Sexually Transmitted Infections: Recommendations from the U.S. Preventive Services Task Force.

The U.S. Preventive Services Task Force (USPSTF) has issued recommendations on behavioral counseling to prevent sexually transmitted infections (STIs) and recommendations about screening for individual STIs. Clinicians should obtain a sexual history to assess for behaviors that increase a patient's risk. Community and population risk factors should also be considered. The USPSTF recommends intensive behavioral counseling for all sexually active adolescents and for adults whose history indicates an increased risk of STIs. These interventions can reduce STI acquisition and risky sexual behaviors, and increase condom use and other protective behaviors. The USPSTF recommends screening for chlamydia and gonorrhea in all sexually active women 24 years and younger, and in older women at increased risk. It recommends screening for human immunodeficiency virus (HIV) infection in all patients 15 to 65 years of age regardless of risk, as well as in younger and older patients at increased risk of HIV infection. The USPSTF also recommends screening for hepatitis B virus infection and syphilis in persons at increased risk. All pregnant women should be tested for hepatitis B virus infection, HIV infection, and syphilis. Pregnant women 24 years and younger, and older women with risk factors should be tested for gonorrhea and chlamydia. The USPSTF recommends against screening for asymptomatic herpes simplex virus infection. There is inadequate evidence to determine the optimal interval for repeat screening; clinicians should rescreen patients when their sexual history reveals new or persistent risk factors.

Understanding the context of health for persons with multiple chronic conditions: moving from what is the matter to what matters.

PURPOSE: An isolated focus on 1 disease at a time is insufficient to generate the scientific evidence needed to improve the health of persons living with more than 1 chronic condition. This article explores how to bring context into research efforts to improve the health of persons living with multiple chronic conditions (MCC). METHODS: Forty-five experts, including persons with MCC, family and friend caregivers, researchers, policy makers, funders, and clinicians met to critically consider 4 aspects of incorporating context into research on MCC: key contextual factors, needed research, essential research methods for understanding important contextual factors, and necessary partnerships for catalyzing collaborative action in conducting and applying research. RESULTS: Key contextual factors involve complementary perspectives across multiple levels: public policy, community, health care systems, family, and person, as well as the cellular and molecular levels where most research currently is focused. Needed research involves moving from a disease focus toward a person-driven, goal-directed research agenda. Relevant research methods are participatory, flexible, multilevel, quantitative and qualitative, conducive to longitudinal dynamic measurement from diverse data sources, sufficiently detailed to consider what works for whom in which situation, and generative of ongoing communities of learning, living and practice. Important partnerships for collaborative action include cooperation among members of the research enterprise, health care providers, community-based support, persons with MCC and their family and friend caregivers, policy makers, and payers, including government, public health, philanthropic organizations, and the business community. CONCLUSION: Consistent attention to contextual factors is needed to enhance health research for persons with MCC. Rigorous, integrated, participatory, multimethod approaches to generate new knowledge and diverse partnerships can be used to increase the relevance of research to make health care more sustainable, safe, equitable and effective, to reduce suffering, and to improve quality of life.

Enhancing the primary care team to provide redesigned care: the roles of practice facilitators and care managers.

Efforts to redesign primary care require multiple supports. Two potential members of the primary care team-practice facilitator and care manager-can play important but distinct roles in redesigning and improving care delivery. Facilitators, also known as quality improvement coaches, assist practices with coordinating their quality improvement activities and help build capacity for those activities-reflecting a systems-level approach to improving quality, safety, and implementation of evidence-based practices. Care managers provide direct patient care by coordinating care and helping patients navigate the system, improving access for patients, and communicating across the care team. These complementary roles aim to help primary care practices deliver coordinated, accessible, comprehensive, and patient-centered care.

Projecting US primary care physician workforce needs: 2010-2025.

PURPOSE: We sought to project the number of primary care physicians required to meet US health care utilization needs through 2025 after passage of the Affordable Care Act. METHODS: In this projection of workforce needs, we used the Medical Expenditure Panel Survey to calculate the use of office-based primary care in 2008. We used US Census Bureau projections to account for demographic changes and the American Medical Association's Masterfile to calculate the number of primary care physicians and determine the number of visits per physician. The main outcomes were the projected number of primary care visits through 2025 and the number of primary care physicians needed to conduct those visits. RESULTS: Driven by population growth and aging, the total number of office visits to primary care physicians is projected to increase from 462 million in 2008 to 565 million in 2025. After incorporating insurance expansion, the United States will require nearly 52,000 additional primary care physicians by 2025. Population growth will be the largest driver, accounting for 33,000 additional physicians, while 10,000 additional physicians will be needed to accommodate population aging. Insurance expansion will require more than 8,000 additional physicians, a 3% increase in the current workforce. CONCLUSIONS: Population growth will be the greatest driver of expected increases in primary care utilization. Aging and insurance expansion will also contribute to utilization, but to a smaller extent.

