Beta Testing a Novel Smartphone Application to Improve Medication Adherence.

BACKGROUND: We developed and beta-tested a patient-centered medication management application, PresRx optical character recognition (OCR), a mobile health (m-health) tool that auto-populates drug name and dosing instructions directly from patients' medication labels by OCR. MATERIALS AND METHODS: We employed a single-subject design study to evaluate PresRx OCR for three outcomes: (1) accuracy of auto-populated medication dosing instructions, (2) acceptability of the user interface, and (3) patients' adherence to chronic medications. RESULTS: Eight patients beta-tested PresRx OCR. Five patients used the software for ≥6 months, and four completed exit interviews (n = 4 completers). At baseline, patients used 3.4 chronic prescription medications and exhibited moderate-to-high adherence rates. Accuracy of auto-populated information by OCR was 95% for drug name, 98% for dose, and 96% for frequency. Study completers rated PresRx OCR 74 on the System Usability Scale, where scores ≥70 indicate an acceptable user interface (scale 0-100). Adherence rates measured by PresRx OCR were high during the first month of app use (93%), but waned midway through the 6-month testing period (78%). Compared with pharmacy fill rates, PresRx OCR underestimated adherence among completers by 3%, while it overestimated adherence among noncompleters by 8%. DISCUSSION: Results suggest smartphone applications supporting medication management are feasible and accurately assess adherence compared with objective measures. Future efforts to improve medication-taking behavior using m-health tools should target specific patient populations and leverage common application programming interfaces to promote generalizability. CONCLUSIONS: Our medication management application PresRx OCR is innovative, acceptable for patient use, and accurately tracks medication adherence.

Self-report tool for recognizing mania (SToRM): a new scale for aiding in the diagnosis of bipolar disorder.

OBJECTIVE: Bipolar disorder is a disabling disease that is difficult to diagnose. Primary care physicians share in the burden of diagnosing and caring for significant mental illness, including bipolar disorder, but they lack an adequate screening and diagnostic tool that can fit into use in a primary care practice. Modeling after the Patient Health Questionnaire-9, we created the Self-report Tool for Recognizing Mania (SToRM) to aid primary care physicians in the screening and diagnosis of bipolar disorder. METHODS: A 13-question tool was created and distributed to returning patients over an 11-month time period at the psychiatric clinic of a university health center. Each completed questionnaire was scored as positive or negative and then compared to the preexisting psychiatric diagnosis for that respondent, as shown on the problem list of the respondent's electronic medical record. RESULTS: A total of 102 subjects completed and returned their questionnaires. Twenty-eight surveys were scored as positive for bipolar disorder while 25 subjects carried this diagnosis on their problem list, giving a sensitivity of 72% and a specificity of 87% (CI at 95%). When alternative scoring was used, sensitivity increased to 96% with only a slight decrease in specificity to 84%. CONCLUSIONS: In this pilot study, we find that the SToRM shows potential in the pursuit of a highly reliable, self-report tool which could help primary care providers screen and diagnose bipolar disorder. As such, the SToRM deserves further study.

How do medical students view the work life of primary care and specialty physicians?

BACKGROUND AND OBJECTIVES: Student perceptions of day-to-day physician work life, and relationships between these perceptions and specialty choices, have not been quantitatively explored. The study's purposes were to measure student perceptions of primary care and specialist physician work life, including administrative burden, time pressures, autonomy, and relationships with patients, to determine whether senior students' perceptions vary from junior students' perceptions and to determine whether students with primary care career plans view primary care work life differently than their peers. METHODS: A cross-sectional anonymous survey was offered to all students at three allopathic US medical schools between 2006 and 2008. RESULTS: Of 1,533 eligible students, 983 submitted usable surveys (response rate 64.1%). Students viewed the day-to-day work life of all physicians negatively but viewed primary care physician work life more negatively. Senior students viewed specialist work life more positively and primary care work life more negatively than junior students. Students planning primary care and specialist careers had similar views of primary care and specialist work life. CONCLUSIONS: Students have negative views of the work life of all physicians, especially primary care physicians. Students planning careers in primary care share this negative view of their future work life, suggesting that their career choices are not based on different work life perceptions.

