University of Oklahoma Health Sciences Center

C-Reactive Protein Testing to Guide Antibiotic Prescribing for COPD Exacerbations

Author/s:

Butler, Christopher C., Gillespie, David, White, Patrick, Bates, Janine, Lowe, Rachel, Thomas-Jones, Emma, Wootton, Mandy, Hood, Kerenza, Phillips, Rhiannon, Melbye, M., Llor, Carl, Cals, Jochen W.L.

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BACKGROUND

Point-of-care testing of C-reactive protein (CRP) may be a way to reduce unnecessary use of antibiotics without harming patients who have acute exacerbations of chronic obstructive pulmonary disease (COPD).

METHODS

We performed a multicenter, open-label, randomized, controlled trial involving patients with a diagnosis of COPD in their primary care clinical record who consulted a clinician at 1 of 86 general medical practices in England and Wales for an acute exacerbation of COPD. The patients were assigned to receive usual care guided by CRP point-of-care testing (CRP-guided group) or usual care alone (usual-care group). The primary outcomes were patient-reported use of antibiotics for acute exacerbations of COPD within 4 weeks after randomization (to show superiority) and COPD-related health status at 2 weeks after randomization, as measured by the Clinical COPD Questionnaire, a 10-item scale with scores ranging from 0 (very good COPD health status) to 6 (extremely poor COPD health status) (to show noninferiority).

RESULTS

A total of 653 patients underwent randomization. Fewer patients in the CRP-guided group reported antibiotic use than in the usual-care group (57.0% vs. 77.4%; adjusted odds ratio, 0.31; 95% confidence interval [CI], 0.20 to 0.47). The adjusted mean difference in the total score on the Clinical COPD Questionnaire at 2 weeks was −0.19 points (two-sided 90% CI, −0.33 to −0.05) in favor of the CRP-guided group. The antibiotic prescribing decisions made by clinicians at the initial consultation were ascertained for all but 1 patient, and antibiotic prescriptions issued over the first 4 weeks of follow-up were ascertained for 96.9% of the patients. A lower percentage of patients in the CRP-guided group than in the usual-care group received an antibiotic prescription at the initial consultation (47.7% vs. 69.7%, for a difference of 22.0 percentage points; adjusted odds ratio, 0.31; 95% CI, 0.21 to 0.45) and during the first 4 weeks of follow-up (59.1% vs. 79.7%, for a difference of 20.6 percentage points; adjusted odds ratio, 0.30; 95% CI, 0.20 to 0.46). Two patients in the usual-care group died within 4 weeks after randomization from causes considered by the investigators to be unrelated to trial participation.

CONCLUSIONS

CRP-guided prescribing of antibiotics for exacerbations of COPD in primary care clinics resulted in a lower percentage of patients who reported antibiotic use and who received antibiotic prescriptions from clinicians, with no evidence of harm. (Funded by the National Institute for Health Research Health Technology Assessment Program; PACE Current Controlled Trials number, ISRCTN24346473.)

Keywords

C-reactive protein primary care chronic obstructive pulmonary disease copd CRP randomized control trial antibiotics

Chronic Constipation

Author/s:

Bharucha, Adil E., Wald, Arnold

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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

Press Conference: New Value-Based Approach to Primary Care

Author/s:

Azar, Alex, Verma, Seema, Boehler, Adam

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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.

Keywords

conference primary care

Gen-Equip: Genetics Education for Primary Care

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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

Obesity Treatment, Beyond the Guidelines: Practical Suggestions for Clinical Practice

Author/s:

Kahan, Scott, Manson, JoAnn E.

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No abstract available.

Keywords

obesity primary care overweight weight loss

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

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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

Patient Education Resources at FamilyDoctor.org

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Familydoctor.org is the AAFP’s award-winning consumer website, featuring physician-reviewed patient education materials.

Keywords

patient education health literacy health resources primary care

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

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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

primary care

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