Journal of Primary Care & Community Health

Background: More than half of eligible individuals are not up-to-date with colon cancer screening. Purpose: To assess the characteristics of those who received a colonoscopy screening recommendation and those who followed the physician recommendation. Methods: Patient self-administered questionnaire and medical record review in 16 private family physician practices. Results: From 8372 patients invited to participate, 685 were enrolled and had a medical record review; 219 (32%) had a colonoscopy recommendation and 86 (39%) received a colonoscopy. Independent factors associated with having a recommendation for colonoscopy were significantly younger in age (odds ratios [OR] = 1.6), higher incomes (annual income ≥$40 000 vs <$40 000; OR = 1.8), physician or nurse discussion about colon cancer tests (OR = 1.6), physical visit in the preceding 26 months (OR = 1.7), distant relative with colon cancer (OR = 2.4), and a medical diagnosis of hyperlipidemia (OR = 2.1). Independent factors associated with following through on colonoscopy after a recommendation were age ≥65 years (OR = 0.3), male patient (OR = 0.4), and feeling that colon cancer screening is very important (OR = 3.2). Conclusions: Socioeconomic factors are associated with receipt of a colonoscopy recommendation. Fewer than one third of patients had documentation of a physician colonoscopy recommendation and of those, less than half followed through.

Background. The incidence of pertussis in the United States has been increasing. Adult vaccination is important to reduce disease burden and prevent transmission to infants at high risk of complications. The tetanus–diphtheria–acellular pertussis (Tdap) vaccine has been available in the United States since 2005 and is indicated as a one-time replacement for the routine tetanus–diphtheria (Td) booster. However, among adults receiving tetanus vaccination, only about half receive Tdap. Purpose. To identify predictors of adult Tdap vaccination among individuals who receive tetanus vaccine. Methods. National Health Interview Survey data from 2008 were analyzed in 2011. Respondents were 18 to 64 years old, received tetanus vaccination during 2005-2008, and were aware if it contained pertussis. Predictors of Tdap vaccination were identified with multivariate logistic regression using procedures for complex survey methods. Results. Overall, 51.1% of respondents received Tdap. Vaccination was less likely for those 50 to 64 years old compared with those 18 to 24 years old (odds ratio [OR] = 0.61, 95% confidence interval [CI] = 0.38-0.96). Some college education was associated with higher odds of vaccination compared with lower education levels (OR = 1.55, 95% CI = 1.16-2.07). Having 2 to 3 office visits (OR = 2.01, 95% CI = 1.32-3.06) or 4 to 9 office visits (OR = 1.60, 95% CI = 1.06-2.42) in the previous year increased the odds of vaccination compared with no visits. Individuals with functional limitation due to illness had lower odds compared with no limitation (OR = 0.70, 95% CI = 0.54-0.91). Conclusions. In 2008, 51.1% of adult Td vaccinations included pertussis, suggesting continued efforts to remove barriers are needed. Interventions should target older, functionally impaired, and educationally disadvantaged populations.

Background: Polypharmacy has been identified as a quality indicator, but no studies have been reported about the epidemiology of polypharmacy among hospital patients at discharge. Methods: Records of 142 family medicine patients aged ≥65 years who were discharged from the hospital during the period November 2008 to October 2009 were extracted. Forty-six of these patients were readmitted within 30 days and the remaining 96 not readmitted within 30 days. Polypharmacy was measured as >16 medications at dismissal. Independent variables related to person (use of medical care in the 12 months prior to hospitalization, number of high-risk diagnoses, and demographic characteristics), place (living situation at admission and disposition location), and time (month of admission). Chronic obstructive pulmonary disease, cancer, diabetes mellitus, congestive heart failure, and coronary artery disease were diagnoses determined to be high-risk. Results: Mean number of medications at dismissal was 13.5 and 23.2% of patients were prescribed more than 16 medications. No interactions were found between readmission status and any of the independent variables. Use of medical services in the previous year was not related to polypharmacy and no seasonal pattern was detected. Two or more high-risk diagnoses were independently related to polypharmacy (odds ratio [OR] = 4.75, confidence interval [CI] = 1.0-11.2, P = .00). Being discharged to a location with personal health services such as home care or a skilled nursing facility was also related to polypharmacy (OR = 3.07, CI = 1.3-7.2, P = .01). Conclusion: Drug reviews intended to reduce the rate of polypharmacy among discharged persons aged ≥65 years can be targeted at patients who have 2 or more high-risk diagnoses and at those discharged to receive personal health services either at home or in a convalescence facility.

