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Chronic Constipation

Author/s: 
Bharucha, Adil E., Wald, Arnold

Constipation is a common symptom that may be primary (idiopathic or functional) or associated with a number of disorders or medications. Although most constipation is self-managed by patients, 22% seek health care, mostly to primary care physicians (>50%) and gastroenterologists (14%), resulting in large expenditures for diagnostic testing and treatments. There is strong evidence that stimulant and osmotic laxatives, intestinal secretagogues, and peripherally restricted μ-opiate antagonists are effective and safe; the lattermost drugs are a major advance for managing opioid-induced constipation. Constipation that is refractory to available laxatives should be evaluated for defecatory disorders and slow-transit constipation using studies of anorectal function and colonic transit. Defecatory disorders are often responsive to biofeedback therapies, whereas slow-transit constipation may require surgical intervention in selected patients. Both efficacy and cost should guide the choice of treatment for functional constipation and opiate-induced constipation. Currently, no studies have compared inexpensive laxatives with newer drugs that work by other mechanisms.

Keywords 
chronic constipation primary care

Gen-Equip: Genetics Education for Primary Care

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.

Keywords 
genetics primary care education of patients health literacy

Proton‐Pump Inhibitors and Long‐Term Risk of Community‐Acquired Pneumonia in Older Adults

Author/s: 
Zirk-Sadowski, Jan, Masoli, Jane A., Delgada, Joao, Hamilton, Willie, Strain, W. David, Henley, William, Melzer, David, Ble, Alessandro

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.

Keywords 
pneumonia primary care proton pump inhibitors

Partnering to Catalyze Comprehensive Community Wellness

Author/s: 
Gerd, Dilley, Abby, Katie, Hines, Mason, Heise, Georgia, Im, Ji, Kaiman, Sherry, Levi, Jeffrey, Moerhle, Carole, Pierce-Wrobel, Clare, Schoof, Bellinda, Wiesman, John, Fraser, Michael

The Public Health Leadership Forum (PHLF) at RESOLVE teamed with the Health Care Transformation Task Force (HCTTF) to develop a framework that supports enhanced collaboration between health care and public health entities. Join a webinar on November 27th at 1pm CST to learn more about essential elements of the framework: Partnering to Catalyze Comprehensive Community Wellness: An Actionable Framework for Health Care and Public Health Collaboration. Register here

Keywords 
public health primary care collaboration

Start-Up and Ongoing Practice Expenses of Behavioral Health and Primary Care Integration Interventions in the Advancing Care Together (ACT) Program

Author/s: 
Wallace, Neal T., Cohen, Deborah J., Gunn, Rose, Beck, Arne, Melek, Steve, Bechtold, Donald, Green, Larry A.

PURPOSE:

Provide credible estimates of the start-up and ongoing effort and incremental practice expenses for the Advancing Care Together (ACT) behavioral health and primary care integration interventions.

METHODS:

Expenditure data were collected from 10 practice intervention sites using an instrument with a standardized general format that could accommodate the unique elements of each intervention.

RESULTS:

Average start-up effort expenses were $44,076 and monthly ongoing effort expenses per patient were $40.39. Incremental expenses averaged $20,788 for start-up and $4.58 per patient for monthly ongoing activities. Variations in expenditures across practices reflect the differences in intervention specifics and organizational settings. Differences in effort to incremental expenditures reflect the extensive use of existing resources in implementing the interventions.

CONCLUSIONS:

ACT program incremental expenses suggest that widespread adoption would likely have a relatively modest effect on overall health systems expenditures. Practice effort expenses are not trivial and may pose barriers to adoption. Payers and purchasers interested in attaining widespread adoption of integrated care must consider external support to practices that accounts for both incremental and effort expense levels. Existing knowledge transfer mechanisms should be employed to minimize developmental start-up expenses and payment reform focused toward value-based, Triple Aim-oriented reimbursement and purchasing mechanisms are likely needed.

