To give or not to give: Approaches to early childhood immunization delivery in Oregon rural primary care practices.

CONTEXT: Little is known about rural clinicians' perspectives regarding early childhood immunization delivery, their adherence to recommended best immunization practices, or the specific barriers they confront. PURPOSE: To examine immunization practices, beliefs, and barriers among rural primary care clinicians for children in Oregon and compare those who deliver all recommended immunizations in their practices with those who do not. METHODS: A mailed questionnaire was sent to all physicians, nurse practitioners, and physician assistants practicing primary care in rural communities throughout Oregon. FINDINGS: While 39% of rural clinicians reported delivering all childhood immunizations in their clinic, 43% of clinicians reported that they refer patients elsewhere for some vaccinations, and 18% provided no immunizations in the clinic whatsoever. Leading reasons for referral include inadequate reimbursement, parental request, and storage and stocking difficulties. Nearly a third of respondents reported that they had some level of concern about the safety of immunizations, and 14% reported that concerns about safety were a specific reason for referring. Clinicians who delivered only some of the recommended immunizations were less likely than nonreferring clinicians to have adopted evidence-based best immunization practices. CONCLUSIONS: This study of rural clinicians in Oregon demonstrates the prevalence of barriers to primary care based immunization delivery in rural regions. While some barriers may be difficult to overcome, others may be amenable to educational outreach and support. Thus, efforts to improve population immunization rates should focus on promoting immunization "best practices" and enhancing the capacity of practices to provide immunizations and ensuring that any alternative means of delivering immunizations are effective.

One practice's experiment in refusing detail rep visits.

PURPOSE: The physician-pharmaceutical industry relationship has come under increasing scrutiny. Little guidance exists concerning how smaller practices should manage this relationship.In 2006, Madras Medical Group, a small family practice in rural Oregon, implemented a policy prohibiting visits from representatives of the pharmaceutical industry and the acceptance of drug samples. This qualitative study documents the attitudes of clinic personnel in response to this policy. METHODS: Semistructured interviews were conducted using standardized questions related to 4 areas of policy perception: verification of policy decision, impact on clinic operations,influence of pharmaceutical industry, and lessons to share. Common themes were identified. RESULTS: Three physicians and 3 nurses participated in the study. There was consensus on the existence and effectiveness of the clinic policy. Key themes identified from both groups of interviewees included the perception of enhanced clinic operation after eliminating interruptions from pharmaceutical representatives, positive response from the public, and reduced diversion of samples for personal use. Clinicians interviewed agreed that samples were of questionable benefit,that information obtained from industry representatives was incomplete or of questionable veracity or objectivity, and that it was helpful to substitute other drug information sources and clinic-sponsored lunches for past industry offerings. CONCLUSION: In this case study, a policy prohibiting pharmaceutical representatives from a small family practice was well accepted and a source of pride among physicians and nurses. Other clinics wishing to enact a similar policy may wish to supplement their efforts by proactively using other sources of drug information.

Turning on the care coordination switch in rural primary care: voices from the practices--clinician champions, clinician partners, administrators, and nurse care managers.

This study sought to understand the acceptability and feasibility of office-based nurse care management in medium to large rural primary care practices. A qualitative assessment of Care Management Plus (a focused medical home model for complex patients) implementation was conducted using semistructured interviews with 4 staff cohorts. Cohorts included clinician champions, clinician partners, practice administrators, and nurse care managers. Seven key implementation attributes were: a proven care coordination program; adequate staffing; practice buy-in; adequate time; measurement; practice facilitation; and functional information technology. Although staff was positive about the care coordination concept, model acceptability was varied and additional study is required to determine sustainability.

Emergency department coverage by primary care physicians in a rural practice-based research network: incentives, confidence, and training.

