HelpDesk answers: do hormonal contraceptives lead to weight gain?

It depends. Weight doesn't appear to increase with combined oral contraception (OC) compared with nonhormonal contraception, but percent body fat may increase slightly. Depot-medroxyprogesterone acetate injection (DMPA) users experience weight gain compared with OC and nonhormonal contraception (NH) users.

A technology-based quality innovation to identify undiagnosed hypertension among active primary care patients.

PURPOSE: The goal of this study was to develop a technology-based strategy to identify patients with undiagnosed hypertension in 23 primary care practices and integrate this innovation into a continuous quality improvement initiative in a large, integrated health system. METHODS: In phase 1, we reviewed electronic health records (EHRs) using algorithms designed to identify patients at risk for undiagnosed hypertension. We then invited each at-risk patient to complete an automated office blood pressure (AOBP) protocol. In phase 2, we instituted a quality improvement process that included regular physician feedback and office-based computer alerts to evaluate at-risk patients not screened in phase 1. Study patients were observed for 24 additional months to determine rates of diagnostic resolution. RESULTS: Of the 1,432 patients targeted for inclusion in the study, 475 completed the AOBP protocol during the 6 months of phase 1. Of the 1,033 at-risk patients who remained active during phase 2, 740 (72%) were classified by the end of the follow-up period: 361 had hypertension diagnosed, 290 had either white-coat hypertension, prehypertension, or elevated blood pressure diagnosed, and 89 had normal blood pressure. By the end of the follow-up period, 293 patients (28%) had not been classified and remained at risk for undiagnosed hypertension. CONCLUSIONS: Our technology-based innovation identified a large number of patients at risk for undiagnosed hypertension and successfully classified the majority, including many with hypertension. This innovation has been implemented as an ongoing quality improvement initiative in our medical group and continues to improve the accuracy of diagnosis of hypertension among primary care patients.

Implementation of EHR-based strategies to improve outpatient CAD care.

OBJECTIVES: To evaluate the effects of a multifaceted quality improvement intervention during 2 time periods on 4 coronary artery disease [CAD] measures in 4 primary care practices. During the first phase, electronic reminders prompted physicians to order indicated medications or record contraindications and refusals (exceptions). In the second phase, physicians also received reports about their performance (including lists of patients not satisfying these measures), and financial incentives were announced. STUDY DESIGN: Time series analysis. METHODS: Adult CAD patients seen within the preceding 18 months were included. The primary outcome was the performance on each measure (proportion of eligible patients satisfying each measure after removing those with exceptions). Secondary outcomes were the proportion with the medication on their medication list, and the proportion with exceptions. RESULTS: Median performance at baseline was 78.8% for antiplatelet treatment, 85.1% for statin treatment, 77.0% for beta-blocker after myocardial infarction (MI), and 67.1% for angiotensinconverting enzyme inhibitor or angiotensin receptor blocker after MI. Performance improved slightly for 3 measures during the first phase and improved more substantially for all 4 measures during the second phase. For 3 of 4 measures, however, documentation of exceptions increased but not medication prescribing. Most exceptions were judged to be appropriate by peer review. CONCLUSIONS: Physicians responded more to the combination of feedback and financial incentives than they had to electronic reminders alone. High performance was only achieved for 1 of 4 measures and recording of exceptions rather than increases in medication prescribing accounted for most of the observed improvements.

Disaster medicine training in family medicine: a review of the evidence.

When disasters strike, local physicians are at the front lines of the response in their community. Curriculum guidelines have been developed to aid in preparation of family medicine residents to fulfill this role. Disaster responsiveness has recently been added to the Residency Review Committee Program Requirements in Community Medicine with little family medicine literature support. In this article, the evidence in support of disaster training in a variety of settings is reviewed. Published evidence of improved educational or patient-oriented outcomes as a result of disaster training in general, or of specific educational modalities, is weak. As disaster preparedness and disaster training continue to be implemented, the authors call for increased outcome-based research in disaster response training.

Disaster Medicine Training in Family Medicine: A Review of the Evidence

Este artículo presenta la revisión de las experiencias en apoyo a la formación de desastre en una variedad de escenarios. La evidencia publicada acerca de la mejora de los resultados educativos y orientada al paciente, arroja como resultado que la capacitación de desastres en general, o de determinadas modalidades educativas, es débil

Changes in performance after implementation of a multifaceted electronic-health-record-based quality improvement system.

