Evaluation of provider documentation of medication management in a Patient-Centered Medical Home (PCMH)

Purpose: The National Committee for Quality Assurance (NCQA) has standards for recognizing Patient-Centered Medical Homes (PCMH) including one for medication management. Study objectives were to identify if and how providers within a PCMH recognized under the 2008 guidelines were documenting components of medication management to meet NCQA’s 2011 requirements including: 1) providing information about new prescriptions to >80% of patients; 2) assessing understanding of medications for >50% of patients; and 3) assessing response and barriers to medication adherence for >50% of patients. Methods: Physician and pharmacist-led patient visits from a family medicine office, from February 1 to August 1, 2012 were assessed. Patients over 18 years old taking at least one medication were included. A retrospective chart review was performed to assess documented components of medication management. Descriptive statistics were used to analyze data. Results: A systematic sampling of 450 physician-led and 195 pharmacist-led patient visits, demonstrated providers did not meet documentation goals for providing patients information on new prescriptions (65% pharmacist, 24% physician, 36% of total provider notes) or for assessment of patients’ understanding of medications (9% pharmacist 12% physician, 11% of total provider notes). Individually each type of provider did not meet the goal of assessing patient response and barriers to adherence to medication, but with combined intervention by the pharmacists and the physicians, the site was able to surpass NCQA’s percentage goal (57% and 58%). Conclusions: No components of medication management are well documented. Using the electronic medical record, pharmacists may be able to develop documentation tools and assist sites to meet NCQA’s goals for medication management

Self-administered gerocognitive examination (SAGE) aids early detection of cognitive impairment at primary care provider visits

IntroductionCurrent estimates indicate that up to 50–75% of dementia cases are undiagnosed at an early stage when treatments are most effective. Conducting robust accurate cognitive assessments can be time-consuming for providers and difficult to incorporate into a time-limited Primary Care Provider (PCP) visit. We wanted to compare PCP visits with and without using the self-administered SAGE to determine differences in identification rates of new cognitive disorders.MethodsThree hundred patients aged 65–89 without diagnosed cognitive disorders completing a non-acute office visit were enrolled (ClinicalTrials.gov identifier: NCT04063371). Two PCP offices conducted routine visits for 100 consecutive eligible patients each. One office used the SAGE in an additional 100 subjects and asked available informants about cognitive changes over the previous year. Chart reviews were conducted 60 days later. One-way analysis of variance and Fisher exact tests were used to compare the groups and outcomes.ResultsWhen SAGE was utilized, the PCP documented the detection of new cognitive conditions/concerns six times (9% versus 1.5%) as often (p = 0.003). The detection rate was nearly 4-fold for those with cognitively impaired SAGE scores (p = 0.034). Patients having impaired SAGE score and informant concerns were 15-fold as likely to have new cognitive conditions/concerns documented (p = 0.0007). Among providers using SAGE, 86% would recommend SAGE to colleagues.DiscussionSAGE was easily incorporated into PCP visits and significantly increased identification of new cognitive conditions/concerns leading to new diagnoses, treatment, or management changes. The detection rate increased 15-fold for those with impaired SAGE scores combined with informant reports

Comparison of outcomes for routine versus American Heart Association-recommended technique for blood pressure measurement (CORRECT BP): a randomised cohort studyResearch in context

Summary: Background: Optimal clinical care, diagnosis and treatment requires accurate blood pressure (BP) values. The primary objective was to compare BP readings taken while adhering to American Heart Association (AHA) guidelines to those typical of routine clinical care. Specifically studied: the combined effect of feet flat on the floor, back supported, and arm supported with cuff at heart level, while adhering to other guideline recommendations. Methods: In this prospective, randomised, three-group cohort study, a modified cross-over design was applied in a primary care outpatient office setting in Columbus (OH, USA). Eligible participants were adults (aged ≥18 years) with an arm circumference of ≥18 cm and ≤42 cm who did not have a renal dialysis shunt or a previous or current diagnosis of atrial fibrillation. 150 recruited volunteers meeting the inclusion criteria were randomly randomised into the three groups. Group methodologies were BP readings taken on a fixed-height exam table followed by readings taken in an exam chair with adjustable positioning options (Group A), readings taken in the reverse order, chair then table (Group B), and both sets of readings in the exam chair (Group C). A rest period occurred before each set of readings. Group C was included for the purpose of obtaining an independent estimate of the order effect. The order in which the two types of readings (table vs chair) were taken was randomised. The primary outcome was the difference between the mean of three BP readings taken on the table and the mean of three readings taken in the chair. Findings: Between September and October, 2022, 150 participants were enrolled in the study; all 150 of whom completed testing: 48 in Group A, 49 in Group B, 53 in Group C. The mean systolic/diastolic BP (SBP/DBP) of readings taken on the table (Group A first readings, Group B second readings) were 7.0/4.5 mmHg higher than those taken in the chair (Group A second readings, Group B first readings); both statistically significant, p < 0.0001. These findings show that AHA-recommended positioning—feet flat on the floor, back supported, arm supported with the BP cuff at heart level—results in substantially lower BP values than improper positioning. The mean SBP/DBP of the first set of readings taken on the chair were 1.6/0.6 mmHg higher than for the second set of readings (Group C, included to estimate order effect). Interpretation: The observed benefit of proper positioning is sufficient to change the BP classification of several million patients from having hypertension to not having hypertension and therefore avoiding medication and/or intense follow-up. Funding: Midmark Corporation, Versailles, Ohio, USA

Differences in Adherence to American Heart Association's Life's Essential 8, Diet Quality, and Weight Loss Strategies Between Those With and Without Recent Clinically Significant Weight Loss in a Nationally Representative Sample of US Adults

Background The American Heart Association defines ideal cardiovascular health based on 8 risk factors (Life's Essential 8 [LE8]); a high LE8 score (range 0–100) reflects greater adherence to their recommendations. Weight status influences cardiovascular health, yet individuals may use detrimental diet and weight loss strategies to improve weight status. We assessed differences in LE8 adherence, diet quality, and weight loss strategies between those with and without a recent history of clinically significant weight loss (CSWL). Methods and Results Data from 2007 to 2016 National Health and Nutrition Examination Survey questionnaires, clinical measures, and 24‐hour dietary recalls were assessed to determine LE8 adherence, diet quality (Healthy Eating Index), and weight loss strategies between adults with: (1) intentional CSWL ≥5%; and (2) non‐CSWL <5%, weight maintenance, or weight gain over the past 12 months using ANCOVA and chi‐square tests. Those with CSWL demonstrated higher scores for diet quality (P=0.014), physical activity (P<0.001), and blood lipids (P<0.001). Those without CSWL reported lower BMI (P<0.001). There were no differences in total LE8 cardiovascular health scores between those with and without CSWL. More individuals with CSWL reported weight loss strategies of exercising (P=0.016); those without CSWL reported skipping meals (P=0.002) and using prescription diet pills (P<0.001). Conclusions Greater adherence to the LE8 recommendations was observed among individuals with CSWL, although overall LE8 scores were low. Future research should address the implementation of evidence‐based strategies that improve diet quality while promoting optimal cardiovascular health among those with intent to lose weight