CONTEXT: In rural areas of the United States, emergency departments (EDs) are often staffed by primary care physicians, as contrasted to urban and suburban hospitals where ED coverage is usually provided by physicians who are residency-trained in emergency medicine. PURPOSE: This study examines the reasons and incentives for rural Oregon primary care physicians to cover the ED and their reported measures of confidence and priorities for additional training. METHODS: We conducted a cross-sectional survey of primary care physicians in rural Oregon who are members of the Oregon Rural Practice-Based Research Network (ORPRN). The survey was sent to 70 primary care physicians in 27 rural Oregon practices. FINDINGS: Fifty-two of 70 (74%) ORPRN physicians representing 24 practices returned the questionnaire. Nineteen of the 52 responding physicians reported covering the ED. The majority (75%) of physicians covering the ED did so as a requirement for practice employment and/or hospital privileges. Physicians covering the ED reported low confidence in pediatric emergencies and expressed the need for additional training in pediatric emergencies as their top priority. CONCLUSIONS: Almost two fifths of surveyed primary care physicians in a rural practice-based research network provide ED coverage. Based on these physicians' low levels of confidence and desire for additional training in pediatric emergencies, effective education models are needed for physicians covering the ED at their rural hospitals.

Outcomes for rural Medicaid clients with severe mental illness in fee for service versus managed care.

This study compared outcomes for rural Medicaid clients with severe mental illness in fee for service versus managed care programs. Interviews were conducted with 305 Medicaid clients in rural Oregon (166 in fee for service and 139 in managed care). Logistic and multivariate regression analyses were used to examine client satisfaction, safety, symptoms, functioning, and family satisfaction in the fee for service versus managed care groups. There was no evidence that conversion of the Medicaid mental health system from fee for service to managed care led to changes in outcomes for rural clients with severe mental illness.

Validity and reliability of an inpatient severity of psychiatric illness measure.

Inpatient psychiatric severity measures are often used but few psychometric data are available. This study evaluated the psychometric properties (reliability and validity) of a measure used to assess severity of psychiatric illness among inpatients. Using the severity measure, minimally trained raters conducted retrospective patient record reviews to assess medical necessity for psychiatric hospitalization. The data analysis compared 135 civilly committed psychiatric inpatients with a heterogeneous group of 248 psychiatric inpatients at a general hospital. The severity measure showed acceptable inter-rater reliability in both populations. Two-way analysis of variance showed that the intra-class correlation coefficient for the total score was 0.65 for general hospital subjects and 0.63 for civilly committed subjects. Differences in mean scores were substantial (15 out of a possible 75 points for general hospital subjects versus 42 for civilly committed subjects, Mann-Whitney U = 562, p < 0.001). As expected, all civilly committed subjects were well above admission cut-off score of 12, versus only 64% of the general hospital patients. The measure is appropriate for retrospective severity assessment and may also be useful for pre-admission screening.

Outcomes of patients in a low-intensity, short-duration involuntary outpatient commitment program.

This study examined the outcomes of patients in a low-intensity, short-duration involuntary outpatient commitment program. After release from inpatient commitment, one group (N = 150) entered an involuntary outpatient commitment program that lasted up to six months; a comparison group (N = 140) was released into the community without further involuntary care. After the analysis adjusted for confounding variables, patients who were in the involuntary outpatient commitment program had greater use of follow-up outpatient and residential services and psychotropic medications than patients in the comparison group. No differences were found between the groups in follow-up acute psychiatric hospitalization or arrests. Low-intensity, short-duration involuntary outpatient commitment appears to have a limited, but important, impact.

Psychiatric hospital length of stay for Medicaid clients before and after managed care.

Managed care systems allegedly discharge psychiatric inpatients "quicker and sicker" than fee-for-service programs. Study subjects were admitted to a general hospital that served adjacent counties. During 1994, both counties operated fee-for-service Medicaid mental health systems. In 1995, one county remained fee-for-service and the other assumed inpatient financial risk. Lengths of stay declined in both counties between 1994 and 1996. Managed care patients had longer lengths of stay than their fee-for-service counterparts (even after adjustment for confounders). Secular trends and practice patterns may influence length of stay more than managed care.