Patient-centered medical home and integrated care in the United States: An opportunity to maximize delivery of primary care

The reciprocal relationship between mental and physical health is well established.Undiagnosed,untreated,and poorly managed mental health conditions are associated with numerous physical health complications,poor treatment adherence,and decreased quality of life.Despite growing evidence regarding the importance of effectively addressing these conditions in primary care,the rates of identification remain low and follow-up and management by primary care providers has been criticized.The objective of this review was to demonstrate the role of Patient-Centered Medical Home(PCMH)and mental health integration in addressing comprehensive health care needs in primary care patients,and to describe common barriers and facilitators to the implementation of these types of programs.

Exploring point-of-care transformation in diabetic care:A quality improvement approach

Objective:This quality improvement project evaluated the impact of a point-of-care(POC)HbA1c stat lab intervention and a nurse-assisted expanded visit implemented among patients with uncontrolled type 2 diabetes(T2D)at a community health center in Houston,TX.Methods:This was a before-and-after POC intervention among adult patients who received primary care services between 1 July 2014 and 31 December 2014(baseline visit)and who had at least one 3-month follow-up visit.Results:Three hundred eighty-seven patients were included in the study.The majority were<60 years of age(72.1%),female(60.5%),and Hispanic(63%),followed by black(16.5%)and Asian(11.1%).Almost 87%of the patients had uncontrolled T2D(HbA1c>9%)at baseline,with the highest average levels among Hispanic(10.9%)and black(10.7%)patients.There was a significant difference in the HbA1c level before(mean=10.65,SD=1.9291)and after(mean=9.25,SD=1.8187)intervention.The absolute reduction in the level of HbA1c was 1.4%(t=12.834,p<0.001),corresponding to a 13%overall percentage decrease from baseline.Conclusion:There is a distinct advantage in using a stat HbA1c lab when combined with shared POC visits to assist patients with uncontrolled T2D in lowering the HbA1c,improving self-management,and reducing long-term costs.

Socioeconomic, environmental, and geographic factors and US lung cancer mortality, 1999-2009

Background:The American Cancer Society estimates that about 25%of all US cancer deaths will be due to lung cancer-more than from cancers of the colon,breast,and prostate combined.Methods:We ascertained county-level age-adjusted and age-specific death rates and 95%confidence intervals from the Centers for Disease Control and Prevention Compressed Mortality File.Multiple regression analyses were used to estimate the strength and direction of relationships between county poverty,smoking,fine particulate matter(PM2.5)air pollution,and US Census divisions and race-and sex-specific lung cancer deaths.Results:Poverty,smoking,and particulate matter air pollution were positively and signifi-cantly related to lung cancer deaths among white men,but of these,only poverty and smoking were significantly associated with lung cancer deaths among white women.Residence in the South Atlantic,East South Central,and West South Central US Census divisions at the time of death was significantly associated with lung cancer deaths for both white men and white women.As with white men,poverty and smoking were associated with lung cancer deaths among black men,but of these,only adult smoking had a statistically significant association among black women.Conclusions:The results support the need for further research,particularly in high-risk areas,to better differentiate factors specific to race and sex and to understand the impact of local risk factors.

Temporal trends in colorectal cancer incidence among Asian American populations in the United States, 1994-2013

Objective:To investigate the incidence and trends in colorectal cancer(CRC)among Asian American populations in the United States.Methods:CRC incidence data from 1994 through 2013 were obtained from 13 Surveillance,Epidemiology,and End Results registries.SEER*Stat and IBM SPSS Statistics were used.Results:The age-adjusted incidence of CRC among Asian Americans decreased from 45.6 per 100,000 in 1994 to 33.0 per 100,000 in 2013,with the annual percent change being−1.8%(P<0.05).The incidences were higher for men,the elderly(aged 60 years or older),and several geographic areas.For those younger than 70 years,the rectal site was more affected compared with those aged 70 years or older,in whom the proximal site were more affected.Most patients presented with localized and regional stages.Men,80 years or older,in situ stage,and some geo-graphic areas such as Connecticut and California experienced significant incidence decreases in the 20-year observation period.Conclusion:Although CRC incidence has declined among Asian American populations in the United States in the past 2 decades,there are persistent differences by age and geographic areas.Further research is needed to guide the design and implementation of tailored strategies to reduce CRC outcome differences across Asian American populations.

Adult immunization improvement in an underserved family medicine practice

Objective:Vaccines prevent many cases of infectious disease,yet immunization campaigns are hindered by various barriers.This work presents the results of a quality improvement project addressing barriers to vaccine compliance in an underserved teaching practice by reducing missed opportunities and increasing provider and patient compliance rates for pneumococcal,Tdap,influenza,and zoster vaccines in adults.Methods:The study intervention aimed to address patient knowledge,provider knowledge and skills,proactive care coordination,and outreach and counselling of high-risk groups.Aggre-gate patient data from intervention at year-end were compared to the prior year.Outcome targets were as follows:improved vaccination rates by one-half of the difference between baseline and Healthy People 2020 goals;reduced patient refusals by 10%;and reduced missed opportunities by 50%.Results:All of the vaccination rates improved,but with mixed results regarding the target outcomes.The rates of vaccine refusal were mixed in terms of the direction of the change,the significance,and achieving targets.Missed opportunities all improved,but the significance was mixed and none reached targets.Conclusion:This project has helped to identify patient and provider knowledge of vacci-nation as a key to increasing compliance,and missed opportunities as the greatest challenge in achieving targets.The burden of documentation is significant on providers,and future work should focus on methods to improve the ease of documentation.Clinical outcomes and improvements were encouraging;however,it is clear that there remain challenges to reaching Healthy People 2020 goals within the study population and nationally.

