Join HHS Secretary Alex Azar, Centers for Medicare and Medicaid Services Administrator Seema Verma, and Center for Medicare and Medicaid Innovation Director Adam Boehler for a press conference on a new value-based approach to primary care.
Context
The purpose of this systematic literature review was to summarize current evidence from RCTs for the efficacy of interventions involving pediatric health care to prevent poor outcomes associated with adverse childhood experiences measured in childhood (C-ACEs).
Evidence acquisition
On January 18, 2018, investigators searched PubMed, PsycInfo, SocIndex, Web of Science, Cochrane, and reference lists for English language RCTs involving pediatric health care and published between January 1, 1990, and December 31, 2017. Studies were included if they were (1) an RCT, (2) on a pediatric population, and (3) recruited or screened based on exposure to C-ACEs. Investigators extracted data about the study sample and recruitment strategy, C-ACEs, intervention and control conditions, intermediate and child outcomes, and significant associations reported.
Evidence synthesis
A total of 22 articles describing results of 20 RCTs were included. Parent mental illness/depression was the most common C-ACE measured, followed by parent alcohol or drug abuse, and domestic violence. Most interventions combined parenting education, social service referrals, and social support for families of children aged 0–5years. Five of six studies that directly involved pediatric primary care practices improved outcomes, including three trials that involved screening for C-ACEs. Eight of 15 studies that measured child health outcomes, and 15 of 17 studies that assessed the parent–child relationship, demonstrated improvement.
Conclusions
Multicomponent interventions that utilize professionals to provide parenting education, mental health counseling, social service referrals, or social support can reduce the impact of C-ACEs on child behavioral/mental health problems and improve the parent–child relationship for children aged 0–5years.
Our experiences studying exemplar primary care practices, and our work assisting other practices to become more patient centered, led to a formulation of the essential elements of primary care, which we call the 10 building blocks of high-performing primary care. The building blocks include 4 foundational elements-engaged leadership, data-driven improvement, empanelment, and team-based care-that assist the implementation of the other 6 building blocks-patient-team partnership, population management, continuity of care, prompt access to care, comprehensiveness and care coordination, and a template of the future. The building blocks, which represent a synthesis of the innovative thinking that is transforming primary care in the United States, are both a description of existing high-performing practices and a model for improvement.
No abstract available.
About us
The partners in this project currently work in six different European countries. We have partners with expertise in primary care practice, genetics and adult education, as well as a patient support organisation. The project was originally designed by Professor Heather Skirton, who has a background in nursing, midwifery and genetic counselling, and Dr Isa Houwink, a GP from the Netherlands.
Oklahoma ranked 5th nationally in rates of opioid prescribing in 2016, with 97.9 opioid prescriptions per 100 people. Opioids account for the majority of prescription drug-related overdose deaths. Despite recent declines, deaths from opioids remain common.
Objectives
To estimate associations between long‐term use of proton pump inhibitors (PPIs) and pneumonia incidence in older adults in primary care.
Design
Longitudinal analyses of electronic medical records.
Setting
England
Participants
Individuals aged 60 and older in primary care receiving PPIs for 1 year or longer (N=75,050) and age‐ and sex‐matched controls (N=75,050).
Measurements
Net hazard ratios for pneumonia incidence in Year 2 of treatment were estimated using the prior event rate ratio (PERR), which adjusts for pneumonia incidence differences before initiation of treatment. Inverse probability weighted models adjusted for 78 demographic, disease, medication, and healthcare usage measures.
Results
During the second year after initiating treatment, PPIs were associated with greater hazard of incident pneumonia (PERR‐adjusted hazard ratio=1.82, 95% confidence interval=1.27–2.54), accounting for pretreatment pneumonia rates. Estimates were similar across age and comorbidity subgroups. Similar results were also obtained from propensity score– and inverse probability–weighted models.
Conclusion
In a large cohort of older adults in primary care, PPI prescription was associated with greater risk of pneumonia in the second year of treatment. Results were robust across alternative analysis approaches. Controversies about the validity of reported short‐term harms of PPIs should not divert attention from potential long‐term effects of PPI prescriptions on older adults.
OBJECTIVE:
Project TrEAT (Trial for Early Alcohol Treatment) was designed to test the efficacy of brief physician advice in reducing alcohol use and health care utilization in problem drinkers.
DESIGN:
Randomized controlled clinical trial with 12-month follow-up.
SETTING:
A total of 17 community-based primary care practices (64 physicians) located in 10 Wisconsin counties.