Background: Despite the existence of effective screening, colorectal cancer remains the second leading cause of cancer death in the United States. Adults living in rural areas and members of minority populations both experience disparities in colorectal cancer screening. Methods: Cross-sectional prevalence study of Behavioral Risk Factor Surveillance System from the Centers for Disease Control from 1998 to 2005. Primary outcome: Predicted probability of reporting timely colorectal cancer screening. Independent variables: rural residence, race/ethnicity. We adjusted for demographic and socioeconomic characteristics of respondents. Results: After adjustment rural non-Hispanic whites (44.3%), rural African American/blacks (44.8%), urban and rural Hispanic/Latinos (43.7% and 40.8%, respectively), urban and rural American Indian/Alaska Natives (45.8% and 46.8%), and urban and rural Asians (35.4% and 39.6%) had lower compared with urban non-Hispanic whites (49.5%; P < .05% for all comparisons). Urban Asians were least likely to report use of fecal occult blood testing (8.6%, 95% confidence interval = 6.3% to 10.9%) and rural Asians were least likely to report use of endoscopy screening (21.2%, 95% confidence interval = 16.2% to 26.2%). Discussion: Rural minorities may face different barriers to colorectal cancer screening than urban minorities or rural non-Hispanic whites. Further research to develop interventions to improve screening in these populations is warranted.

Objective: Engaging individuals in their own health care proves challenging for policy makers, health plans, and providers. Florida Medicaid introduced the Enhanced Benefits Rewards (EBR) program in 2006, providing financial incentives as rewards to beneficiaries who engage in health care seeking and healthy behaviors. Methods: This study analyzed beneficiary survey data from 2009 to determine predictors associated with awareness of and participation in the EBR program. Results: Non-English speakers, those in a racial and ethnic minority group, those with less than a high school education, and those with limited or no connection to a health care provider were associated with lower awareness of the program. Among those aware of the program, these factors were also associated with reduced likelihood of engaging in the program. Individuals in fair or poor health were also less likely to engage in an approved behavior. Individuals who speak Spanish at home and those without a high school diploma were more likely than other groups to spend their earned program credits. Conclusions: Findings underscore the fact that initial engagement in such a program can prove challenging as different groups are not equally likely to be aware of or participate in an approved activity or redeem a credit. Physicians may play important roles in encouraging participation in programs to incentivize healthy behaviors.

Obesity and depression are often comorbid conditions. There appears to be a bidirectional relationship between these. Obesity at baseline has been shown to increase the risk of onset of depression and depression at baseline increased the odds for developing obesity. Less is understood about the impact of obesity on depression treatment outcomes. The authors’ hypothesis was that obesity (body mass index [BMI] ≥30 kg/m²) and morbid obesity (BMI ≥ 40 kg/m²) would each have negative effects on depression remission rates after 6 months of enrollment into collaborative care management for depression. In a retrospective analysis of 1111 depressed patients with a PHQ-9 (Patient Health Questionnaire) score of 10 or greater, multivariate analysis for the odds ratio of achieving remission at 6 months demonstrated that the patient’s BMI at baseline was not an independent risk factor for depression outcome at 6 months. Collaborative care management for depression has been shown to be effective for improving depression outcomes, yet minimal prior research has focused on other clinical comorbidities that might affect outcomes. Although obesity was common in the study population, it was reassuring, based on this study that 6-month depression treatment outcomes do not appear to be significantly affected by the patient’s baseline BMI.

This study measures waiting times and consultation times at convenient care clinics (CCCs), and compares them with equivalent times in traditional, family practice, physician offices. The analysis was limited to conditions most commonly treated at CCCs. It was found that patients using CCCs had significantly shorter waiting times from check-in to seeing a clinician than the equivalent waiting times reported by patients at family practice physicians’ offices and that CCC patients had significantly longer consultation times with the clinician than those reported by family practice patients. Applying a correction factor to adjust for potential differences between real waiting times and perceived waiting times did not substantially alter the conclusions. Shorter waiting times may increase satisfaction and thereby encourage patients to seek care; and spending additional time with the clinician may help ensure that all of a patient’s concerns or questions are addressed. This study provides objective evidence from a large database that CCCs provide prompt, satisfying care.

