Association of a Multimodal Educational Intervention for Primary Care Physicians With Prescriptions of Buprenorphine for Opioid Use Disorders.

Importance: Opioid use disorder (OUD) is a public health crisis in the United States, but only 5% of US physicians have obtained a Drug Addiction Treatment Act (DATA) waiver to prescribe buprenorphine to treat OUD. Increasing the number of primary care physicians (PCPs) who have obtained the waiver and are able to treat patients with OUD is of utmost importance. Objective: To determine whether a multimodal educational intervention of PCPs is associated with an increase in the number of buprenorphine waivers obtained and patients initiated into treatment in a primary care setting. Design, Setting, and Participants: This quality improvement study was conducted in primary health care clinics within a large, integrated health care system. Patients included those who had received a diagnosis of OUD, and had Providence Health Plan Medicare or Medicaid insurance. Included PCPs were divided into 2 groups: those who obtained a DATA waiver after an education intervention (uptake PCPs) vs those who did not obtain a DATA waiver (nonuptake PCPs). The study took place between January 1, 2016, and December 31, 2017. Data analyses were conducted from December 2017 to August 2019. Exposures: Multimodal educational intervention including video, in-person visits to clinical practitioner meetings by physician champions, and a primary care toolkit with training resources and clinic protocols. Main Outcomes and Measures: The number of new uptake clinics where at least 1 PCP obtained a DATA waiver, the number of new PCPs with DATA waivers, the number of patients receiving a buprenorphine prescription, and the number of patients who received 12 or more weeks of treatment. Results: Twenty-seven of 41 invited clinics implemented the intervention, and 620 PCPs were included. The number of PCPs with DATA waivers increased from 5 PCPs (0.8%) to 44 PCPs (7.1%), and the number of clinics with at least 1 buprenorphine prescriber increased from 3 clinics (7.3%) to 17 clinics (41.5%). In total, 213 patients underwent buprenorphine treatment, and 140 patients received 12 or more weeks of treatment. A total of 646 patients had Providence Health Plan Medicare or Medicaid insurance and were eligible for the study (mean [SD] age, 61.7 [16.5] years; 410 [63.5%] women). There was a statistically significant difference in treatment with buprenorphine between patients with uptake PCPs vs patients with nonuptake PCPs (23 patients [16.4%] vs 18 patients [3.5%]; odds ratio, 4.61 [95% CI, 2.32-10.51]; P = .01) after the intervention. Conclusions and Relevance: In this quality improvement study, an educational intervention was associated with an increase in the number of PCPs and clinics that could provide buprenorphine treatment for OUD and with an increase in the patients who were able to access care with medications for OUD.

A multisite, multistakeholder validation of the Accreditation Council for Graduate Medical Education competencies.

PURPOSE: The Accreditation Council for Graduate Medical Education's (ACGME's) six-competency framework has not been validated across multiple stakeholders and sites. The objective of this study was to perform a multisite validation with five stakeholder groups. METHOD: This was a cross-sectional, observational study carried out from October to December, 2011, in the internal medicine residency continuity clinics of eight internal medicine residency programs in the Pacific Northwest, including a VA, two academic medical centers, a military medical center, and four private hospitals. The authors performed a cultural consensus analysis (CCA) and a convergent-discriminant analysis using previously developed statements based on internal medicine milestones related to the six competencies. Ten participants were included from each of five stakeholder groups: patients, nurses, residents, faculty members, and administrators from each training site (total: 400 participants). RESULTS: Moderate to high agreement and coherence for all groups were observed (CCA eigenvalue ratios ranging from 2.16 to 3.20); however, high differences in ranking order were seen between groups in four of the CCA statements, which may suggest between-group tension in these areas. Analyses revealed excellent construct validity (Zcontrast score of 5.323, P < .0001) for the six-competency framework. Average Spearman correlation between same-node statements was 0.012, and between different-node statements it was -0.096. CONCLUSIONS: The ACGME's six-competency framework has reasonable face and construct validity across multiple stakeholders and sites. Stakeholders appear to share a single mental model of competence in this learning environment. Data patterns suggest possible improvements to the competency-milestone framework.

Prevalence of diagnosed sleep apnea among patients with type 2 diabetes in primary care.

BACKGROUND: Although up to 90% of patients with type 2 diabetes mellitus (T2DM) have obstructive sleep apnea (OSA), the rate at which primary care providers diagnose OSA in patients with diabetes has not been assessed. METHODS: A retrospective, population-based, multiclinic study was performed to determine the proportion of patients with T2DM managed in primary care clinics who were given a diagnosis of OSA and to identify factors associated with an OSA diagnosis. Electronic health records of adult patients with a diagnosis of T2DM were reviewed for a coexisting diagnosis of OSA, and the diagnostic prevalence of OSA was compared with the expected prevalence. RESULTS: A total of 16,066 patients with diabetes with one or more primary care office visits in 27 primary care ambulatory practices during an 18-month period from 2009 to 2010 were identified. Analysis revealed that 18% of the study population received an OSA diagnosis, which is less than the 54% to 94% prevalence reported previously. The 23% prevalence of OSA among obese study patients was lower than the expected 87% prevalence. In a logistic model, male sex, BMI, several chronic conditions, and lower low-density lipoprotein levels and hemoglobin A1c identified patients more likely to carry an OSA diagnosis (likelihood ratio, χ(2) = 1,713; P < .0001). CONCLUSIONS: Primary care providers underdiagnose OSA in patients with T2DM. Obese men with comorbid chronic health conditions are more likely to receive a diagnosis of OSA. Efforts to improve awareness of the association of OSA with T2DM and to implement OSA screening tools should target primary care physicians.

Diverticulite de apêndice cecal; relato de caso / Diverticulitis of cecal appendix; a case report

Os autores apresentam o relato de um caso de diverticulose apendicular com diverticulite associada. A histologia, formas clínicas e diagnóstico diferencial com apendicite aguda säo discutidos