Browsing by Subject "Primary care"

Now showing 1 - 7 of 7

Determining predictors of response to ambulatory pharmacist-led diabetes care
(2020-05-08) Palka, Samuel James; Reveles, Kelly Renee; Davidson, DeWayne A; Koeller, Jim
Purpose: There is a lack of guidance in referring patients to the clinical pharmacist for diabetes management, which likely results in patients missing out on this beneficial service. It would be useful to know which patients and specific clinical interventions are most likely to show benefit from pharmacy services. To our knowledge, only one study has assessed patient predictors of response to diabetes care provided by a clinical pharmacist, which was limited to baseline variables. Therefore, the primary objective was to describe clinical responses to pharmacist-led diabetes care and to identify baseline and interventional variables that are independently predictive of clinical response. Methods: This was a retrospective cohort study using patient data from two health systems in San Antonio, Texas. Included patients were ≥18 years old with a referral to the pharmacist for Type 2 Diabetes management. Patients were followed for up to 6 months and data were collected at baseline, during follow-up, and at the end of the study. Clinical response was defined as a reduction in the A1C from baseline by ≥1% or meeting the documented A1C goal. Non-responders failed to meet these A1C goals. Variables with P<0.20 on bivariate analysis were included in the multiple variable logistic regression model to determine predictors of response. Results: A total of 180 patients were included. Overall, patients were predominantly female (63%) and obese (58%) with a disease duration ≥10 years (67%). The median (IQR) change in A1C from baseline for responders and non-responders was -2.2% (-3.7 to 1.3) and 0.4% (-0.4 to 1.05) (P<0.001), respectively. Sixty-six percent of patients were considered responders. Significant predictors of response included baseline A1C (OR 1.41; 95% CI 1.08-1.85), number of completed visits with both the physician (OR 0.69; 95% CI 0.49-0.96) and the pharmacist (OR 1.65; 95% CI 1.03-2.64), and medication optimization (OR 10.7; 95% CI 1.04-109.9). Conclusion: Pharmacists are effective in diabetes management. Specifically, more visits with the pharmacist and utilizing medication optimization are especially helpful in lowering the A1C. Higher baseline A1C values are also predictive of response and should be incorporated into new protocols for pharmacist management of diabetes.
Evaluation of a collaborative care model of mental healthcare for low-SES Latinx children and adolescents
(2021-05-05) George-Jones, Julia Lauren; Rodríguez, Erin M.
Integrated behavioral health (IBH) is a promising approach to improving access to mental healthcare. Low-SES Latinx and Black youth face various barriers when accessing mental healthcare, and current IBH research focuses more on patients with a single mental health condition as opposed to multiple conditions. The proposed study seeks to evaluate a collaborative care IBH model for primarily low-SES Latinx children at a clinic. Medical record data will be analyzed quantitatively to understand how Spanish-speaking families, patients with complex mental health concerns, and patients with chronic physical health conditions benefit from IBH, using regressions. A subset of parents and children will also be interviewed qualitatively to explore patient perspectives on receiving treatment through IBH.
Promoting positive parenting for families in pediatric primary care : program development and a pilot randomized controlled trial
(2020-09-03) Bailin, Abby Pauline; Bearman, Sarah Kate; Calzada, Esther; Carlson, Cindy I; Mackert, Michael S; Rodriguez, Erin M
Positive parenting practices protect children and families from a host of adverse outcomes, but evidence-based interventions that support these practices are often unavailable to families in need. The current study sought to target barriers to access and reach of evidence-based parenting interventions using innovative approaches. This study utilized an embedded experimental mixed methods design to support the development of an intervention informed by the preferences and feedback of end-users to enhance its cultural and ecological fit. The resulting preventive e-health intervention on positive parenting, titled Parenting A to Z (PAZ) was tested in a pilot randomized controlled trial (N = 60) during well-child visits in pediatric primary care. Results indicated the feasibility and acceptability of the intervention, its delivery format, and electronic follow up procedures. There were no significant differences between the PAZ condition and the control condition related to the growth of child disruptive behavior, parental stress, parental self-efficacy, knowledge of effective parenting practices, and parenting practices over time. However, the effect size of the intervention on parental stress (d = .11) was commensurate with other evidence-based preventive interventions. These findings suggest the potential to attenuate parenting stress with a very brief, self-directed, electronic parenting intervention within the scope of a well-child visit. The current study outlines the feasibility, acceptability, and impact of a brief-single-session, self-administered preventive intervention and its potential to reduce risk in a population unlikely to access traditional mental health services.
