Associations between hearing loss, peripheral neuropathy, balance, and survival in older primary care patients.

Background: Both age-associated hearing loss (AAHL) and peripheral neuropathy (PN) are common in older patients, and both are associated with impaired balance, falls, and premature mortality. The objectives of this study were to document the prevalence and severity of AAHL in older primary care patients, and to explore associations between AAHL, PN, balance, falls, and mortality.

Methods: We analyzed information obtained in 1999 from 793 primary care patients recruited from practices participating in the Oklahoma Longitudinal Assessment of the Health Outcomes of Mature Adults (OKLAHOMA) Studies.

Person-Centered, Goal-Oriented Care Helped My Patients Improve Their Quality of Life.

When the goal is to help patients improve their quality of life, it makes sense to focus directly on the activities and relationships that are most important to each patient. This can be accomplished most effectively by following a three-step process that includes 1) connecting with the patient around what matters to them, 2) co-creating a goal-oriented plan, and 3) collaborating with patient, family, team members, and consultants to increase the probability of success. Once this approach has been mastered and the necessary systems, processes, and relationships are in place, this should not take more time than a problem-oriented approach, and it will almost certainly be more satisfying for both physician and patient.

Peripheral Neuropathy in Older People Is Associated with Reduced Life Expectancy.

Introduction: We analyzed data from a prospective cohort of older primary care patients to determine whether the presence of peripheral neuropathy (PN) was associated with premature mortality and to investigate potential mechanisms.

Methods: PN was defined as the presence of 1 or more bilateral lower extremity sensory deficits detectable by physical examination. Mortality was determined from key contacts and Internet sources.

Goal-Oriented Prevention: How to Fit a Square Peg into a Round Hole.

Prevention does not fit well within our problem-oriented medical paradigm in which the focus is on curing or ameliorating existing diseases. It is easier and more satisfying to solve existing problems than it is to advise and motivate patients to implement measures to prevent future problems that may or may not occur. Clinician motivation is further diminished by the time required to help people make lifestyle changes, the low reimbursement rate, and the fact that the benefits, if any, are often not apparent for years.

How Patient-Centered Medical Homes Can Bring Meaning to Health Care: A Call for Person-Centered Care.

The development of patient-centered medical homes in the United States was, among other things, an attempt to improve patients' experiences of care. This and other improvement strategies, however, have failed to confront a major barrier, our disease-oriented medical model. Focusing on diseases has contributed to subspecialization and reductionism, which, for patients, has increased medical complexity and made it more difficult to engage in collaborative decision making.

Failure of the Problem-Oriented Medical Paradigm and a Person-Centered Alternative.

Our problem-oriented approach to health care, though historically reasonable and undeniably impactful, is no longer well matched to the needs of an increasing number of patients and clinicians. This situation is due, in equal parts, to advances in medical science and technologies, the evolution of the health care system, and the changing health challenges faced by individuals and societies. The signs and symptoms of the failure of problem-oriented care include clinician demoralization and burnout; patient dissatisfaction and non-adherence; overdiagnosis and labeling; polypharmacy and iatrogenesis; unnecessary and unwanted end-of-life interventions; immoral and intolerable disparities in both health and health care; and inexorably rising health care costs.

A Person-Centered Interdisciplinary Plan-of-Care Program for Dialysis: Implementation and Preliminary Testing.

Rationale & Objective: Despite growing interest in individualizing care, routine dialysis processes, including the interdisciplinary plan of care, often fail to account for patient-identified priorities. To better align dialysis care with patient priorities and improve care planning experiences, we implemented a person-centered care plan program at a single clinic. We also sought to gain insight into key implementation considerations and areas for program improvement.

Development of a person-centered interdisciplinary plan-of-care program for dialysis.

Background: Dialysis care often focuses on outcomes that are of lesser importance to patients than to clinicians. There is growing international interest in individualizing care based on patient priorities, but evidence-based approaches are lacking. The objective of this study was to develop a person-centered dialysis care planning program.

Physicians' Response to Patients' Quality-of-Life Goals.

Purpose: Patients are able to participate in quality-of-life (QOL) discussions, but clinicians struggle to incorporate this information into encounters and shared decision making. We designed a study to determine if a clinician-initiated prompt could make patient visits more goal directed.

Methods: Patients were given a previsit questionnaire that included QOL questions.

Disseminating, implementing, and evaluating patient-centered outcomes to improve cardiovascular care using a stepped-wedge design: healthy hearts for Oklahoma.

Background: Cardiovascular disease (CVD) is the leading cause of death in the US and incurs high health care costs. While many initiatives promote the implementation of ABCS (aspirin therapy, blood pressure control, cholesterol management, and smoking cessation) measures, most primary care practices (PCPs) lack quality improvement (QI) support and resources to achieve meaningful targets. The Healthy Hearts for Oklahoma (H2O) Study proposes to build a QI infrastructure by (1) constructing a sustainable Oklahoma Primary Healthcare Improvement Collaborative (OPHIC) to support dissemination and implementation (D&I) of QI methods; (2) providing QI support in PCPs to better manage patients at risk for CVD events.

The Alarming Rate of Major Disruptive Events in Primary Care Practices in Oklahoma.

