Robert J. Fortuna

Prescribing of Controlled Medications to Adolescents and Young Adults in the United States

OBJECTIVE: The nonmedical use of prescription drugs by adolescents and young adults has surpassed all illicit drugs except marijuana, yet little is known about prescribing patterns. We examined the prescribing of controlled medications to adolescents aged 15 to 19 and young adults aged 20 to 29. METHODS: We used cross-sectional data from the National Ambulatory Medical Care Survey (N = 4304 physicians) and the National Hospital Ambulatory Medical Care Survey (N = 2805 clinics; N = 1051 emergency departments) between 2005 and 2007. We also used consecutive data from 1994 to describe trends. RESULTS: A controlled medication was prescribed at 2.3 million visits by adolescents and 7.8 million visits by young adults in 2007. Between 1994 and 2007, controlled medications were prescribed at an increasing proportion of visits from adolescents (6.4%–11.2%) and young adults (8.3%–16.1%) (P < .001 for trend). This increase was seen among males and females, in ambulatory offices and emergency departments, and for injury-related and non–injury-related visits (all P < .001). A controlled medication was prescribed during 9.6% of all adolescent visits and 13.8% of young-adult visits for non–injury-related indications and at 14.5% of adolescent visits and 27.0% of young-adult visits for injury-related reasons. Controlled medications were prescribed at a substantial proportion of visits for common conditions, such as back pain, to both adolescents (23.4%) and young adults (36.9%). CONCLUSIONS: Controlled medications are prescribed at a considerable proportion of visits from adolescents and young adults, and prescribing rates have nearly doubled since 1994. This trend and its relationship to misuse of medications warrants further study.