Reduction of N-terminal methionylation while increasing titer by lowering metabolic and protein production rates in E. coli auto-induced fed-batch fermentation.

A standard fed-batch fermentation process using 1 mM isopropyl-ß-D: -thiogalactopyranoside (IPTG) induction at 37 °C in complex batch and feed media had been developed for manufacturing of a therapeutic protein (TP) expressed in inclusion bodies (IBs) by E. coli BL21 (DE3) driven by T7 promoter. Six unauthentic TP N-terminal variants were identified, of which methionylated TP (Met-TP) ratio was predominant. We hypothesized that lowering metabolic and protein production rates would reduce the Met-TP ratio while improving TP titer. The standard process was surprisingly auto-induced without added IPTG due to galactose in the complex media. Without changing either the clone or the batch medium, a new process was developed using lower feed rates and auto-induction at 29 °C after glucose depletion while increasing induction duration. In comparison to the standard process, the new process reduced the unauthentic Met-TP ratio from 23.6 to 9.6 %, increased the TP titer by 85 %, and the specific production yield from 210 to 330 mg TP per gram of dry cell weight. Furthermore, the TP recovery yield in the purified IBs was improved by ~20 %. Adding together, ~105 % more TP recovered in the purified IBs from per liter of fermentation broth for the new process than the standard process. The basic principles of lowering metabolic and production rates should be applicable to other recombinant protein production in IBs by fed-batch fermentations.

Early evaluations of the medical home: building on a promising start.

OBJECTIVES: To systematically review the current evidence on the patient-centered medical home (PCMH, or medical home), which aims to reinvigorate primary care and achieve the triple aim of better quality, improved experience, and lower costs. STUDY DESIGN: Systematic review of quantitative evidence on the PCMH. METHODS: Out of 498 studies published or disseminated from January 2000 to September 2010 on US-based interventions, 14 evaluations of 12 interventions met our inclusion criteria: (1) tested a practice-level intervention with 3 or more of 5 key PCMH components and (2) conducted a quantitative study of one of the triple aim outcomes or of healthcare professional experience. We synthesized findings on interventions that were evaluated using rigorous methods. We also provide guidance to structure future evaluations to maximize learning. RESULTS: The interventions most often cited to support the medical home can be viewed as precursors to the medical home. Evaluations of 6 of these interventions provided rigorous evidence on 1 or more outcomes. This evidence indicates some favorable effects on all 3 triple aim outcomes, a few unfavorable effects on costs, and many inconclusive results. CONCLUSIONS: Although the PCMH is a promising innovation, rigorous quantitative evaluations and comprehensive implementation analyses are needed to assess effectiveness and refine the model to meet stakeholders' needs. Findings from future evaluations will help guide the substantial efforts practices and payers invest to adopt the PCMH with the goal of achieving the triple aim outcomes.

Screening for chlamydial infection: an evidence update for the U.S. Preventive Services Task Force.

BACKGROUND: Chlamydial infection is the most common sexually transmitted bacterial infection in the United States, with an estimated 3 million new cases annually. In 2001, the U.S. Preventive Services Task Force (USPSTF) recommended that clinicians screen all sexually active women at increased risk for infection for Chlamydia trachomatis. PURPOSE: To summarize a systematic evidence review commissioned by the USPSTF in preparation for an update of its 2001 recommendation. DATA SOURCES: English-language articles identified in PubMed between July 2000 and July 2005. Additional articles were identified by bibliographic reviews and discussions with experts. A total of 452 articles were identified. STUDY SELECTION: Explicit inclusion and exclusion criteria were used for each of 3 key questions. For studies of screening in nonpregnant women at increased risk, review was limited to randomized, controlled trials. For other groups, both randomized, controlled studies and nonrandomized, prospective, controlled studies were included. DATA ABSTRACTION: Using standardized forms, staff of the Agency for Healthcare Research and Quality abstracted data on study design, setting, sample, randomization, blinding, results, and harms. DATA SYNTHESIS: Only 1 new study met inclusion criteria. This poor-quality study of the effectiveness of screening for chlamydial infection among nonpregnant women at increased risk found that screening was associated with a lower prevalence of chlamydial infection and fewer reported cases of pelvic inflammatory disease at 1-year follow-up. LIMITATIONS: No new evidence was found on screening in pregnant women, nonpregnant women not at increased risk, or men. CONCLUSIONS: A systematic review found a small amount of new evidence to inform the USPSTF as it updates its recommendations regarding screening for chlamydial infection. There are large gaps in the evidence about screening men to improve health outcomes in women.