Introduction: Collaborative care management (CCM) for the treatment of depression has been shown to be an effective therapy. CCM can be seen as a resource intensive treatment. Early identification of patients who would not be effectively treated with CCM could allow for alteration of therapy or change in modality. Methods: A retrospective case-controlled study used 132 patients with prolonged enrollment (>1 year) in CCM (cases) and 396 randomized CCM patients who achieved remission within 6 months (controls). The hypothesis was that by studying the epidemiology of patients in prolonged care management (PCM), characteristics could be determined to help define this group. Results: With regression modeling, the odds of a patient having PCM at 1 year was highly significant for those unmarried patients (odds ratio [OR] = 1.736, confidence interval [CI] = 1.115-2.703, P = .015) with dysthymia (OR = 2.362, CI = 1.104-5.052, P = .027) and severe depression (OR = 2.856, CI = 1.551-5.260, P = .001). The adjusted baseline Patient Health Questionnaire–9 (PHQ-9) score showed a difference of 16.0 for the cases versus 14.8 for the controls (P < .001). By 10 weeks, the difference is much larger at (10.7 vs 4.9, P < .001). At 26 weeks, the control group had an adjusted average PHQ-9 score of 2.0, whereas the case group was still elevated at 10.2 (P < .001). Conclusions: Case-controlled analysis of PCM patients demonstrated independent predictors (such as unmarried status, diagnosis of dysthymia or severe depression), however, no baseline data was of sufficient clarity to suggest changes in clinical practice. The trend of the patient’s PHQ-9 over time was strongly suggestive of allowing differentiation between the groups.

Background: Access to primary care could reduce use of more costly health care by uninsured individuals through prevention and early treatment. We analyzed data from a program providing free primary care to test this hypothesis. Methods: We compared emergency room (ER) visits and hospitalizations among uninsured, low-income adults who received immediate versus delayed access to a program providing free primary care, including labs, X-rays, and specialty consultation. We used surveys to identify ER visits and hospitalizations during the 12 months preceding and following program enrollment or wait list entry. Results: Hospitalizations decreased from the year before entry to the year following entry in participants with immediate and delayed (6.0% vs 8.8% decrease) access. ER use also decreased in both groups (11.2% vs 15.4%). Conclusions: Free primary care services and specialty consultation did not reduce use of more costly health care services during its first year. More prolonged availability of primary care might have greater impact.

Background: The annual number of emergency department (ED) visits in the United States increased 23% between 1997 and 2007. The uninsured and those with chronic medical conditions are high users of emergency care. Objective: We sought to determine whether access to comprehensive outpatient primary and specialty care and care coordination provided by The Access Partnership (TAP) reduced ED utilization among uninsured patients relative to patients who chose not to enroll. Methods: Multiple time series analysis was performed to examine rates of ED utilization and inpatient admission among TAP patients and a comparison group of eligible patients who did not join (non-TAP patients). Monthly ED utilization and inpatient admission rates for both groups were examined prior to and subsequent to referral to TAP, within a study period 2007-2011. Results: During the study period, 623 patients were eligible to enroll, and 374 joined the program. Rates of ED visits per month increased in both groups. Compared with non-TAP patients, TAP patients had 2.0 fewer ED visits not leading to admission per 100 patient-months post-TAP (P = .03, 95% confidence interval = 0.2-3.9). TAP status was a moderate predictor of ED visits not leading to admission, after controlling for age, gender, and zip code (P = .04, 95% confidence interval = 0.1-3.9). Conclusions: Although overall ED utilization did not change significantly between program participants and nonparticipants, TAP patients had a lower rate of ED visits not resulting in inpatient admission relative to the comparison group.

Purpose: The purpose of this study was to compare continuity of care for family medicine patients using retail medicine clinics to continuity for patients not using retail clinics. Retail medicine clinics have become popular in some markets. However, their impact on continuity of care has not been studied. Methods: Electronic medical records of adult primary care patients seen in a large group practice in Minnesota in 2011 were analyzed for this study. Two randomly chosen groups of patients were selected (N = 400): those using 1 of 3 retail walk-in clinics staffed by nurse practitioners in addition to standard office care and a comparison group that only used standard office care. Continuity was measured as the percentage of visits that involved the primary care provider. We also compared patients who made zero visits to their primary care providers with those who made some visits to their primary care providers. Results: Continuity of care was lower for patients who used retail clinics than for patients who did not use retail clinics (0.17 vs 0.44, mean difference 0.27). The percentage of patients who made zero visits to their primary care providers was 54.5 for users of retail clinics versus 31.0 for those who did not use retail clinics. Conclusions: Continuity of care should be monitored as retail medicine continues to expand.