Medical student debt and primary care specialty intentions.

BACKGROUND AND OBJECTIVES: This study's purpose was to evaluate the relationship between medical student debt and primary care specialty choice, while examining the potentially confounding effects of family income and race/ethnicity. METHODS: A cross-sectional survey was offered to all students at three medical schools between 2006 and 2008. The survey assessed students' anticipated educational debt and intended specialty choice. The relationship between debt and primary care or non-primary care specialty choice was assessed for all students and also for all students stratified by year in medical school, family income level, and racial/ethnic group. RESULTS: A total of 983 students participated (response rate 64.1%). Students from lower income families and under-represented minority students anticipated more educational debt. There was no relationship between anticipated debt and career plans when participants were analyzed as a whole. However, among students from middle income families, those anticipating more debt were less likely to plan primary care careers. CONCLUSIONS: Confounding factors, including income of family of origin, may mask a relationship between debt and specialty choice in observational studies. This study suggests that medical students from middle income families are sensitive to debt when making career choices.

Megestrol acetate improves weight gain in pediatric patients with chronic kidney disease.

OBJECTIVE: Megestrol acetate (MA) has been used to treat weight loss in pediatric patients with malignancies, cystic fibrosis and HIV/AIDS. We herein report our experience with MA in pediatric patients with chronic kidney disease (CKD). DESIGN: We conducted a retrospective cohort study. Charts were evaluated for clinical, treatment, and laboratory data at six time points: approximately 6 months prior to initiation of MA, at initiation and cessation of MA, and at 2-, 4-, and 8-month follow-up. Anthropometric measurements were corrected for age and sex by conversion to z scores. SETTING: Division of Pediatric Nephrology, Helen DeVos Children's Hospital, Grand Rapids, MI. PATIENTS: Pediatric patients (n = 25) with CKD and poor weight gain. INTERVENTION: Patients were administered MA at initial and tapered doses of 14.4 ± 8.1 mg/kg/d and 10.1 ± 6.5 mg/kg/d, respectively, for 5.4 ± 6.3 months. RESULTS: The study population (n = 25) was 60% male, 16% African American, 72% white, and 12% Hispanic with a mean ± SD age of 8.9 ± 5.4 years. Prior to MA therapy, patients demonstrated a decrease in BMI and poor weight gain. The treatment phase was associated with significant increases in BMI (P < .0001) and weight (P < .0001), which were well sustained at 8-month follow-up (P < 0.01 and P < 0.001, respectively). Patients demonstrated continued increases in height. A single patient exhibited physical adverse side effects (cushingoid features) associated with MA; otherwise, MA was well tolerated. CONCLUSIONS: MA appears to effectively improve weight gain in pediatric CKD patients with minimal adverse side effects and may therefore serve as a safe, short-term, nutritional strategy.

Severe paediatric systemic lupus erythematosus nephritis--a single-centre experience.

BACKGROUND: Paediatric patients with systemic lupus erythematosus (SLE) often have severe presentations including lupus nephritis (LN). Few paediatric studies have evaluated the anticardiolipin antibody (aCL) and renal histology. The purpose of this study was to evaluate clinicopathologic features, including aCL, short-term clinical and renal histologic outcomes of paediatric patients with new-onset SLE nephritis. METHODS: We conducted a single centre, retrospective inception cohort study. Charts were reviewed at presentation (initial renal biopsy), 6-month (follow-up biopsy) and 12-month follow-up. RESULTS: The population consisted of 21 patients (median age, 14.5 years): 19/21 were female, 6/21 African American, 3/21 Asian, 9/21 Caucasian and 3/21 Hispanic. At presentation, 19/21 had elevated aCL, 15/21 hypertensive, 12/21 nephrotic and 7/21 required haemodialysis (HD)-2/7 HD patients had thrombotic microangiopathy, 1/7 crescentic glomerulonephritis. Two patients had thromboembolism: both had aCL, were taking oral contraceptives and required HD, one was nephrotic and the other had elevated lupus anticoagulant. Initial biopsies revealed 6/21 ISN/RPS class II nephritis, 3/21 class III, 7/21 class IV and 5/21 class V. Treatment consisted of methylprednisolone, corticosteroids, cyclophosphamide or mycophenolate mofetil. Follow-up biopsies revealed 12/13 to have improved histology. Indication for a follow-up biopsy was severe illness at presentation. At 12-month follow-up, no patients were nephrotic (P < 0.001) or required HD (P < 0.001), and 3/14 had elevated aCL (P < 0.001). CONCLUSION: Elevated aCL, hypertension, nephrotic syndrome and need for HD were common presentations among our paediatric SLE nephritis population. Renal histology and aCL were helpful in the therapeutic management.

