Bridging the Gap Between Symptom Onset and Diagnosis in Axial Spondyloarthritis.

OBJECTIVE: To evaluate a stratified screening process for the early identification of axial spondyloarthritis (SpA) with consideration of the following: 1) wait times from primary care to rheumatology screen, 2) incremental precision and accuracy from primary care to rheumatology screening, and 3) diagnostic delay. METHODS: Adults with low back pain attending primary care at low back pain clinics prospectively underwent a primary standardized clinical screening. Patients with low back pain of >3 months who experienced symptom onset at age <50 years were referred for a comprehensive secondary screening by a physical therapist with advanced rheumatology training. At secondary screening, patients with features of inflammation were classified as being at a low, medium, or high risk for axial SpA versus no risk for axial SpA. Precision and accuracy of this screening strata were measured against a rheumatologist with expertise in axial SpA. RESULTS: Overall, 405 patients underwent primary and secondary screening in the present study. The study cohort had a mean ± SD age of 36.9 ± 9.9 years, and 55% were women. HLA-B27 was present in 14.4% of patients. Median wait time from primary screening to secondary screening was 15 days. Axial SpA risk assignment by rheumatologist was 64.9% for no risk or low risk for axial SpA and 35.1% for medium risk or high risk for axial SpA. The best combination of sensitivity (68%), specificity (90%), positive predictive values (80%), and negative predictive values (84%) was evident in the secondary screening. In this cohort, 15.6% of patients received a final diagnosis of axial SpA. Median low back pain duration from symptom onset to diagnosis was 2 years for nonradiographic axial SpA and 7 years for ankylosing spondylitis. CONCLUSION: A stratified interprofessional screening process can facilitate rapid diagnosis of persistent low back pain with high precision and accuracy in patients who have axial SpA.

Development and evaluation of a primary care antimicrobial stewardship program (PC-ASP) in Toronto, Ontario, Canada.

Background: Effective community-based antimicrobial stewardship programs (ASPs) are needed because 90% of antimicrobials are prescribed in the community. A primary care ASP (PC-ASP) was evaluated for its effectiveness in lowering antibiotic prescriptions for six common infections. Methods: A multi-faceted educational program was assessed using a before-and-after design in four primary care clinics from 2015 through 2017. The primary outcome was the difference between control and intervention clinics in total antibiotic prescriptions for six common infections before and after the intervention. Secondary outcomes included changes in condition-specific antibiotic use, delayed antibiotic prescriptions, prescriptions exceeding 7 days duration, use of recommended antibiotics, and emergency department visits or hospitalizations within 30 days. Multi-method models adjusting for demographics, case mix, and clustering by physician were used to estimate treatment effects. Results: Total antibiotic prescriptions in control and intervention clinics did not differ (difference in differences = 1.7%; 95% CI -12.5% to 15.9%), nor did use of delayed prescriptions (-5.2%; 95% CI -24.2% to 13.8%). Prescriptions for longer than 7 days were significantly reduced (-21.3%; 95% CI -42.5% to -0.1%). However, only 781 of 1,777 encounters (44.0%) involved providers who completed the ASP education. Where providers completed the education, delayed prescriptions increased 17.7% (p = 0.06), and prescriptions exceeding 7 days duration declined (-27%; 95% CI -48.3% to -5.6%). Subsequent emergency department visits and hospitalizations did not increase. Conclusions: PC-ASP effectiveness on antibiotic use was variable. Shorter prescription durations and increased use of delayed prescriptions were adopted by engaged primary care providers.