Unplanned hospitalizations for metastatic cancers:The changing patterns of inpatient palliative care,discharge to hospice care,and in-hospital mortality in the United States

Objective:To describe the rates and temporal trends of inpatient end-of-life care among patients hospitalized with metastatic cancer in the United States.Methods:We used data from the Nationwide Inpatient Sample to conduct a cross-sectional analysis of unplanned inpatient hospitalizations of patients aged 18 years or older with metastatic cancer from 2002 to 2011.Multivariable logistic regression was used to assess patient-and hospital-level predictors of discharge to hospice care,palliative care,and in-hospital mortality.Temporal trends in outcomes were characterized with use of joinpoint regression.Results:There were an estimated 350,241 unplanned hospitalizations per year of patients with a diagnosis of metastatic cancer.During their inpatient stay,5.8%of patients received palliative care,and among those discharged alive,12.2%were referred to hospice care.The rate of inpatient palliative care increased from 2.3%to 13.6%,the rate of discharge to hospice care increased from 4.1%to 15.6%,and the in-hospital mortality rate decreased from more than 14.0%to 9.8%.These patterns were consistent across cancer subtypes,and were most pronounced among patients with extreme risk of mortality.Conclusion:Despite increases in the provision of comfort-oriented care to patients with meta-static cancer,few receive such services.We recommend screening protocols in hospitals to identify patients who are good candidates for palliative care consultation and hospice referral.

Modified Advanced Life Support in Obstetrics course: Feasibility, trainee satisfaction, and sustainability potential

Objective:The main objective of this initiative was to present evaluation results from an inno-vative adaptation of the Advanced Life Support in Obstetrics(ALSO)training course.We modified the traditional ALSO curriculum in our institution by adding hands-on training in laceration repairs and simulation scenarios on acute maternity care.Methods:The modified ALSO provider course was designed to enhance cognitive and proce-dural skills of health care professionals in managing obstetric emergencies.Forty-nine participants attended this course and completed a posttraining survey.Descriptive statistics were used to de-scribe the participant-reported assessment scores for the ALSO course on three domains(subject knowledge,organization and clarity,and teaching effectiveness)for each of 12 course topics.Results:Evaluation of the results showed a high rate of trainee satisfaction as evidenced by the mean assessment scores across all topics ranging from 4.80 to 4.98(out of 5.00).All trainees said they would refer others to the course.Our modified ALSO course effectively addressed the important needs of primary care physicians involved in maternity care,especially in underserved communities where specialized obstetric care is not readily available.Both simulation scenarios and workshops using simulated human tissue provide a better foundation before formal training.Conclusion:Given the changing legal and regulatory climate,we expect that learning to treat complex obstetric situations on the job will become increasingly risky.With this in mind,both simulation scenarios and workshops using simulated human tissue will provide a better foundation before formal training.

Self-reported preferences for patient and provider roles in cancer treatment decision-making in the United States

Objective:To describe differences in preferred roles in cancer treatment decision-making and identify associated sociodemographic and health-related factors among adults in the United States.Methods:We conducted a cross-sectional analysis of nationally representative data from the 2014 Health Information National Trends Survey.Descriptive statistics were calculated and multi-variable logistic regression was conducted to examine associations.Results:Half(48.3%)of respondents preferred a collaborative role in decision-making under the supposition of a moderate chance of survival;while 53.4%preferred a more active role when the chance of survival was low.Approximately 7%-8%indicated a preference for a passive role in decision-making,for both low and moderate chances of survival.Several predictors of role prefer-ence for cancer treatment decision-making emerged,including age,sex,education,race/ethnicity,and having a regular health care provider.At both low and moderate chances of survival,the col-lege educated were less likely to prefer a passive role,whereas Hispanics were two to three times more likely than whites to indicate a preference for a passive role.Conclusion:Adults’role preference for cancer treatment decision-making may be influenced by sociodemographic and health-related factors.Increased awareness of these factors,paired with enhanced patient-provider communication,may assist health care professionals in providing indi-vidualized and high-quality,patient-centered cancer care.

The global burden of preventable cancer mortality

I am pleased to present this special issue of Family Medicine and Community Health,entitled“The Global Burden of Preventable Cancer Mortality.”This issue was completed in collaboration with the Baylor College of Medicine(BCM)Department of Family and Community Medicine in Houston,Texas,USA.The mission of the department is to enhance population health and advance the primary care discipline through rigorous and evidence-based prevention and research.We focus our research efforts on a broad range of research areas including,but not limited to,cancer con-trol,nutrition and health,medical education,and health disparities.