Clinician perceptions of factors influencing referrals to a smoking cessation program.

BACKGROUND: Referral of patients to smoking cessation telephone counseling (i.e., quitline) is an underutilized resource by primary care physicians. Previously, we conducted a randomized trial to determine the effectiveness of benchmarked feedback on clinician referrals to a quitline. Subsequently, we sought to understand the successful practices used by the high-referring clinicians, and the perceptions of the barriers of referring patients to a quitline among both high and non-referring clinicians in the trial. METHODS: We conducted a qualitative sub-study with subjects from the randomized trial, comparing high- and non-referring clinicians. Structured interviews were conducted and two investigators employed a thematic analysis of the transcribed data. Themes and included categories were organized into a thematic framework to represent the main response sets. RESULTS: As compared to non-referring clinicians, high-referring clinicians more often reported use of the quitline as a primary source of referral, an appreciation of the quitline as an additional resource, reduced barriers to use of the quitline referral process, and a greater personal motivation related to tobacco cessation. Time and competing demands were critical barriers to initiating smoking cessation treatment with patients for all clinicians. Clinicians reported that having one referral source, a referral coordinator, and reimbursement for tobacco counseling (as a billable code) would aid referral. CONCLUSION: Further research is needed to test the effectiveness of new approaches in improving the connection of patients with smoking cessation resources. TRIAL REGISTRATION NUMBER: Clinicaltrials.gov NCT00529256.

The feasibility of risk-based cervical cancer screening.

OBJECTIVE: This study examined the feasibility of risk-based cervical cancer screening in primary care practices in Lansing, Michigan (United States). METHODS: We recruited adult women regardless of the reason for visit from March to June of 2001. Women completed a risk factor questionnaire including number of current and lifetime sexual partners, history of sexually transmitted diseases and smoking. We also explicitly extracted from the patients' medical records: Pap smear results, presence of a sexual history, and screening for sexually transmitted infections (STI). RESULTS: Of 1271 eligible women, 809 (64%) completed the questionnaire and 601 agreed to have their records reviewed. Women of minority race represented 28.6% of the sample and one-third were insured through Medicaid. The mean number of lifetime partners was 9 and average age of first intercourse was 17. Eighty-six percent of women provided complete information. Most women (83%) had at least one risk factor for cervical cancer. We found low rates of documented sexual history taking (54%) and STI testing (4%). CONCLUSION: Women seeking care from a primary care clinician will provide, if asked, sensitive information, making risk-based cervical cancer screening feasible. However, since so many women had at least one identifiable risk factor, multivariate models or alternative approaches to assessing risk need to be developed.

Practice-based referrals to a tobacco cessation quit line: assessing the impact of comparative feedback vs general reminders.

PURPOSE: We undertook a study to assess the impact of comparative feedback vs general reminders on practice-based referrals to a tobacco cessation quit line and estimated costs for projected quit responses. METHODS: We conducted a group-randomized clinical trial comparing the impact of 6 quarterly (18 months) feedback reports (intervention) with that of general reminders (control) on practice-based clinician referrals to a quit-line service. Feedback reports were based on an Achievable Benchmark of Care approach using baseline practice, clinician, and patient survey responses, and referrals per quarter. Comparable quit responses and costs were estimated. RESULTS: Three hundred eight clinicians participated (171 family medicine, 88 internal medicine, 49 obstetrics-gynecology) from 87 primary care practices in Michigan. After 18 months, there were more referrals from the intervention than from the control practices (484 vs 220; P <.001). Practice facsimile (fax) referrals (84%, n = 595) exceeded telephone referrals (16%, n = 109), but telephone referrals resulted in greater likelihood of enrollment (77% telephone vs 44% fax, P <.001). The estimated number of smokers who quit based on the level of services utilized by referred smokers was 66 in the feedback and 36 in the gentle reminder practices. CONCLUSION: Providing comparative feedback on clinician referrals to a quit-line service had a modest impact with limited increased costs.