Texas primary care and the Affordable Care Act : implications for the primary care physician workforce
(2012-05) Lavelle, Tanya Josée Holland; Angel, Jacqueline Lowe; Warner, David C.
Primary care physicians are the first point of contact for patients entering the formal health care system. A shortage of primary care physicians in the United States has left approximately 60 million people without adequate access to a physician, resulting in lowered health care outcomes and excess stress on the health care safety net. Texas has one of the most severe shortages of primary care physicians with more than 5.7 million people living in rural and urban areas considered to be underserved. The state’s rapid population growth, as well as the wide geographic distribution of its residents, makes it particularly vulnerable to health care disparities. Although there is a decisive need, factors like high medical school debt and low anticipated salaries are leading more students to specialize instead of pursue a primary care career. A variety of solutions have been proposed to address this problem including: rethinking the physician reimbursement structure; expanding graduate medical education opportunities for primary care students; and incentivizing primary care with loan repayment. In 2014, the new insurance exchanges created by the Patient Protection and Affordable Care Act will begin operating, giving millions more Texans access to health insurance. The current Texas primary care physician workforce shortage will be exacerbated once the major components of the Patient Protection and Affordable Care Act are fully enacted; therefore, state policymakers must take steps to increase Texas’ primary care physician workforce by making primary care a more attractive and accessible career path for medical students.
The effectiveness of empirically supported brief interventions for depressive and/or anxiety disorders for primary care patients : a systematic review and meta-analysis
(2018-05) Zhang, Anao; Franklin, Cynthia; Beretvas, Natasha; Choi, Namkee G.; DiNitto, Diana M.
Depressive and anxiety disorders (DADs) are highly prevalent in U.S. primary care systems. Consequences of DADs for primary care patients are real and substantial. While there exist many empirically supported interventions for DADs, only a few them have been adopted for a primary care population. To date, limited investigation has focused on the effectiveness of these empirically supported interventions for DADs when delivered in primary care settings. This dissertation aims to evaluate the effectiveness of empirically supported brief interventions for DADs for primary care patients. Using a systematic review and meta-analysis approach, this dissertation searches across seven electronic databases, six professional websites, peer-reviewed journal articles’ reference list, and contact field experts for a pool of articles for meta-analysis. An initial pool of 1,140 articles are identified, after title/abstract screening and full-text review, a final sample of 65 articles are included for final summary and data analysis. Publication bias, risk of bias, and study quality rating are conducted in accordance with the Cochrane guidelines. In addition to descriptive statistics of individual studies, an overall treatment effect, assuming a random-effect model, and moderator analysis, assuming a mixed-effect model, are performed using Robust Variance Estimation in Meta-regression. Meta-analytic results indicate an overall statistically significant treatment effect of included interventions for primary care patients’ DADs. Single-predictor moderator analyses find percentage of married participants, treatment modality (individual versus group), and treatment composition (one versus combined approach) significantly moderates treatment effect size estimate. Multiple-predictor moderator analysis finds that, after controlling for other treatment characteristics, interventions delivered outside primary care settings reported significantly higher treatment effect than those delivered inside primary care settings. Discussions on these results and implications for social work practice, research, education and policy are presented
Understanding how change occurs for women of childbearing age : the role of depression and marijuana use on reducing alcohol consumption
(2018-05) Lee, Sharon Narae; Velasquez, Mary Marden; von Sternberg, Kirk; DiNitto, Diana; Salas-Wright, Christopher
