Sampling from different populations: Sociodemographic, clinical, and functional differences between samples of first episode psychosis individuals and clinical high-risk individuals who progressed to psychosis.

Over the past two decades, research and clinical resources on clinical high risk (CHR) for psychosis have both expanded, with goals to better understanding risk and protective factors on the course of illness and inform early intervention efforts. However, some studies have highlighted potential sampling bias among CHR research studies, raising questions about generalizability of findings and inequitable access to early detection and intervention. The current study sought to explore these questions by comparing 94 participants in a CHR longitudinal monitoring study across North America (NAPLS-2) who converted to syndromal psychosis over the course of the study (CHR-CV) to 171 participants who presented for treatment at a localized first-episode psychosis service (FES) after converting. CHR-CV participants were significantly more likely to be White and have a college-educated parent, while FES participants were more likely to be Black and first- or second-generation immigrants. On average, CHR-CV participants were younger at onset of attenuated positive symptoms, had a longer period of attenuated symptoms prior to conversion, and were more likely to be treated with antipsychotics prior to conversion compared to those in FES programs. After controlling for time since conversion, CHR-CV participants had higher global functioning and were less likely to have experienced recent psychiatric hospitalization. Findings suggest that CHR research and FES clinics may be sampling from different populations, although conclusions are limited by inconsistent sampling frames and methods. Integrated early detection that targets defined geographic catchments may deliver more epidemiologically representative samples to both CHR research and FES.

Trauma and Suicide: A Pilot Study Assessing Risk in Adults Diagnosed With Schizophrenia Spectrum Disorders.

This pilot study explored suicide risk in patients suffering from trauma and psychosis. Forty-seven participants diagnosed with schizophrenia spectrum disorders participated in the study. An archival design was used to identify the severity of suicide risk in participants with trauma and psychosis. Data included a chart review of documented trauma and responses to the Childhood Experience of Care and Abuse Questionnaire, Columbia-Suicide Severity Rating Scale, Beck Depression Inventory-II, and the Positive and Negative Syndrome Scale. Results of a linear regression indicated that chart-documented trauma and heightened depression scores were predictive of increased suicidality. Results suggest that, for patients with schizophrenia, depression severity and chart-documented trauma may be strong predictors of suicidality. Interestingly, data also revealed that, although depression and trauma were predictors of suicidality, psychosis was not. The implications of these results are discussed, in addition to suggestions for future research.

Closing the loop with an enhanced referral management system.

Objective: To evaluate the impact of a referral manager tool on primary care practices. Materials and Methods: We evaluated a referral manager module in a locally developed electronic health record (EHR) that was enhanced to improve the referral management process in primary care practices. Baseline (n = 61) and follow-up (n = 35) provider and staff surveys focused on the ease of performing various steps in the referral process, confidence in completing those steps, and user satisfaction. Additional metrics were calculated that focused on completed specialist visits, acknowledged notes, and patient communication. Results: Of 1341 referrals that were initiated during the course of the study, 76.8% were completed. All the steps of the referral process were easier to accomplish following implementation of the enhanced referral manager module in the EHR. Specifically, tracking the status of an in-network referral became much easier (+1.43 [3.91-2.48] on a 5-point scale, P < .0001). Although we found improvement in the ease of performing out-of-network referrals, there was a greater impact on in-network referrals. Discussion: Implementation of an electronic tool developed using user-centered design principles along with adequate staff to monitor and intervene when necessary made it easier for primary care practices to track referrals and to identify if a breakdown in the process occurred. This is especially important for high-priority referrals. Out-of-network referrals continue to present challenges, which may eventually be helped by improving interoperability among EHRs and scheduling systems. Conclusion: An enhanced referral manager system can improve referral workflows, leading to enhanced efficiency and patient safety and reduced malpractice risk.

An intraorganizational model for developing and spreading quality improvement innovations.

BACKGROUND: Recent policy reforms encourage quality improvement (QI) innovations in primary care, but practitioners lack clear guidance regarding spread inside organizations. PURPOSE: We designed this study to identify how large organizations can facilitate intraorganizational spread of QI innovations. METHODOLOGY/APPROACH: We conducted ethnographic observation and interviews in a large, multispecialty, community-based medical group that implemented three QI innovations across 10 primary care sites using a new method for intraorganizational process development and spread. We compared quantitative outcomes achieved through the group's traditional versus new method, created a process model describing the steps in the new method, and identified barriers and facilitators at each step. FINDINGS: The medical group achieved substantial improvement using its new method of intraorganizational process development and spread of QI innovations: standard work for rooming and depression screening, vaccine error rates and order compliance, and Pap smear error rates. Our model details nine critical steps for successful intraorganizational process development (set priorities, assess the current state, develop the new process, and measure and refine) and spread (develop support, disseminate information, facilitate peer-to-peer training, reinforce, and learn and adapt). Our results highlight the importance of utilizing preexisting organizational structures such as established communication channels, standardized roles, common workflows, formal authority, and performance measurement and feedback systems when developing and spreading QI processes inside an organization. In particular, we detail how formal process advocate positions in each site for each role can facilitate the spread of new processes. PRACTICE IMPLICATIONS: Successful intraorganizational spread is possible and sustainable. Developing and spreading new QI processes across sites inside an organization requires creating a shared understanding of the necessary process steps, considering the barriers that may arise at each step, and leveraging preexisting organizational structures to facilitate intraorganizational process development and spread.