BACKGROUND: Electronic health record (EHR) systems have the potential to revolutionize quality improvement (QI) methods by enhancing quality measurement and integrating multiple proven QI strategies. OBJECTIVES: To implement and evaluate a multifaceted QI intervention using EHR tools to improve quality measurement (including capture of contraindications and patient refusals), make point-of-care reminders more accurate, and provide more valid and responsive clinician feedback (including lists of patients not receiving essential medications) for 16 chronic disease and preventive service measures. DESIGN: Time series analysis at a large internal medicine practice using a commercial EHR. SUBJECTS: All adult patients eligible for each measure (range approximately 100-7500). MEASURES: The proportion of eligible patients who satisfied each measure after removing those with exceptions from the denominator. RESULTS: During the year before the intervention, performance improved significantly for 8 measures. During the year after the intervention, performance improved significantly for 14 measures. For 9 measures, the primary outcome improved more rapidly during the intervention year than during the previous year (P < 0.001 for 8 measures, P = 0.02 for 1). Four other measures improved at rates that were not significantly different from the previous year. Improvements resulted from increases in patients receiving the service, documentation of exceptions, or a combination of both. For 5 drug-prescribing measures, more than half of physicians achieved 100% performance. CONCLUSIONS: Implementation of a multifaceted QI intervention using EHR tools to improve quality measurement and the accuracy and timeliness of clinician feedback improved performance and/or accelerated the rate of improvement for multiple measures simultaneously.

Effect of financial incentives on improvement in medical quality indicators for primary care.

PURPOSE: The efficacy of rewarding physicians financially for preventive services is unproven. The objective of this study was to evaluate the effect of a physician pay-for-performance program similar to the Medicare Physician Quality Reporting Initiative program on quality of preventive care in a network of community health centers. METHODS: A retrospective review of administrative data was done to evaluate a natural quasi-experiment in a network of publicly funded primary care clinics. Physicians in 6 of 11 clinics were given a financial incentive twice the size of the current Centers for Medicare and Medicaid Services' incentive for achieving group targets in preventive care that included cervical cancer screening, mammography, and pediatric immunization. They also received productivity incentives. Six years of performance indicators were compared between incentivized and nonincentivized clinics. We also surveyed the incentivized clinicians about their perception of the incentive program. RESULTS: Although some performance indicators improved for all measures and all clinics, there were no clinically significant differences between clinics that had incentives and those that did not. A linear trend test approached conventional significance levels for Papanicolaou smears (P = .08) but was of very modest magnitude compared with observed nonlinear variations; there was no suggestion of a linear trend for mammography or pediatric immunizations. The survey revealed that most physicians felt the incentives were not very effective in improving quality of care. CONCLUSION: We found no evidence for a clinically significant effect of financial incentives on performance of preventive care in these community health centers. Based on our findings and others, we believe there is great need for more research with strong research designs to determine the effects, both positive and negative, of financial incentives on clinical quality indicators in primary care.

PT or cervical collar for cervical radiculopathy?

To shorten recovery time for adults with acute cervical radiculopathy, recommend either physical therapy (PT) and a home exercise plan or a cervical collar and rest. Both are more effective than a wait-and-see strategy.

Initiating antidepressant therapy? Try these 2 drugs first.

When you initiate antidepressant therapy for patients who have not been treated for depression previously, select either sertraline or escitalopram. A large meta-analysis found these medications to be superior to other "new-generation" antidepressants.

Houston's medical disaster response to Hurricane Katrina: part 2: transitioning from emergency evacuee care to community health care.

After Hurricane Katrina hit the Gulf Coast on August 29, 2005, thousands of ill and injured evacuees were transported to Houston, TX. Houston's regional disaster plan was quickly implemented, leading to the activation of the Regional Hospital Preparedness Council's Catastrophic Medical Operations Center and the rapid construction of a 65-examination-room medical facility within the Reliant Center. A plan for triage of arriving evacuees was quickly developed and the Astrodome/Reliant Center Complex mega-shelter was created. Herein, we discuss major elements of the regional disaster response, including regional coordination, triage and emergency medical service transfers into the region's medical centers, medical care in population shelters, and community health challenges.

Houston's medical disaster response to Hurricane Katrina: part 1: the initial medical response from Trauma Service Area Q.

After Hurricane Katrina hit the Gulf Coast on August 29, 2005, thousands of ill and injured evacuees were transported to Houston, TX. Houston's regional disaster plan was quickly implemented, leading to the activation of the Regional Hospital Preparedness Council's Catastrophic Medical Operations Center and the rapid construction of a 65-examination-room medical facility within the Reliant Center. A plan for triage of arriving evacuees was quickly developed and the Astrodome/Reliant Center Complex mega-shelter was created. Herein, we discuss major elements of the regional disaster response, including regional coordination, triage and emergency medical service transfers into the region's medical centers, medical care in population shelters, and community health challenges.

A systematic review of COPC: evidence for effectiveness.

PURPOSE: This systematic review was conducted to assess the evidence for effectiveness of the community oriented primary care (COPC) model and discuss alternative approaches to community medicine practice and education. METHODS: A literature search for all articles referring to COPC was conducted. Articles were categorized by type, and the extent of the use of elements of the COPC model, and the level of community involvement. RESULTS: The majority of articles on COPC (60% of those reviewed) describe the general theory or educational use of the methodology. Many published studies are project descriptions not utilizing the complete model as initially described. Few of project descriptions include all elements of COPC or document community participation. Evidence for or against the effectiveness of the COPC model in improving community health outcomes (using the Strength of Recommendation Taxonomy (SORT) classification system as evidence) was found to be limited. CONCLUSIONS: Most publications related to COPC do not use the complete COPC model as originally described and evidence for its effectiveness is lacking. Further research with evaluation of community health outcomes and community participation is needed. Diverse models of community health intervention can be considered for training and collaborative practice with underserved populations.

