An extensive background and methods for a study to determine the rates of follow-up after abnormal breast cancer screening mammography using the Carolina Mammography Registry

Objective: To review the literature on rates follow-up after abnormal medical tests with a particular focus on follow-up after abnormal mammograms and also propose a study using the Carolina Mammography Registry which will 1) determine if the CMR data can be used for this purpose, 2) establish rates of incomplete follow-up after abnormal mammograms in the patients in the CMR data base, 3) compare rates of incomplete follow-up among participating CMR mammography centers, and 4) identify patient and radiological demographics associated with lower rates of follow-up after an abnormal screening mammogram. Data Sources: Most of the articles in the review portion of the paper were found via PubMed searches and reports published by the Institute of Medicine. Design: The proposed study is a descriptive study using patients in the CMR who had an abnormal mammogram requiring follow-up between 1998 and 2003. The number of women without follow-up divided by the total number who had abnormal mammograms requiring follow-up will define the rate of incomplete followed-up. Setting: The CMR is a member of the National Cancer Institutes Breast Cancer Surveillance Consortium. The CMR sites include mainly community based mammography facilities representing hospital-based, private radiology and multi-specialty facilities in 39 counties in North Carolina. As of 2004, data on over 1,450,000 records on more that 460,000 NC women are included in the database. Patients: The study will include all women in the CMR aged 40 years old and older without personal histories of breast cancer who had abnormal screening mammograms by Breast Imaging and Reporting Data System (BI-RADS®) assessment in between January 1998 and December 2003. Those who received follow-up within three months and those who did not receive follow-up within three months will be compared. Demographic data to be extracted include: race, age, education level, family history of a first-degree relative with breast cancer, personal history of breast procedures, time interval since the last mammogram, BIRADS assessment code, recommended follow- up procedure, and radiology facility. Follow-up interval will be established by assessing the number of days in between the mammogram reading and first date pertaining to follow-up information. The follow-up date will be abstracted from pathology specimen laboratory information, date of return to a follow-up facility as ascertained by the mammography sites, the Lineberger Comprehensive Cancer Center's Rapid Case Ascertainment system, the North Carolina Cancer Registry or from other patient information supplied to a CMR site. Main outcome measure: Overall rates of abnormal screening mammograms that are not resolved within 3 months after the index abnormal MMG. This will be established for the CMR in the 1998-2003 interval and for individual radiology practices. Results: Rates of follow-up for the CMR will be calculated as well as rates of each particular mammography site. Bivariate analysis will be used to examine the relationship between lack of follow-up and patient and radiographic characteristics. Multivariate logistic regression will be performed to find the set of risk factors that best predict the probability of not returning for follow-up. Associations between demographic characteristics and the probability of not following up will be presented as adjusted odds ratios with 95% confidence intervals. Conclusions: The literature review supports the use of tracking and reminder systems by health care providers and care systems to improve upon the rates of follow-up after abnormal screening and other medical tests. We hope that findings will reveal that the CMR practices have higher rates of complete patient follow-up after abnormal mammograms than what is detailed in the literature. This would then suggest that the CMR systems are effective for tracking and resolving mammographic abnormalities, thus provide an element of safety for its participants. Information on characteristics associated with more concerning rates of follow-up will then be able to guide the direction of improvement efforts. The information may help in the design of better systems or offer comparative data to stakeholders as they make decisions regarding other computerized data systems for their patients and staff.Master of Public Healt

A method to determine the impact of patient-centered care interventions in primary care

The implementation of patient-centered care (PCC) innovations continues to be poorly understood. We used the implementation effectiveness framework to pilot a method for measuring the impact of a PCC innovation in primary care practices

The Cost to Successfully Apply for Level 3 Medical Home Recognition

The NCQA Patient Centered Medical Home (PCMH) recognition program provides practices an opportunity to implement Medical home activities. Understanding the costs to apply for recognition may enable practices to plan their work

Positive Predictive Value of Mammography: Comparison of Interpretations of Screening and Diagnostic Images by the Same Radiologist and by Different Radiologists

The purpose of this study was to evaluate whether the positive predictive value (PPV) after a recommendation for biopsy differs when one as opposed to more than one radiologist performs the workup after abnormal findings are discovered at screening mammography

Patient Perspectives on Tobacco Use Treatment in Primary Care

IntroductionEvidence-based tobacco cessation interventions increase quit rates, yet most smokers do not use them. Every primary care visit offers the potential to discuss such options, but communication can be tricky for patients and provider alike. We explored smokers’ personal interactions with health care providers to better understand what it is like to be a smoker in an increasingly smoke-free era and the resources needed to support quit attempts and to better define important patient-centered outcomes.MethodsThree 90-minute focus groups, involving 33 patients from 3 primary care clinics, were conducted. Participants were current or recent (having quit within 6 months) smokers. Topics included tobacco use, quit attempts, and interactions with providers, followed by more pointed questions exploring actions patients want from providers and outcome measures that would be meaningful to patients.ResultsFour themes were identified through inductive coding techniques: 1) the experience of being a tobacco user (inconvenience, shame, isolation, risks, and benefits), 2) the medical encounter (expectations of providers, trust and respect, and positive, targeted messaging), 3) high-value actions (consistent dialogue, the addiction model, point-of-care nicotine patches, educational materials, carbon monoxide monitoring, and infrastructure), and 4) patient-centered outcomes.ConclusionEngaged patient-centered smoking cessation counseling requires seeking the patient voice early in the process. Participants desired honest, consistent, and pro-active discussions and actions. Participants also suggested creative patient-centered outcome measures to consider in future research