Historique: Des programmes de gestion antimicrobienne (PGA) communautaires efficaces doivent exister, parce que 90 % des antimicrobiens sont prescrits dans la communauté. Des chercheurs ont évalué un PGA en première ligne (PGA-PL) afin d'en déterminer l'efficacité à réduire les prescriptions d'antibiotiques pour six infections courantes. Méthodologie: Les chercheurs ont évalué un programme de formation polyvalent au moyen d'une méthodologie avant-après dans quatre cliniques de soins de première ligne entre 2015 et 2017. Le résultat clinique primaire était la différence entre les cliniques de contrôle et d'intervention pour ce qui est du total de prescriptions antibiotiques contre six infections courantes avant et après l'intervention. Les résultats cliniques secondaires incluaient des modifications à l'utilisation des antibiotiques propres au trouble de santé, le report des prescriptions d'antibiotiques, des prescriptions de plus de sept jours, l'utilisation des antibiotiques recommandés et les visites à l'urgence ou les hospitalisations dans les 30 jours. Les chercheurs ont utilisé des méthodes multimodèles tenant compte de la démographie, du mélange de cas et du regroupement par médecin pour évaluer l'effet des traitements. Résultats: Les prescriptions totales d'antibiotiques dans les cliniques de contrôle et d'intervention ne différaient pas (différences des différences = 1,7 %; IC à 95 %, ­12,5 % à 15,9 %), ni l'utilisation de prescriptions reportées (­5,2 %; IC à 95 %, ­24,2 % à 13,8 %). Les prescriptions de plus de sept jours étaient très peu courantes (­21,3 %; IC à 95 %, ­42,5 % à ­0,1 %). Cependant, seulement 781 des 1 777 rencontres (44,0 %) avaient eu lieu avec des dispensateurs qui avaient suivi la formation sur le PGA. Lorsque les dispensateurs avaient suivi la formation, les reports de prescriptions augmentaient de 17,7 % (p = 0,06) et les prescriptions de plus de sept jours diminuaient (­27 %; IC à 95 %, ­48,3 % à ­5,6 %). Les visites subséquentes à l'urgence et les hospitalisations n'ont pas augmenté. Conclusions: L'efficacité du PGA-PL pour l'utilisation d'antibiotiques était variable. Les dispensateurs de soins de première ligne qui y avaient participé préparaient des prescriptions de moins longue durée et reportaient davantage leurs prescriptions.

Academic family health teams: Part 2: patient perceptions of access.

OBJECTIVE: To explore patients' perceptions of primary care (PC) in the early development of academic family health teams (aFHTs)--interprofessional PC teams delivering care where family medicine and other health professional learners are trained--focusing on patients' perceptions of access and patients' satisfaction with services. DESIGN: Self-administered survey. SETTING: Six aFHTs in Ontario. PARTICIPANTS: Adult patients attending appointments and administrators at each of the aFHTs. MAIN OUTCOME MEASURES: Answers to questions about access from the Primary Care Assessment Tool Adult Expanded Version, the Primary Care Assessment Survey, and research team questions. RESULTS: The response rate was 47.3% (1026 of 2167). The mean (SD) Primary Care Assessment Tool first-contact accessibility score was 2.28 (0.36) out of 4, with 96.5% of patients rating access less than 3, which was the minimum expected level of care. Two-thirds (66.6%) indicated someone from their aFHTs would definitely or probably see them the same day if they were sick, 56.8% could definitely or probably get advice quickly by telephone, and 14.5% indicated it was definitely or probably difficult to be seen by their primary health care provider (HCP). Additionally, 46.9% indicated they would like to get medical advice by e-mail. For a routine or follow-up visit, 73.4% would be willing to see another aFHT physician if their regular provider were unavailable, while only 48.3% would see a nonphysician HCP. If sick, 88.2% would see another aFHT physician and 55.2% would see a nonphysician HCP. Most (75.3%) were satisfied with access to their regular HCP. CONCLUSION: Although patients are generally satisfied with care, there is room for improvement in access. Strategies are needed to enhance access to care, including addressing appropriate roles and scopes of practice for nonphysician HCPs. The accessibility challenges for aFHTs will likely affect new family physicians and other HCPs training in these practices and their approach to future practice.

Academic family health teams: Part 1: patient perceptions of core primary care domains.

OBJECTIVE: To explore patients' perceptions of primary care (PC) in the early development of academic family health teams (aFHTs)--interprofessional PC teams delivering care where family medicine and other health professional learners are trained--focusing on the 4 core domains of PC. DESIGN: Self-administered survey using the Primary Care Assessment Tool Adult Expanded Version (PCAT), which addresses 4 core domains of PC (first contact, continuity, comprehensiveness, and coordination). The PCAT uses a 4-point Likert scale (from definitely not to definitely) to capture patients' responses about the occurrence of components of care. SETTING: Six aFHTs in Ontario. PARTICIPANTS: Adult patients attending appointments and administrators at each of the aFHTs. MAIN OUTCOME MEASURES: Mean PCAT domain scores, with a score of 3 chosen as the minimum expected level of care. Multivariate log binomial regression models were used to estimate the adjusted relative risks of PCAT score levels as functions of patient- and clinic-level characteristics. RESULTS: The response rate was 47.3% (1026 of 2167). The mean age of respondents was 49.6 years, and most respondents were female (71.6%). The overall PC score (2.92) was just below the minimum expected care level. Scores for first contact (2.28 [accessibility]), coordination of information systems (2.67), and comprehensiveness of care (2.83 [service available] and 2.36 [service provided]) were below the minimum. Findings suggest some patient groups might not be optimally served by aFHTs, particularly recent immigrants. Characteristics of aFHTs, including a large number of physicians, were not associated with high performance on PC domains. Distributed practices across multiple sites were negatively associated with high performance for some domains. The presence of electronic medical records was not associated with improved performance on coordination of information systems. CONCLUSION: Patients of these aFHTs rated several core domains of PC highly, but results indicate room for improvement in several domains, particularly first-contact accessibility. A future study will determine what changes were implemented in these aFHTs and if patient ratings have improved. This reflective process is essential to ensuring that aFHTs provide effective models of PC to learners of all disciplines.