PARTICIPANTS:
Of the 17695 patients screened for problem drinking, 482 men and 292 women met inclusion criteria and were randomized into a control (n=382) or an experimental (n=392) group. A total of 723 subjects (93%) participated in the 12-month follow-up procedures.
INTERVENTION:
The intervention consisted of two 10- to 15-minute counseling visits delivered by physicians using a scripted workbook that included advice, education, and contracting information.
MAIN OUTCOME MEASURES:
Alcohol use measures, emergency department visits, and hospital days.
RESULTS:
There were no significant differences between groups at baseline on alcohol use, age, socioeconomic status, smoking status, rates of depression or anxiety, frequency of conduct disorders, lifetime drug use, or health care utilization. At the time of the 12-month follow-up, there were significant reductions in 7-day alcohol use (mean number of drinks in previous 7 days decreased from 19.1 at baseline to 11.5 at 12 months for the experimental group vs 18.9 at baseline to 15.5 at 12 months for controls; t=4.33; P<.001), episodes of binge drinking (mean number of binge drinking episodes during previous 30 days decreased from 5.7 at baseline to 3.1 at 12 months for the experimental group vs 5.3 at baseline to 4.2 at 12 months for controls; t=2.81; P<.001), and frequency of excessive drinking (percentage drinking excessively in previous 7 days decreased from 47.5% at baseline to 17.8% at 12 months for the experimental group vs 48.1% at baseline to 32.5% at 12 months for controls; t=4.53; P<.001). The chi2 test of independence revealed a significant relationship between group status and length of hospitalization over the study period for men (P<.01).
CONCLUSIONS:
This study provides the first direct evidence that physician intervention with problem drinkers decreases alcohol use and health resource utilization in the US health care system.
BACKGROUND:
The objective of this study was to determine the effects of a brief primary care provider-delivered counseling intervention on the reduction of alcohol consumption by high-risk drinkers. The intervention was implemented as part of routine primary care medical practice.
METHODS:
We performed a controlled clinical trial with 6- and 12-month follow-up. Three primary care practices affiliated with an academic medical center were randomly assigned to special intervention (SI) or usual care (UC). A total of 9,772 primary care patients were screened for high-risk drinking. A fourth site was added later. From the group that was screened, 530 high-risk drinkers entered into the study, with 447 providing follow-up at 12 months. The intervention consisted of brief (5-10 minute) patient-centered counseling plus an office system that cued providers to intervene and provided patient educational materials.
RESULTS:
At 12-month follow-up, after controlling for baseline differences in alcohol consumption, SI participants had significantly larger changes (P=.03) in weekly alcohol intake compared to UC (SI=-5.7 drinks per week; UC=-3.1 drinks per week), and of those who changed to safe drinking at 6 months more SI participants maintained that change at 12 months than UC.
CONCLUSIONS:
Project Health provides evidence that screening and very brief (5-10 minute) advice and counseling delivered by a patient's personal physician or nurse practitioner as a routine part of a primary care visit can reduce alcohol consumption by high-risk drinkers.
BACKGROUND:
The U.S. Preventive Services Task Force (USPSTF) has recommended screening and behavioral counseling interventions in primary care to reduce alcohol misuse. This study was designed to develop a standardized rating for the clinically preventable burden and cost effectiveness of complying with that recommendation that would allow comparisons across many recommended services.
METHODS:
A systematic review of the literature from 1992 through 2004 to identify relevant randomized controlled trials and cost-effectiveness studies was completed in 2005. Clinically preventable burden (CPB) was calculated as the product of effectiveness times the alcohol-attributable fraction of both mortality and morbidity (measured in quality-adjusted life years or QALYs), for all relevant conditions. Cost effectiveness from both the societal perspective and the health-system perspective was estimated. These analyses were completed in 2006.
RESULTS:
The calculated CPB was 176,000 QALYs saved over the lifetime of a birth cohort of 4,000,000, with a range in sensitivity analysis from -43% to +94% (primarily due to variation in estimates of effectiveness). Screening and brief counseling was cost-saving from the societal perspective and had a cost-effectiveness ratio of $1755/QALY saved from the health-system perspective. Sensitivity analysis indicates that from both perspectives the service is very cost effective and may be cost saving.
CONCLUSIONS:
These results make alcohol screening and counseling one of the highest-ranking preventive services among the 25 effective services evaluated using standardized methods. Since current levels of delivery are the lowest of comparably ranked services, this service deserves special attention by clinicians and care delivery systems.