Ambulatory Care Among Young Adults in the United States

Context Little is known about how young adults 20 to 29 years of age use ambulatory medical care. Contribution The authors found that young adults have fewer ambulatory care visits than adolescents or adults 30 to 39 years of age. In addition, young adults who are male, black, or Hispanic have fewer visits than other young adults. Implication Young adults underutilize ambulatory care relative to other age groups. The Editors Young adults face many of the same health care challenges as adolescents, yet fewer resources are available to care for this patient population (1). Although the mortality rate among young adults is more than twice that among adolescents, young adults remain the most likely age group to be uninsured (2, 3). Approximately one third of young adults are uninsured, which hinders access to care and results in delayed treatment and difficulty filling prescription medications (2, 3). The prevalence of homicide, motor vehicle accidents, substance abuse, and sexually transmitted diseases (STDs) all peak in young adulthood (1, 4, 5). Compared with adolescents, young adults have 3 times the suicide rate; nearly 3 times the incidence of HIV; and higher rates of smoking (41.8% vs. 12.4), binge drinking (41.8% vs. 9.7%), and illicit drug use (19.7% vs. 9.5%) (1, 5). Similarly, young adults have considerably higher rates of STDs, illicit drug use, alcohol use, and tobacco use than older adults (4, 5). Finally, young adults have the highest rate of serious psychological distress among all adults (17.9%), yet fewer than half (46.9%) of those with a major depressive episode receive treatment (5, 6). Healthy People 2010 established several national objectives, including reducing mortality, alcohol- and drug- related injuries, motor vehicle accidents, and the incidence of STDs among young adults (7, 8), yet where young adults are receiving care and what preventive services are being provided to help reach these goals are unclear. Although several studies have described health care in adolescents (911), little is known about ambulatory care of young adults. A comprehensive understanding of where young adults access care and what preventive services are provided are needed to guide future initiatives toward improving health care for young adults and achieving the national objectives. We used data from the National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) between 1996 and 2006 to characterize ambulatory medical care among young adults age 20 to 29 years. We sought to compare health care utilization among young adults with that among adolescents and older adults, to describe ambulatory medical care of young adults (types of visits, reasons for visits, and sites of care), and to examine the provision of preventive care to young adults. On the basis of studies in adolescents (11, 12), we hypothesized that young adults utilize health care less than other age groups and infrequently receive age-appropriate preventive care directed at the most common threats to their health. Methods This study was approved by the University of Rochester Research Subjects Review Board under exempt status (RSRB00026060). Design of the NAMCS and NHAMCS The NAMCS is a national cross-sectional survey of patient visits to nonfederal, office-based physicians in the United States. Similarly, NHAMCS is a cross-sectional survey of patient visits to outpatient departments of general and short-stay hospitals. The surveys both utilize a multistage probability design to select a stratified systematic sample of patient visits and use visit weights to extrapolate these encounters to estimates of national utilization of ambulatory medical services (13). The NAMCS uses a 3-stage sampling design based on geographic area, physician practices within the area, and patient visits within the practice (13). The NHAMCS uses a 4-stage probability design based on geographically defined areas, hospitals within these areas, clinics within the outpatient departments, and patient visits to these clinics (14). A comprehensive explanation of the methods used for data collection, sampling, and weighting in NAMCS and NHAMCS are available online at www.cdc.gov/nchs/about/major/ahcd/ahcd1.htm. The protocols used by NAMCS were approved by the National Center for Health Statistics Institutional Review Board (15). Creation of Variables We defined young adults as people between 20 and 29 years of age. We chose this age range because it represents a period when many people lose their insurance coverage, it conforms to census data, and it is commonly used by insurers to determine the number of reimbursable visits for preventive care (16). To ensure that our findings were not dependent on the definition of young adult, we also ran our key analyses after redefining young adults as people 18 to 24 years of age. To focus our analyses and allow for sex comparisons, we excluded all visits related to pregnancy. We estimated utilization rates by using visit data from NAMCS and NHAMCS and population data from the U.S. Census (17, 18) between 2000 and 2006 to calculate the number of annual visits per capita for adolescents, young adults, and older adults, stratified by sex, race, and ethnicity. We used the American Community Survey March Supplements between 2001 and 2007 (in which data are reported for the previous year, that is, 2000 to 2006) to obtain the proportion of young adults without insurance during this period (dataferrett.census.gov). We used data from NAMCS and NHAMCS between 1996 and 2006 to characterize types of visits from young adults (acute, chronic, or preventive), the locations where young adults receive care, the specialties of providers seen, and the counseling rendered to young adults during office visits. The NAMCS and NHAMCS recorded the major reason for the patient visit as acute problem; chronic problem, routine; chronic problem, flare-up; pre/post-surgery; and preventive care. We combined the 2 chronic problem visits in our analysis because both represent similar types of visits for management of chronic disease. We used the reason for visits classification codes to tabulate the principal reason for the ambulatory encounter. If the principal reason for the visit was listed as a follow-up visit or an administrative visit or could not be coded, we used the secondary reason for the visit. We defined primary care physicians to include physicians practicing in internal medicine, pediatrics, family practice, general practice, general preventive medicine, or public health and general preventive medicine. We defined public insurance as Medicaid or Medicare and uninsured visits as those with payment listed as no charge, charity care, or self-pay. Statistical Analysis We performed all statistical tests and variance estimates by using SAS, version 9.1 (SAS Institute, Cary, North Carolina), and SAS-callable SUDAAN (Research Triangle Institute, Research Triangle Park, North Carolina) functions to appropriately weight visits and account for the complex sampling design (19). All proportions were compared by using an adjusted Wald F test that accounted for the complex sampling design. We did not include data with missing type of visit (2.6%), missing payment type (1.4%), missing reason for visit (6.3%), uncodeable reason for visit (<0.1%), or visit for administrative reason (<0.1%) in analyses involving these variables. The National Center for Health Statistics considers estimates reliable if the relative SE is less than 30% of the point estimate and considers estimates derived from fewer than 30 total visits unreliable regardless of the relative SE (13). All values reported are based on 30 or more visits, unless otherwise noted. All tests are 2-tailed, and a P value less than 0.05 was considered statistically significant. Role of the Funding Source This study was not supported by extramural funding. Results Between 1996 and 2006, 14599 physicians (67.3% of eligible physicians) participated in NAMCS. During the same period, 4363 hospitals participated in NHAMCS, representing a 94.0% overall participation rate. A total of 52709 unweighted visits were recorded by young adults between 1996 and 2006. Table 1 reports weighted characteristics of the data. Table 1. Ambulatory Care Visits by Young Adults Age 20 to 29 Years Between 1996 and 2006, by Patient Characteristic Utilization of Ambulatory Care Figure 1 shows utilization rates among different age groups of white, black, and Hispanic males and females. For males, utilization rates were highest among children and older men, and the lowest utilization rates were seen among young men. Young men had lower rates of annual utilization of ambulatory medical care per capita (1.10 [95% CI, 1.06 to 1.15] annual visits per capita) than male adolescents age 15 to 19 years (1.65 [CI, 1.60 to 1.70]) or older men age 30 to 39 years (1.73 [CI, 1.67 to 1.79]) (Appendix Table). Young men had less than half the rate of per-capita utilization than young women (1.10 [CI, 1.06 to 1.15] vs. 2.31 [CI, 2.26 to 2.35]) (Appendix Table). For both males and females, black and Hispanic individuals had lower utilization than white individuals. Figure 1. Per-capita annual ambulatory care utilization between 2000 and 2006, by age group. Appendix Table. Per-Capita Annual Ambulatory Health Care Visits by Adolescents and Adults, 2000 to 2006 Table 2 shows utilization rates for young adults with and without health insurance. Young adults with insurance had more than triple the rate of health care utilization than those without insurance. In addition, among insured and uninsured young adults, men had lower rates of utilization than women and black men had lower rates of utilization than white men. Table 2. Per-Capita Annual Ambulatory Care Visits by Young Adults Age 20 to 29 Years Between 2000 and 2006, by Insurance Status Types of Visits Figure 2 shows visits per capita for acute problems, chronic problem