Primary care physicians' perceptions of the effect of insurance status on clinical decision making.

PURPOSE: Americans who do not have health insurance receive fewer health services and have poorer health status than those who have insurance. To better understand this disparity, in this study we characterize primary care physician's perceptions of what effect, if any, patients' insurance status has on their clinical decision making during office visits. METHODS: Twenty-five physician members of CAPRICORN, a primary care practice-based research network in metropolitan Washington, DC, completed a brief paper-card survey instrument immediately after each patient encounter during 2 half-day office sessions. Participants saw patients in their usual manner and were given no additional information about their patients or their insurance. RESULTS: Eighty-eight percent of participating physicians reported making at least 1 change in clinical management as a result of a patient's insurance status. They reported altering their management during 99 of 409 patient encounters (24.2%). There was a significant difference in the percentage of visits that involved a change in management for privately insured, publicly insured, and uninsured patients (18.7%, 29.5%, and 43.5% respectively, P = .01). Physicians reported discussing insurance issues with patients during 62.6% of visits during which they made a change in management based on insurance status. CONCLUSION: Physicians incorporate their patients' insurance status into their clinical decision making and acknowledge they frequently alter their clinical management as a result. Additional research is needed to understand the effect of these changes on patient health and to assist both physicians and patients in enhancing the quality of care delivered within the constraints of the current insurance system.

Variation in participation in health care settings associated with race and ethnicity.

OBJECTIVE: To use the ecology model of health care to contrast participation of black, non-Hispanics (blacks); white, non-Hispanics (whites); and Hispanics of any race (Hispanics) in 5 health care settings and determine whether disparities between those individuals exist among places where they receive care. DESIGN: 1996 Medical Expenditure Panel Survey data were used to estimate the number of black, white, and Hispanic people per 1,000 receiving health care in each setting. SETTING: Physicians' offices, outpatient clinics, hospital emergency departments, hospitals, and people's homes. MAIN MEASUREMENT: Number of people per 1,000 per month who had at least one contact in a health care setting. RESULTS: Fewer blacks and Hispanics than whites received care in physicians' offices (154 vs 155 vs 244 per 1,000 per month, respectively) and outpatient clinics (15 vs 12 vs 24 per 1,000 per month, respectively). There were no significant differences in proportions hospitalized or receiving care in emergency departments. Fewer Hispanics than blacks or whites received home health care services (7 vs 14 vs 14 per 1,000 per month, respectively). After controlling for 7 variables, blacks and Hispanics were less likely than whites to receive care in physicians' offices (odds ratio [OR], 0.65, 95% confidence interval [CI], 0.60 to 0.69 for blacks and OR, 0.79, 95% CI, 0.73 to 0.85 for Hispanics), outpatient clinics (OR, 0.73, 95% CI, 0.60 to 0.90 for blacks and OR, 0.71, 95% CI, 0.58 to 0.88 for Hispanics), and hospital emergency departments (OR, 0.80, 95% CI, 0.69 to 0.94 for blacks and OR, 0.80, 95% CI, 0.68 to 0.93 for Hispanics) in a typical month. The groups did not differ in the likelihood of receiving care in the hospital or at home. CONCLUSIONS: Fewer blacks and Hispanics than whites received health care in physicians' offices, outpatient clinics, and emergency departments in contrast to hospitals and home care. Research and programs aimed at reducing disparities in receipt of care specifically in the outpatient setting may have an important role in the quest to reduce racial and ethnic disparities in health.

The association of Title VII funding to departments of family medicine with choice of physician specialty and practice location.

BACKGROUND: Title VII predoctoral and departmental grants for departments of family medicine are intended to increase the number of family and primary care physicians in the United States and increase the number of practices in rural and underserved communities. This study assessed the relationships of Title VII funding with physicians' choices of practice specialty and location. METHODS: Non-federal direct patient care physicians who graduated from US medical schools from 1981-1993 were identified in the 2000 American Medical Association Masterfile. A grant history file was used to annotate Masterfile records with Title VII funding data for the physicians' 4-year medical school enrollment. Characteristics of the county in which they practice were taken from the Area Resource File. Title VII funding variables were then related to practice specialty and location. RESULTS: Predoctoral training and departmental development funding were strongly related to attainment of each of the Title VII program objectives evaluated. CONCLUSIONS: Title VII has been successful in achieving its stated goals and legislative intent and has had an important role in addressing US physician workforce policy issues.