Managing Chronic Back Pain in a Rural Primary Care Setting

Chronic back pain management is complex and is often challenging for Primary Care Providers (PCPs). Rural PCPs are managing chronic back pain despite limited training and availability of pain management specialists. Pharmacological interventions are often used to treat chronic back pain despite current evidence suggesting physical therapy and aquatic therapy are first-line treatments. A directory of local therapy facilities offering physical and aquatic therapy and a review of clinical practice guidelines (CPG) were provided to three PCPs in a rural clinic in the Midwest. Use of the directory and the CPG was intended to help decrease reliance on pharmacological options and increase reliance on non-pharmacologic options when treating chronic back pain. There were 595 encounters pre-implementation and 641 post implementation for the complaint of chronic back pain reflecting the six most frequent diagnoses. Comparison of pre and post physical and aquatic therapy referrals for chronic back pain indicated that there was not a statistically significant increase in therapy referrals but rather a clinically relevant increase of post implementation referrals (5.88 to 8.58%, an additional 20 referrals). This project impacted the clinic by heightening awareness of the use of non-pharmacological interventions, such as physical and aquatic therapy, for chronic back pain management. Barriers to adaption included patient-oriented reasons, insurance limitations, and provider reluctance

Normalization of a conversation tool to promote shared decision making about anticoagulation in patients with atrial fibrillation within a practical randomized trial of its effectiveness: a cross-sectional study.

BACKGROUND: Shared decision making (SDM) implementation remains challenging. The factors that promote or hinder implementation of SDM tools for use during the consultation, including contextual factors such as clinician burnout and organizational support, remain unclear. We explored these factors in the context of a practical multicenter randomized trial evaluating the effectiveness of an SDM conversation tool for patients with atrial fibrillation considering anticoagulation therapy. METHODS: In this cross-sectional study, we recruited clinicians who were regularly involved in conversations with patients regarding anticoagulation for atrial fibrillation. Clinicians reported their characteristics and burnout symptoms using the two-item Maslach Burnout Inventory. Clinicians were trained in using the SDM tool, and they recorded their perceptions of the tool's normalization potential using the Normalization MeAsure Development (NoMAD) survey instrument and verbally reflected on their answers to these survey questions. When possible, the training sessions and clinicians' verbal responses to the conversation tool were recorded. RESULTS: Our study comprised 183 clinicians recruited into the trial (168 with survey responses and 112 with recordings). Overall, clinicians gave high scores to the normalization potential of the intervention; they endorsed all domains of normalization to the same extent, regardless of site, clinician characteristics, or burnout ratings. In interviews, clinicians paid significant attention to making sense of the tool. Tool buy-in seemed to depend heavily on their ability to see the tool as accurate and "evidence-based" and their perceptions of having time in the consultation to use it. CONCLUSIONS: While time in the consultation remains a barrier, we did not find a significant association between burnout symptoms and normalization of an SDM conversation tool. Possible areas for improving the normalization of SDM conversation tools in clinical practice include enabling collaboration among clinicians to implement the tool and reporting how clinicians elsewhere use the tool. Direct measures of normalization (i.e., observing how often clinicians access the tool in practice outside of the clinical trial) may further elucidate the role that contextual factors, such as clinician burnout, play in the implementation of SDM. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02905032. Registered on 9 September 2016

Sustainability of an HIV PEP Program for Sexual Assault Survivors: “Lessons Learned” from Health Care Providers

This study explored challenges to continuing an HIV post-exposure prophylaxis (PEP) program of care provided to sexual assault survivors in the province of Ontario, Canada. Data were collected as part of an implementation and evaluation of a universal offering of HIV PEP (known as the HIV PEP Program) at 24 of 34 provincial hospital-based sexual assault treatment centres. Experienced health care providers were surveyed (n = 132) and interviewed in four focus groups (n = 26) about their perceptions of what, if any, factors threatened their ability to maintain the HIV PEP Program. All focus groups were audio-recorded and the recordings transcribed. The transcriptions and open-ended survey responses were analyzed using content analysis. Administrator, nurse, physician, social worker, and pharmacist respondents perceived important barriers to sustainability of the HIV PEP Program. Eight constructs were identified within four broad themes: resources (inadequate funds, overworked and unacknowledged staff), expertise (insufficient external supports, insufficiently trained and knowledgeable staff), commitment (lack of institutional support, physician resistance to offering HIV PEP), and accommodation (lack of flexibility in addressing specific client and community needs, inaccessibility and lack of clarity of tools). We discuss the implications of these findings and the actions that were taken to address the challenges

Automated Determination of Serum (Plasma) and Urine Iron: A Comparative Investigation of Chromogens. Improved Tripyridyltriazine Micromethod

Peer Reviewe