Purpose: In primary care practices, sustainability of performance improvements and ability to deliver continuity of care to patients can be adversely affected by major disruptive events, such as relocations and changes in ownership, clinicians, and key staff. This study documented the rates of major disruptive events in a cohort of primary care practices in Oklahoma.

Methods: Practices were included if they had existed for 1 year before enrollment and remained in the project for at least 1 year after enrollment.

Poison ivy: How effective are available treatments?

In this study, only one treatment approach significantly reduced pruritus. Three approaches were often associated with recurrences of rash or symptoms.

Encouraging Patient-Centered Care by Including Quality-of-Life Questions on Pre-Encounter Forms.

Purpose: Patient participation in clinical decision making improves outcomes, including quality of life (QOL), but the typical problem-oriented approach may impede consideration of functional goals. We wondered if patients could encourage primary care physicians to pay attention to their QOL goals by writing them on pre-encounter forms.

Methods: We conducted a randomized controlled trial comparing the impact of 2 different pre-visit questionnaires on the content of patient-physician encounters in a family medicine practice at an academic medical center.

Selective Serotonin Reuptake Inhibitors and Night Sweats in a Primary Care Population.

Objective: Several small published case reports have suggested that selective serotonin reuptake inhibitors (SSRIs) can cause night sweats. The purpose of this study was to investigate this possibility further and to explore possible associations between night sweats and other commonly prescribed medications.

Design: Cross-sectional, secondary data analysis.

Leveraging practice-based research networks to accelerate implementation and diffusion of chronic kidney disease guidelines in primary care practices: a prospective cohort study.

Background: Four practice-based research networks (PBRNs) participated in a study to determine whether networks could increase dissemination, implementation, and diffusion of evidence-based treatment guidelines for chronic kidney disease by leveraging early adopter practices.

Methods: Motivated practices from four PBRNs received baseline and periodic performance feedback, academic detailing, and weekly practice facilitation for 6 months during wave I of the study. Each wave I practice then recruited two additional practices (wave II), which received performance feedback and academic detailing and participated in monthly local learning collaboratives led by the wave I clinicians.

Extreme pain from brown recluse spider bites: model for cytokine-driven pain.

Importance: Bites from the brown recluse spider (BRS) can cause extreme pain. We propose cytokine release as a cause of the discomfort and a central mechanism through glial cell upregulation to explain measured pain levels and time course.

Observations: Twenty-three BRS bites were scored at a probable or documented level clinically, and an enzyme-linked immunosorbent assay was used to confirm the presence of BRS venom.

Implementing asthma guidelines using practice facilitation and local learning collaboratives: a randomized controlled trial.

Purpose: Guideline implementation in primary care has proven difficult. Although external assistance through performance feedback, academic detailing, practice facilitation (PF), and learning collaboratives seems to help, the best combination of interventions has not been determined.

Methods: In a cluster randomized trial, we compared the independent and combined effectiveness of PF and local learning collaboratives (LLCs), combined with performance feedback and academic detailing, with performance feedback and academic detailing alone on implementation of the National Heart, Lung and Blood Institute's Asthma Guidelines.

Electronic health record functionality needed to better support primary care.

Electronic health records (EHRs) must support primary care clinicians and patients, yet many clinicians remain dissatisfied with their system. This article presents a consensus statement about gaps in current EHR functionality and needed enhancements to support primary care. The Institute of Medicine primary care attributes were used to define needs and meaningful use (MU) objectives to define EHR functionality.

Sterile pyuria in patients admitted to the hospital with infections outside of the urinary tract.

Objectives: The objective of this study was to determine the incidence, associations, evaluation, and management of pyuria in patients admitted to the hospital with nonurinary infections.

Methods: This study abstracted inpatient records of consecutive patients hospitalized for pneumonia, intra-abdominal infections, female genital tract infections (GYN infections), bacterial septicemia, and enteritis in the pediatric and adult medical and surgical units at an academic medical center.

Results: The study population included 210 patients (66 children; 144 adults).

HIE-i-health information exchange with intelligence.

This article demonstrates the development and pilot testing of an innovative approach to implement health information exchange with intelligence (HIE-i) in primary care settings. Records of 346 patients were studied in 6 primary care practices. Clinical workflows were evaluated by time motion studies and observations.

Improving colorectal cancer screening in family medicine: an Oklahoma Physicians Resource/Research Network (OKPRN) study.

Purpose: The purpose of this study was to describe colorectal cancer screening (CRCS) practices across a variety of primary care clinics and identify the methods used by primary care physicians (PCPs) with higher rates of CRCS ("exemplars").

Methods: Physician questionnaires, structured interviews, medical record abstractions, and practice observations were conducted for 48 PCPs in 25 practices within a regional practice-based research network followed by secondary in-depth interviews to further investigate the practices of PCPs in the top quartile of CRCS rates ("exemplars").

Results: We abstracted 3596 medical records (mean of 75 records per PCP).

The primary care extension program: a catalyst for change.

The Affordable Care Act authorized, but did not fund, the Primary Care Extension Program (PCEP). Much like the Cooperative Extension Program of the US Department of Agriculture sped the modernization of farming a century ago, the PCEP could speed the transformation of primary care. It could also help achieve other goals such as integrating primary care with public health and translating research into practice.