Pharmacy dispensing of electronically discontinued medications.

BACKGROUND: Most physician offices do not transmit orders for medication discontinuation to the pharmacy, creating the potential for errors in dispensing of previously prescribed medications. Electronic health records offer the potential to assess this patient safety concern. OBJECTIVE: To assess the frequency of and potential patient harm associated with pharmacy dispensing of discontinued medications in the ambulatory setting. DESIGN: Retrospective cohort study. SETTING: Multispecialty group practice in eastern Massachusetts using an electronic health record. PATIENTS: 30 406 adult patients with an electronic discontinuation order for antihypertensive, antiplatelet, anticoagulant, oral hypoglycemic, and statin medications between November 2008 and October 2009. MEASUREMENTS: Dispensing of discontinued medications within 12 months and associated potential patient harm. RESULTS: Among 83 902 targeted medications that were electronically discontinued, 1218 (1.5% [95% CI, 1.4% to 1.5%]) were subsequently dispensed by the pharmacy a mean of 1.0 (SD, 0.3) time during the 12-month follow-up. Among the top 10 most frequently electronically discontinued medications, the rate of subsequent dispensing by a pharmacy ranged from 0.9% for metformin to 2.5% for metoprolol. Manual chart review of 416 medication-dispensing events that were predefined as high risk according to an automated algorithm identified potential harm in 50 (12%) cases, including clinical reactions (n = 18), laboratory abnormalities (n = 17), duplicated medication classes dispensed (n = 8), and potential allergic reactions (n = 7). LIMITATION: Information on pharmacy dispensing was available for only 52% of medication orders. CONCLUSION: The dispensing of discontinued medications represents an important ambulatory patient safety concern. Electronic health records should be used to facilitate better communication between providers and pharmacies and improve medication safety. PRIMARY FUNDING SOURCE: National Institutes of Health.

Clinician personality and the evaluation of higher-risk patient symptoms.

BACKGROUND: : Acute myocardial infarction, breast cancer, and colorectal cancer are among the most commonly misdiagnosed conditions in primary care, and there is little information regarding physician decision making in this area. METHODS: : We measured clinician risk tolerance and stress from uncertainty among 193 primary care clinicians and determined their association with management of patients presenting with chest pain (n = 700), breast lumps (n = 630), or rectal bleeding (n = 470). We used the 6-item Jackson Personality Inventory (JPI) and the 13-item Stress from Uncertainty Scale (SUS). Extended evaluation was defined as performance of electrocardiogram, cardiac stress testing, or emergency department triage for patients with chest pain; mammography, ultrasound, or surgical referral for patients with breast lumps; and colonoscopy or gastroenterology referral for patients with rectal bleeding. We fit multivariable logistic regression models to determine the association between survey scores and performance of extended evaluation. RESULTS: : The response rate was 79% for the JPI survey and 73% for the SUS survey. The mean JPI score was 8.9 (SD, 4.5) and the mean SUS score was 32.6 (SD, 10.4). Extended evaluation occurred for 60% of patients with chest pain, 93% of patients with breast lumps, and 63% of patients with rectal bleeding. Scores in JPI and SUS were not associated with rates of extended evaluation. CONCLUSIONS: : Primary care clinician risk tolerance and stress from uncertainty were not associated with evaluation decisions. Future research is needed to improve the consistency of evaluations to improve ambulatory patient safety.

Primary care management of chronic kidney disease.

BACKGROUND: Chronic kidney disease (CKD) causes substantial morbidity and mortality; however, there are limited data to comprehensively assess quality of care in this area. OBJECTIVE: To assess quality of care for CKD according to patient risk and identify correlates of improved care delivery. DESIGN: Retrospective cohort. SETTING: Fifteen health centers within a multi-site group practice in eastern Massachusetts. PARTICIPANTS: 166 primary care physicians caring for 11,774 patients with stages 3 or 4 CKD defined as two estimated glomerular filtration rates (eGFR) between 15 and 60. MAIN MEASURES: Two measures of kidney disease monitoring, five measures of cardiovascular disease management, four measures of metabolic bone disease and anemia management, and one measure of drug safety were extracted from the electronic health record. Primary care recognition of CKD was assessed as a problem list diagnosis, and nephrology co-management was assessed as at least one visit with a nephrologist in the prior 12 months. KEY RESULTS: Overall, 46% of patients were high risk for death based on the presence of diabetes, proteinuria, or an eGFR <45. Seventy percent of patients lacked annual urine protein testing, 46% had a blood pressure ≥130/80 mmHg and 25% were not receiving appropriate angiotensin blockade. Appropriate screening for anemia was common (76%), while screening rates for metabolic bone disease were low. Use of potentially harmful drugs was common (26%). Primary care physician recognition and nephrology co-management were both associated with improved quality of care, though rates of both were low (24% and 10%, respectively). CONCLUSIONS: Significant deficiencies in the quality of CKD care exist. Opportunities for improvement include increasing physician recognition of CKD and improving collaborative care with nephrology.