Physical medicine and rehabilitation conditions in the Astrodome clinic after hurricane Katrina.

OBJECTIVE: To report the physical medicine and rehabilitation (PMR) conditions seen in the Astrodome Clinic after Hurricane Katrina. DESIGN: Retrospective chart analysis from the county hospital-sponsored disaster-relief clinic in large urban city, including a study of 239 patients with 292 PMR conditions. The total number of patients seen in the Astrodome Medical Clinic was 11,245. The Astrodome database was reviewed for PMR condition diagnostic codes. A retrospective chart analysis was conducted, including date of visit, age, gender, ethnicity, and PMR diagnosis category. Descriptive statistics were obtained for the entire sample. chi2 or t tests were used to determine gender, age, or date-of-service predominance for the most common diagnostic categories. RESULTS: Mean +/- SD age was 45.7 +/- 14.3 yrs; 56% were women, 43% were men (1% unspecified), and 76% were African American. The majority (75%) of PMR conditions presented in the first week. Most frequent were swollen feet and legs (22%), leg pain and cramps (17%), headache (12%), and neck and back pain (10%). Persons with headaches were younger than those without (41.3 vs. 46.3 yrs, P = 0.048). Persons with neck and/or back pain were older than those without those conditions (51.3 vs. 44.8 yrs, P = 0.004). Women had more headaches (20.9%) than did men (6.7%, P = 0.002). There were no Caucasians with leg pain/cramps, whereas 20.2% of African Americans had this condition (P = 0.028). CONCLUSIONS: This study documents the time of clinic presentation and most frequent types of PMR conditions of patients treated in the Astrodome Clinic after a historic hurricane. Most PMR conditions were treated by PMR personnel during the first week. Thus, future disaster planning should include PMR professionals as early responders.

Widespread outbreak of norovirus gastroenteritis among evacuees of Hurricane Katrina residing in a large "megashelter" in Houston, Texas: lessons learned for prevention.

BACKGROUND: After Hurricane Katrina, an estimated 200,000 persons were evacuated to the Houston metropolitan area, >27,000 of whom were housed in 1 large "megashelter," the Reliant Park Complex. We investigated an outbreak of gastroenteritis reported among the evacuees who resided in the Reliant Park Complex to assess the spread of the infectious agent, norovirus, and to implement and evaluate the effectiveness of interventions used for control. METHODS: Public health authorities conducted surveillance of gastroenteritis among evacuees treated at the Reliant Park Medical Clinic during 2-12 September 2005. Basic demographic and clinical data were recorded. Specimens of stool and vomitus were collected and tested for bacteria, parasites, and viruses. Shelter census data were used to estimate the daily incidence of disease. RESULTS: During a period of 11 days, >1000 patients were treated at the clinic for gastroenteritis, which accounted for 17% of all clinic visits. Norovirus was the sole enteric pathogen identified, but multiple different strains were involved. Among the evacuees residing in the Reliant Park Complex, the incidence of gastroenteritis was estimated to be 4.6 visits per 1000 persons per day, and among the evacuees who resided there for 9 days, 1 (4%) of 24 persons would have been ill. Intensive public health measures were promptly instituted but did not definitively slow the progression of the outbreak of norovirus gastroenteritis. CONCLUSIONS: Our investigation underscores the difficulties in managing such outbreaks in crowded settings and the need for rapid, sensitive laboratory assays to detect norovirus. Additional research is needed to establish more effective measures to control and prevent this highly contagious gastrointestinal illness.

Hurricane Katrina: medical response at the Houston Astrodome/Reliant Center Complex.

On September 1, 2005, with only 12 hours notice, various collaborators established a medical facility--the Katrina Clinic--at the Astrodome/Reliant Center Complex in Houston. By the time the facility closed roughly two weeks later, the Katrina Clinic medical staff had seen over 11,000 of the estimated 27,000 Hurricane Katrina evacuees who sought shelter in the Complex. Herein, we describe the scope of this medical response, citing our major challenges, successes, and recommendations for conducting similar efforts in the future.

Cardiovascular disease.

The primary care physician is in a position to advise patients on the efficacy of alternative and complementary therapies as they relate to cardiovascular diseases. Anti-oxidant vitamin supplementation has not been shown to be efficacious in decreasing cardiovascular events. N-3 fatty acids appear to be beneficial in secondary prevention of cardiovascular events but their use in primary prevention is not clear. Adoption of vegetable-based diets, including whole grains, can be recommended to decrease cardiovascular events, lower cholesterol and help lower blood pressure. For patients with hypercholesterolemia, cholestin, a red-yeast rice supplement, has been shown to be effective. Garlic supplements may have some mild cholesterol-lowering effect, but this effect is not significant enough to recommend clinically. Herbal therapies with hawthorn and ubiquinone (Q10) are of possible benefit in congestive heart failure. An integrated program of rigorous diet, exercise and stress reduction in motivated patients with cardiovascular disease may have value as an alternative to cardiovascular medications and surgical interventions.