Magnetic resonance imaging features of osseous manifestations of early acquired syphilis.

We report the case of a 64-year-old man who initially presented with a maculopapular rash followed several weeks later by bilateral shin pain and infiltrative cutaneous lesions over the lower legs. The plain radiographs were not contributory, and the patient was referred for a whole-body bone scan, which demonstrated multifocal osseous lesions, including such lesions in the lower legs, skull and facial bones. Magnetic resonance imaging (MRI) demonstrated numerous small tibial and fibular nodular lesions involving the medullary cavity and the cortex. A diagnosis of acquired syphilis was made, based on skin biopsy. Results of serological testing were consistent with recent infection. The patient was treated with intramuscular injection of penicillin, and follow-up MRI demonstrated gradual resolution of the osseous lesions. Bone involvement is a relatively rare manifestation of early acquired syphilis. Although the plain radiographic features of the bony changes in acquired syphilis are well documented, there have been no reports of the magnetic resonance imaging findings in the appendicular skeleton.

Enhancing continuity of information: essential components of consultation reports.

OBJECTIVE: To identify elements of data that have been shown to contribute to continuity of information between primary care providers and medical specialists providing care to adult asthma patients. DESIGN: Systematic review of the literature followed by a 2-round modified Delphi consensus process. SETTING: Province of Ontario. PARTICIPANTS: Eight expert panelists, including 3 practising family physicians, a medical specialist knowledgeable in the treatment of asthma, a family physician previously involved in provincial initiatives related to primary care reform, an e-health technologist, a developer of evidence-based guidelines, and an operations and programs specialist. METHODS: We completed a systematic literature review to identify important components of consultation reports. We then engaged an 8-member panel in a 2-round modified Delphi consensus process, which led to the identification of components deemed essential to good continuity of information. MAIN FINDINGS: After 2 rounds, expert panelists reached consensus on 15 components, referred to here as minimum essential elements, of consultation reports generated by medical specialists in response to referring primary care providers' consultation requests. CONCLUSION: The expert panelists considered inclusion of the minimum essential elements in consultation reports essential to achieving good continuity of information. We assembled these elements in a suggested format for a consultation report. The format can be easily modified by practitioners caring for patients with other chronic diseases.

Enhancing continuity of information: essential components of a referral document.

OBJECTIVE: To identify elements of data that have been shown to contribute to continuity of information between primary care providers and medical specialists providing care to adult asthma patients. DESIGN: Systematic review of the literature followed by a 2-round modified Delphi consensus process. SETTING: Province of Ontario. PARTICIPANTS: Eight expert panelists, including 3 practising family physicians, a medical specialist knowledgeable in the treatment of asthma, a family physician previously involved in provincial initiatives related to primary care reform, an e-health technologist, a developer of evidence-based guidelines, and an operations and programs specialist. METHOD: We completed a systematic literature review to develop a list of items or data elements related to patient information transfer in chronic care. We engaged an 8-member expert panel in a 2-round modified Delphi process to assess the importance of the 74 data elements identified in the literature review and to identify any additional important elements. MAIN FINDINGS: The expert panelists reached consensus on 24 components of information, referred to here as minimum essential elements of a referral document, needed for consultations on adult asthma patients. CONCLUSION: The 24 minimum essential elements of information that should be transferred during referral of asthma patients from primary care providers to experts in asthma care were generated by primary care physicians and thought essential for achieving continuity in information transfer. We assembled these elements into a suggested format for a referral document. The format can be easily modified by practitioners caring for patients with other chronic diseases.