Delayed Transition of Care: A National Study of Visits to Pediatricians by Young Adults

OBJECTIVE Despite numerous policy statements and an increased focus on transition of care, little is known about young adults who experience delayed transition to adult providers. METHODS We used cross-sectional data from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey between 1998 and 2008 to examine delayed transition among young adults ages 22 to 30. We defined delayed transition as continuing to visit a pediatrician after the age of 21 years. RESULTS Overall, we found that 1.3% (95% confidence interval [CI] 1.1-1.7) of visits by young adults to primary care physicians were seen by pediatricians, approximately 445,000 visits per year. We did not find a significant change in delayed transition during the past decade (β = -.01; P = .77). Among young adults, visits to pediatricians were more likely than visits to adult-focused providers to be for a chronic disease (25.7% vs 12.6%; P = .002) and more likely to be billed to public health insurance (23.5% vs 14.1%; P = .01). In adjusted models, visits by young adults to pediatric healthcare providers were more likely associated with chronic disease (adjusted relative risk [ARR] 2.2; 95% CI 1.5-3.4), with public health insurance (ARR 1.9; 95% CI 1.3-2.9), or with no health insurance (ARR 1.9; 95% CI 1.1-3.4). CONCLUSIONS Although most young adult visits were to adult providers, a considerable number of visits were to pediatricians, indicating delayed transition of care. There has been no substantial change in delayed transition during the past decade. Visits by young adults with chronic disease, public health insurance, or no health insurance were more likely to experience delayed transition of care.

Reducing the Prescribing of Heavily Marketed Medications: A Randomized Controlled Trial

ContextPrescription drug costs are a major component of health care expenditures, yet resources to support evidence-based prescribing are not widely available.ObjectiveTo evaluate the effectiveness of computerized prescribing alerts, with or without physician-led group educational sessions, to reduce the prescribing of heavily marketed hypnotic medications.DesignCluster-randomized controlled trial.SettingWe randomly allocated 14 internal medicine practice sites to receive usual care, computerized prescribing alerts alone, or alerts plus group educational sessions.MeasurementsProportion of heavily marketed hypnotics prescribed before and after the implementation of computerized alerts and educational sessions.Main ResultsThe activation of computerized alerts held the prescribing of heavily marketed hypnotic medications at pre-intervention levels in both the alert-only group (adjusted risk ratio [RR] 0.97; 95% CI 0.82–1.14) and the alert-plus-education group (RR 0.98; 95% CI 0.83–1.17) while the usual-care group experienced an increase in prescribing (RR 1.31; 95% CI 1.08–1.60). Compared to the usual-care group, the relative risk of prescribing heavily marketed medications was less in both the alert-group (Ratio of risk ratios [RRR] 0.74; 95% CI 0.57–0.96) and the alert-plus-education group (RRR 0.74; 95% CI 0.58–0.97). The prescribing of heavily marketed medications was similar in the alert-group and alert-plus-education group (RRR 1.02; 95% CI 0.80–1.29). Most clinicians reported that the alerts provided useful prescribing information (88%) and did not interfere with daily workflow (70%).ConclusionsComputerized decision support is an effective tool to reduce the prescribing of heavily marketed hypnotic medications in ambulatory care settings.Trial Registrationclinicaltrials.gov Identifier: NCT00788346.