Alcohol and marijuana are reportedly two of the most pervasively used substances in the United States among women of childbearing age (18-44 years). About 10–50% of childbearing-aged women report drinking alcohol and are at risk of an Alcohol-Exposed Pregnancy (AEP). As for marijuana use, about 9.5% of women of childbearing age report marijuana use in the past month, and use has been steadily increasing since 2007. Further compounding concerns for women include mental health disorders like depression. Among women of childbearing age, studies have estimated that about 8-16% suffer from depression. Furthermore, it is all too common for both substance use and mental health disorders to co-occur. Comorbid substance use and mental health disorders among women of childbearing age have emerged as a particularly significant area of concern. However, a key obstacle in further understanding the relationship between these disorders among women, in general, is that women either do not report, or under-report substance abuse and mental health symptoms, and may not be aware of the concerns associated with substance use while at risk for pregnancy. Therefore, it is critical to find a setting where women can receive information about alcohol- and substance-exposed pregnancies, while also identifying and treating these co-occurring disorders. This dissertation explores the feasibility of meeting these needs through primary care settings. Primary care, identified as an “opportunistic setting,” is often the first setting substance use and mental disorders are detected and addressed. However, comorbidity in primary care has not been explored in detail, more so for women of childbearing age, and requires further examination. Alcohol use, marijuana use, and depression are all critical issues for childbearing-aged women, and often occur concurrently, yet research is limited and needs further attention. Therefore, this dissertation aims to better understand comorbid alcohol use and depression, and comorbid alcohol use and marijuana use among women of childbearing age presenting in primary care. To do so, this dissertation draws upon the Transtheoretical Model of Change to study a sample of women from the CDC-funded CHOICES Plus study who were at risk of an AEP.
User-centered design of nutri, a novel goal setting clinical decision support technology to improve the equity of data-driven dietary behavior change interventions in primary care
(2021-08-16) Henning, Jacqueline May; Burgermaster, Marissa; Nordquist, Eric
Interventions for dietary management of chronic disease increasingly leverage smartphone applications with the promise that data-driven personalization will improve effectiveness. However, since these interventions require users to collect, synthesize, and interpret data, users with more resources are more likely to benefit, thereby exacerbating existing health disparities. Multilevel interventions that distribute responsibility for dietary behavior change between patients and providers may improve equity; however, primary care providers (PCPs) lack time and training to elicit, synthesize, and interpret diet data. We hypothesize these limitations can be overcome with clinical decision support (CDS) technology that captures and synthesizes patient diet data into knowledge for PCPs to engage patients in collaborative diet goal setting, an effective behavior change technique. The aim of this study is to identify system requirements that would motivate providers to use a collaborative diet goal setting CDS and evaluate implementation design choices with the CDS prototype. We performed a 2-phase qualitative study with English and Spanish-speaking adult patients and PCPs from a federally qualified health center and an academic clinic in 30 to 60-minute semi-structured generative and usability interviews. We used an iterative design process involving user-experience designers, software engineers, and providers to develop the final CDS prototype. Using inductive thematic analysis, eight PCP and patient themes emerged. From PCP interviews we identified that: (1) Time constraints and patient characteristics influence if PCPs use personalized or generic goal setting, (2) Subjective and non-standardized processes guide personalized goal setting, (3) PCPs regard patient-generated data as an inaccurate and non-holistic representation of the patient’s diet, (4) Current clinical workflows make diet goal setting and monitoring cumbersome. For patients we found that: (1) PCP is seen as an authority figure, (2) Listening and dialog are facilitators for shared decision-making, (3) patients regard diet data as a source of truth, and (4) Goal achievement is distinct from goal setting. These themes, along with refinements identified in usability interviews, guided the iterative design of “Nutri,” a workflow-compatible CDS that synthesizes patient diet data from 24-hour recalls via a series of computational rules and presents diet goals for PCPs to discuss with patients through collaborative goal setting. The results from this study demonstrate the potential of a data-driven CDS for collaborative diet goal setting in primary care. The 2-phase user-centered iterative design process we used to design Nutri demonstrates how usability interviews can refine the operationalization of insights generated from traditional qualitative approaches. Follow-up studies will test Nutri in a clinic setting.