The association of health literacy and blood pressure reduction in a cohort of patients with hypertension: The heart healthy lenoir trial

Lower health literacy is associated with poorer health outcomes. Few interventions poised to mitigate the impact of health literacy in hypertensive patients have been published. We tested if a multilevel quality improvement intervention could differentially improve Systolic Blood Pressure (SBP) more so in patients with low vs. higher health literacy

Patient and Practice Perspectives on Strategies for Controlling Blood Pressure, North Carolina, 2010–2012

IntroductionPatient and practice perspectives can inform development of team-based approaches to improving blood pressure control in primary care. We used a community-based participatory research approach to assess patient and practice perceptions regarding the value of team-based strategies for controlling blood pressure in a rural North Carolina population from 2010 through 2012.MethodsIn-depth interviews were conducted with 41 adults with hypertension, purposely sampled to include diversity of sex, race, literacy, and blood pressure control, and with key office staff at 5 rural primary care practices in the southeastern US “stroke belt.” Interviews explored barriers to controlling blood pressure, the practice’s role in controlling blood pressure, and opinions on the use of team care delivery.ResultsPatients reported that provider strategies to optimize blood pressure control should include regular visits, medication adjustment, side-effect discussion, and behavioral counseling. When discussing team-based approaches to hypertension care, patients valued verbal encouragement, calls from the doctor’s office, and the opportunity to ask questions. However, they voiced concerns about the effect of having too many people involved in their care. Practice staff focused on multiple, broad methods to control blood pressure including counseling, regular office visits, media to improve awareness, and support groups. An explicit focus of delivering care as teams was a newer concept.ConclusionWhen developing a team approach to hypertension treatment, patients value high-quality communication and not losing their primary relationship with their provider. Practice staff members were open to a team-based approach but had limited knowledge of what such an approach would entail

Applicability of Precision Medicine Approaches to Managing Hypertension in Rural Populations

As part of the Heart Healthy Lenoir Project, we developed a practice level intervention to improve blood pressure control. The goal of this study was: (i) to determine if single nucleotide polymorphisms (SNPs) that associate with blood pressure variation, identified in large studies, are applicable to blood pressure control in subjects from a rural population; (ii) to measure the association of these SNPs with subjects’ responsiveness to the hypertension intervention; and (iii) to identify other SNPs that may help understand patient-specific responses to an intervention. We used a combination of candidate SNPs and genome-wide analyses to test associations with either baseline systolic blood pressure (SBP) or change in systolic blood pressure one year after the intervention in two genetically defined ancestral groups: African Americans (AA) and Caucasian Americans (CAU). Of the 48 candidate SNPs, 13 SNPs associated with baseline SBP in our study; however, one candidate SNP, rs592582, also associated with a change in SBP after one year. Using our study data, we identified 4 and 15 additional loci that associated with a change in SBP in the AA and CAU groups, respectively. Our analysis of gene-age interactions identified genotypes associated with SBP improvement within different age groups of our populations. Moreover, our integrative analysis identified AQP4-AS1 and PADI2 as genes whose expression levels may contribute to the pleiotropy of complex traits involved in cardiovascular health and blood pressure regulation in response to an intervention targeting hypertension. In conclusion, the identification of SNPs associated with the success of a hypertension treatment intervention suggests that genetic factors in combination with age may contribute to an individual’s success in lowering SBP. If these findings prove to be applicable to other populations, the use of this genetic variation in making patient-specific interventions may help providers with making decisions to improve patient outcomes. Further investigation is required to determine the role of this genetic variance with respect to the management of hypertension such that more precise treatment recommendations may be made in the future as part of personalized medicine

Integrating a health-related-quality-of-life module within electronic health records: a comparative case study assessing value added

<p>Abstract</p> <p>Background</p> <p>Health information technology (HIT) applications that incorporate point-of-care use of health-related quality of life (HRQL) assessments are believed to promote patient-centered interactions between seriously ill patients and physicians. However, it is unclear how willing primary care providers are to use such HRQL HIT applications. The specific aim of this study was to explore factors that providers consider when assessing the value added of an HRQL application for their geriatric patients.</p> <p>Methods</p> <p>Three case studies were developed using the following data sources: baseline surveys with providers and staff, observations of staff and patients, audio recordings of patient-provider interactions, and semi-structured interviews with providers and staff.</p> <p>Results</p> <p>The primary factors providers considered when assessing value added were whether the HRQL information from the module was (1) duplicative of information gathered via other means during the encounter; (2) specific enough to be useful and/or acted upon, and; (3) useful for enough patients to warrant time spent reviewing it for all geriatric patients. Secondary considerations included level of integration of the HRQL and EHR, impact on nursing workflow, and patient reluctance to provide HRQL information.</p> <p>Conclusions</p> <p>Health-related quality of life modules within electronic health record systems offer the potential benefit of improving patient centeredness and quality of care. However, the modules must provide benefits that are substantial and prominent in order for physicians to decide that they are worthwhile and sustainable. Implications of this study for future research include the identification of perceived "costs" as well as a foundation for operationalizing the concept of "usefulness" in the context of such modules. Finally, developers of these modules may need to make their products customizable for practices to account for variation in EHR capabilities and practice workflows.</p