Paediatric experiences with work-hour limitations.

OBJECTIVES To evaluate the perceived impact of work-hour limitations on paediatric residency training programmes and to determine the various strategies used to accommodate these restrictions. METHODS A three-page pre-tested survey was administered to programme directors at the 2004 Association of Paediatric Programme Directors meeting. The impact of work-hours was evaluated with Likert-type questions and the methods used to meet work-hour requirements were compared between large programmes (>or=30 residents) and small programmes. RESULTS Surveys were received from 53 programme directors. The majority responded that work-hour limitations negatively impacted inpatient continuity, time for education, schedule flexibility and attending staff satisfaction. Supervision by attending staff was the only aspect to significantly improve. Perceived resident satisfaction was neutral. To accommodate work-hour limitations, 64% of programmes increased clinical responsibility to existing non-resident staff, 36% hired more non-resident staff and 17% increased the number of residents. Only one programme hired additional non-clinical staff. Large programmes were more likely to use more total methods on the inpatient wards (P < 0.01) and in the intensive care units (P < 0.05) to accommodate work-hour limitations. CONCLUSIONS Programme directors perceived a negative impact of work-hours on most aspects of training without a perceived difference in resident satisfaction. While a variety of methods are used to accommodate work-hour limitations, programmes are not widely utilizing non-clinical staff to alleviate clerical burdens.

The Influence of Social Networks on Patients’ Attitudes Toward Type II Diabetes

Social networks are increasingly recognized as important determinants of many chronic diseases, yet little data exist regarding the influence of social networks on diabetes. We surveyed diabetic patients to determine how social networks affect their overall level of concern regarding diabetes and its complications. We adapted a previously published instrument and surveyed 240 diabetic patients at two primary care practices. Patients recorded the number of family and friends who had diabetes and rated their level of concern about diabetes on a scale of 0% (no concern) to 100% (extremely concerned). Our primary outcome variable was patients’ level of concern (<75% or ≥75%). We developed logistic regression models to determine the effect of disease burden in patients’ social networks on expressed level of concern about diabetes. We received 154 surveys (64% response rate). We found that for each additional family member with diabetes, patients expressed a greater level of concern about diabetes (AOR 1.5; 95% CI 1.2–2.0) and its potential complications (AOR 1.4; 95% CI 1.1–1.7). Similarly, patients with an increased number of friends with diabetes expressed greater concern about diabetes (AOR 1.5; 95% CI 1.2–1.9) and its complications (AOR 1.3; 95% CI 1.1–1.7). Patients with a higher prevalence of diabetes within their social networks expressed greater concern about diabetes and diabetic complications. Determining disease burden within patients’ social networks may allow physicians to better understand patients’ perspectives on their disease and ultimately help them achieve meaningful behavioral change.

