and transcribed verbatim. Using a framework analysis approach, we systematically coded and analyzed group and interview data to identify salient and convergent themes. Results We reached thematic saturation after five focus groups and seven follow-up interviews with a total of 31 parents of diverse race/ethnicity and education levels. Parents were generally enthusiastic about receiving text messages to support healthy behaviors for their children and preferred them to paper or email communication because they are brief and difficult to ignore. Participants anticipated high responsiveness to messaging endorsed by their child’s doctor and indicated they would appreciate messages 2-3 times/week or more as long as content remains relevant. Suggestions for maintaining message relevance included providing specific strategies for implementation and personalizing information. Most felt the negative features of text messaging (eg, limited message size) could be overcome by providing links within messages to other media including email or websites. Conclusions Text messaging is a promising medium for supporting pediatric obesity-related behavior change. Parent perspectives could assist in the design of text-based interventions. Trial Registration Clinicaltrials.gov NCT01565161; http://clinicaltrials.gov/show/NCT01565161 (Archived by WebCite at http://www.webcitation.org/6LSaqFyPP).

Primary-care Clinician Perceptions of Racial Disparities in Diabetes Care

SummaryBackgroundPrimary-care clinicians can play an important role in reducing racial disparities in diabetes care.ObjectiveThe objective of the study is to determine the views of primary-care clinicians regarding racial disparities in diabetes care.DesignThe design of the study is through a survey of primary-care clinicians (response rate = 86%).ParticipantsThe participants of the study were 115 physicians and 54 nurse practitioners and physician assistants within a multisite group practice in 2007.Measurements and Main ResultsWe identified sociodemographic characteristics of each clinician’s diabetic patient panel. We fit multivariable logistic regression models to identify predictors of supporting the collection of data on patients’ race and acknowledging the existence of racial disparities among patients personally treated. Among respondents, 79% supported the collection of data on patients’ race. Whereas 88% acknowledged the existence of racial disparities in diabetes care within the U.S. health system, only 40% reported their presence among patients personally treated. Clinicians caring for greater than or equal to 50% minority patients were more likely to support collection of patient race data (adjusted odds ratio [OR] 9.0; 95% confidence interval [CI] 1.2–65.0) and report the presence of racial disparities within their patient panel (adjusted OR 12.0; 95% CI 2.5–57.7). Clinicians were more likely to perceive patient factors than physician or health system factors as mediators of racial disparities; however, most supported interventions such as increasing clinician awareness (84%) and cultural competency training (88%).ConclusionsMost primary-care clinicians support the collection of data on patients’ race, but increased awareness about racial disparities at the local level is needed as part of a targeted effort to improve health care for minority patients.

Population Management, Systems-Based Practice, and Planned Chronic Illness Care: Integrating Disease Management Competencies into Primary Care to Improve Composite Diabetes Quality Measures

The increasing prevalence of chronic illnesses in the United States requires a fundamental redesign of the primary care delivery systems structure and processes in order to meet the changing needs and expectations of patients. Population management, systems-based practice, and planned chronic illness care are 3 potential processes that can be integrated into primary care and are compatible with the Chronic Care Model. In 2003, Harvard Vanguard Medical Associates, a multispecialty ambulatory physician group practice based in Boston, Massachusetts, began implementing all 3 processes across its primary care practices. From 2004 to 2006, the overall diabetes composite quality measures improved from 51% to 58% for screening (HgA1c x 2, low-density lipoprotein, blood pressure in 12 months) and from 13% to 17% for intermediate outcomes (HgA1c <or=7, low-density lipoprotein <or=100, systolic blood pressure <or=130). Over the same period, a secondary retrospective cohort analysis noted greater gains in composite screening and intermediate outcome measures for patients with planned visits compared to those who had no planned visits. This study illustrates how 1 delivery system integrated these disease management functions into the front lines of primary care and the positive impact of those changes on overall diabetes quality of care.

Primary Care Physician Visit Continuity: A Comparison of Patient-reported and Administratively Derived Measures

BackgroundStudies find that primary care physician (PCP) visit continuity is positively associated with care quality. Some of the evidence base, however, relies on patient-reported continuity measures, which may be subject to response bias.ObjectiveTo assess the concordance of patient-reported and administratively derived visit continuity measures.DesignRandom samples of patients (n = 15,126) visiting 1 of 145 PCPs from a physician organization in Massachusetts were surveyed. Respondents reported their experienced visit continuity over the preceding 6 months. Usual Provider Continuity (UPC), an administratively derived measure, was calculated for each respondent. The concordance of patient reports and UPC was examined. Associations with patient-reported physician-patient interaction quality were assessed for both measures.ResultsPatient-reported and administratively derived visit continuity measures were moderately correlated for overall (r = 0.30) and urgent (r = 0.30) measures and modestly correlated for the routine (r = 0.17) measure. Although patient reports and UPC were significantly associated with the physician-patient interaction quality (p < 0.001), the effect size for patient-reports was approximately five times larger than the effect size for UPC.ConclusionsStudies and quality initiatives seeking to evaluate visit continuity should rely on administratively derived measures whenever possible. Patient-reported measures appear to be subject to biases that can overestimate the relationship between visit continuity and some patient-reported outcomes.

Cytomegalovirus infection in a newborn dizygous twin

Summary Cytomegalovirus caused the early death of one of newborn dizygous twins but apparently did not infect the surviving twin. The decreased twins urine and kidney tissue grew CMV, and his serum contained antibodies specific for CMV. Postmortem examination showed swollen cells with intranuclear and intracytoplasmic inclusions in the kidney, liver, lung, pancreas, and pituitary gland. Cultures of the throat and urine of the surviving twin remain negative for CMV up to 10 weeks of age; serologic analysis showed the presence of transplacentally acquired CMV antibodies. Only one other similar case has been well documented in the literature. The mechanism for the apparent escape from CMV infection in the surviving twin is unclear. The possibility of an undetected subclinical infection cannot be excluded.