Keywords 
delivery of health care integrated primary care primary health care behavioral medicine

Clinician Staffing, Scheduling, and Engagement Strategies Among Primary Care Practices Delivering Integrated Care

Author/s: 
Davis, Melinda M., Balasubramanian, Bijal A., Cifuentes, Maribel, Hall, Jennifer, Gunn, Rose, Fernald, Douglas, Gilchrist, Emma, Miller, Benjamin F., DeGruy, Frank, III

PURPOSE:

To examine the interrelationship among behavioral health clinician (BHC) staffing, scheduling, and a primary care practice's approach to delivering integrated care.

METHODS:

Observational cross-case comparative analysis of 17 primary care practices in the United States focused on implementation of integrated care. Practices varied in size, ownership, geographic location, and integrated care experience. A multidisciplinary team analyzed documents, practice surveys, field notes from observation visits, implementation diaries, and semistructured interviews using a grounded theory approach.

RESULTS:

Across the 17 practices, staffing ratios ranged from 1 BHC covering 0.3 to 36.5 primary care clinicians (PCCs). BHC scheduling varied from 50-minute prescheduled appointments to open, flexible schedules slotted in 15-minute increments. However, staffing and scheduling patterns generally clustered in 2 ways and enabled BHCs to be engaged by referral or warm handoff. Five practices predominantly used warm handoffs to engage BHCs and had higher BHC-to-PCC staffing ratios; multiple BHCs on staff; and shorter, more flexible BHC appointment schedules. Staffing and scheduling structures that enabled warm handoffs supported BHC engagement with patients concurrent with the identification of behavioral health needs. Twelve practices primarily used referrals to engage BHCs and had lower BHC-to-PCC staffing ratios and BHC schedules prefilled with visits. This enabled some BHCs to bill for services, but also made them less accessible to PCCs in when patients presented with behavioral health needs during a clinical encounter. Three of these practices were experimenting with open scheduling and briefer BHC visits to enable real-time access while managing resources.

CONCLUSION:

Practices' approaches to PCC-BHC staffing, scheduling, and delivery of integrated care mutually influenced each other and were shaped by the local context. Practice leaders, educators, clinicians, funders, researchers, and policy makers must consider these factors as they seek to optimize integrated systems of care.

Keywords 
integrated behavioral medicine delivery of health care primary health care primary care

Approaches to Behavioral Health Integration at High Performing Primary Care Practices

Author/s: 
Blasi, Paula R., Cromp, DeAnn, McDonald, Sarah, Hsu, Clarissa, Coleman, Katie, Flinter, Margaret, Wagner, Edward H.

INTRODUCTION:

Behavioral health (BH) integration has been proposed as an important strategy to help primary care practices meet the needs of their patient population, but there is little research on the ways in which practices are integrating BH services. This article describes the goals for BH integration at 30 high-performing primary care practices and strategies to operationalize these goals.

METHODS:

We conducted a qualitative analysis of BH integration at 30 US primary care practices that had been selected for the Learning from Effective Ambulatory Practices (LEAP) project following an interview-based assessment and rating process. Data collection included formal and informal interviews with practice leaders and staff, as well as observations of clinical encounters. We used a template analysis approach to thematically analyze data.

RESULTS:

Most LEAP practices looked to BH integration to help them provide timely BH care for all patients, share the work of providing BH-related care, meet the full spectrum of patient needs, and improve the capacity and functioning of care teams. Practices operationalized these goals in various ways, including universal BH screening and involving BH specialists in chronic illness care. As they worked toward their BH integration goals, LEAP practices faced common challenges related to staffing, health information technology, funding, and community resources.

DISCUSSION:

High-performing primary care practices share common goals for BH integration, as well as common challenges operationalizing these goals. As US residents increasingly receive BH services in primary care, it is critical to remove barriers to BH integration and support primary care practices in meeting a full spectrum of patient needs.

Keywords 
behavioral medicine primary care
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