Characteristics of Medicine-Pediatrics Practices: Results From the National Ambulatory Medical Care Survey

Background Combined medicine-pediatrics (med-peds) training has existed for 40 years, yet little is known about national med-peds practices. A more comprehensive understanding of med-peds practices is important to inform medical students and guide evolving curricula and accreditation standards. Method The authors used data from the National Ambulatory Medical Care Survey from 2000 to 2006 to characterize the age distribution and types of visits seen by med-peds, internal medicine, pediatric, and family physicians. Results Forty-three percent of visits to med-peds physicians were from children ≤18 years of age. Compared with family physicians, med-peds physicians saw a higher proportion of infants and toddlers ≤2 years of age (21.0% versus 3.7%; P = .002) and children ≤18 years of age (42.9% versus 15.5%; P = .002), but they treated fewer adults age 65 or older (13.8% versus 21.3%; P = .013). Compared with internists, med-peds physicians saw a greater percentage of visits from adults 19 to 64 years of age (75.8% versus 61.2%) and fewer visits from patients age 65 or older (24.2% versus 38.8%; P = .006). Med-peds physicians, like family physicians and pediatricians, most commonly treated patients for acute problems and reported high levels of continuity of care for patients—pediatric (93.6%) and adult (94.6%). Conclusions Med-peds physicians care for a considerable proportion of pediatric patients while maintaining high levels of continuity of care for adult and pediatric patients. Within their practices, med-peds physicians treat a larger percentage of pediatric patients than do family physicians, but they see a smaller percentage of elderly patients.

Effectiveness of a Multidisciplinary Intervention to Improve Hypertension Control in an Urban Underserved Practice

Patient-centered, multidisciplinary interventions offer one of the most promising strategies to improve blood pressure (BP) control, yet effectiveness trials in underserved real-world settings are limited. We used a multidisciplinary strategy to improve hypertension control in an underserved urban practice. We collected 1007 surveys to monitor medication adherence and used weighted generalized estimating equations to examine trends in BP control. We examined 13,404 visits from patients with hypertension between August 2010 and February 2014. Overall, BP control rates increased from 51.0% to 67.4% (adjusted odds ratio, 1.58; 95% confidence interval, 1.44-1.74) by the end of the intervention phase and were maintained during the postintervention phase (adjusted odds ratio, 1.60; 95% confidence interval, 1.41-1.82). Medication adherence scores increased across the intervention (5.9-6.6; P < .001), but were not sustained at the conclusion of the study (5.9-6.2; P = .16). A multidisciplinary team approach involving registered nurses, pharmacists, and physicians resulted in substantial improvements in hypertension control in a real-world underserved setting.

Patient Experience With Care and Its Association With Adherence to Hypertension Medications

BACKGROUND Medication adherence is crucial to effective chronic disease management, yet little is known about the influence of the patient-provider interaction on medication adherence to hypertensive regimens. We aimed to examine the association between the patients experience with care and medication adherence. METHODS We collected 2,128 surveys over 4 years from a convenience sample of hypertensive patients seeking care at three urban safety-net practices in upstate New York. The survey collected adherence measures using the Morisky Medication Adherence Scale (MMAS-8) and patient experience measures. We used regression models to adjust for age, gender, race/ethnicity, self-reported health status, and clustering by patients. The primary outcome was reporting of medium-to-high adherence (MMAS ≥ 6) vs. low adherence. RESULTS A total of 62.5% of respondents reported medium-to-high medication adherence. The concern the provider demonstrated for patient questions or worries (adjusted odds ratio [AOR] 1.4; 95% confidence interval [CI] 1.1-1.7), provider efforts to include the patient in decisions (AOR 1.5; 95% CI 1.8-1.9), information given (AOR 1.3; 95% CI 1.0-1.6), and the overall rating of care received (AOR 1.4; 95% CI 1.1-1.8) were associated with higher medication adherence. The amount of time the provider spent was not associated with medication adherence (AOR 1.2; 95% CI 0.9-1.4). Medium-to-high medication adherence was in turn associated with increased hypertension control rates. CONCLUSIONS Overall, better experiences with care were associated with higher adherence to hypertension regimens. However, the amount of time the provider spent with the patient was not statistically associated with medication adherence, suggesting that the quality of communication may be more important than the absolute quantity of time.

Maximizing Continuity in Continuity Clinic

The inpatient and outpatient rotations during residency impact resident clinic continuity. Even with block systems separating inpatient and outpatient duties, keeping continuity between resident providers and their clinic patients is challenging. This chapter reviews the evidence for continuity, different metrics of measuring continuity, as well as strategies to maximize continuity between residents and patients. It also examines how continuity measures may fail for account for meaningful forms of contact and continuity between patients and providers.