Breaking through the glass ceiling: a survey of promotion rates of graduates of a primary care Faculty Development Fellowship Program.

BACKGROUND: Academic promotion has been difficult for women and faculty of minority race. We investigated whether completion of a faculty development fellowship would equalize promotion rates of female and minority graduates to those of male and white graduates. METHODS: All graduates of the Michigan State University Primary Care Faculty Development Fellowship Program from 1989-1998 were sent a survey in 1999, which included questions about academic status and appointment. We compared application and follow-up survey data by gender and race/ethnicity. Telephone calls were made to nonrespondents. RESULTS: A total of 175 (88%) graduating fellows responded to the follow-up survey. Information on academic rank at entry and follow-up was obtained from 28 of 48 fellows with missing information on promotion. Male and female graduates achieved similar academic promotion at follow-up, but there was a trend toward lower promotion rates for minority faculty graduates compared to white graduates. In the multivariate analysis, however, only age, years in rank, initial rank, and type of appointment (academic versus clinical) were significant factors for promotion. CONCLUSIONS: Academic advancement is multifactorial and appears most related to time in rank, stage of life, and career choice. Faculty development programs may be most useful in providing skill development and career counseling.

Recruiting health plan members receiving pharmacotherapy into smoking cessation counseling.

BACKGROUND: Smokers receiving pharmacotherapy and individualized smoking cessation counseling through telephone quitlines have been found to have higher quit rates than smokers receiving pharmacotherapy alone. Health plans are often positioned to encourage their members to use quitline services in addition to pharmacotherapy. OBJECTIVE: To determine if healthcare members who were receiving pharmacotherapy increased their participation in smoking quitline services after receiving proactive telephone calls or postcards. STUDY DESIGN: Randomized controlled trial. METHODS: Health plan members filing pharmacotherapy claims were identified weekly from health plan pharmacy claims data and randomized to 1 of the following 3 conditions: control, recruitment postcard, or recruitment telephone call by a nurse quitline counselor. Enrollment of study members into the quitline program was tracked for 1 month after randomization. RESULTS: During 5 months, 625 individuals were identified for participation in the study, with the following enrollment into the program: 0% to the control group, 1.3% to the postcard group, and 20.6% to the telephone call group (P < .001 for significance by group). Although costs for the telephone intervention were the most expensive, it was also the most cost effective, given its success in enrolling members into the program. CONCLUSIONS: Proactive telephone calling by smoking cessation nurse counselors to smokers receiving pharmacotherapy may be an effective method of enrolling smokers into a cessation quitline. Health plans should consider proactive telephone recruitment to improve use of quitline services.

Increasing generic prescribing: a resident educational intervention.

BACKGROUND AND OBJECTIVES: Future physicians are urged to balance effectiveness and cost in their prescribing of medications. This study determined whether educational sessions for residents together with a "Resident Report Card" changed residents' prescribing of generic medications in both commercial and Medicaid patient panels, compared with regional performance of physicians in practice in the community. METHODS: Twenty-four family medicine residents providing care for 1,038 (600 Medicaid and 438 commercial) members (or 31,140 total member months) received biannual profiles of their prescribing patterns and participated in four training sessions related to prescription profiling within a regional health plan. We monitored prescribing during two time periods and compared rates of generic prescribing to a baseline rate. RESULTS: Resident generic prescribing increased significantly for commercial members, from a base period (July 1, 2000-June 30, 2001) rate of 38.4% to a period 1 (July 1, 2001-June 30, 2002) rate of 38.0% and a period 2 (July 1, 2002-December 31, 2002) rate of 47.9%. It also increased for Medicaid members, from a base period rate of 47.8% to a period 1 rate of 49.1% and a period 2 rate of 52.6%. There was no similar change in regional prescribing performance during the same periods for physicians in practice in the community. CONCLUSIONS: Feedback systems and training based on actual health plan data can be developed for residency training on prescribing performance, resulting in improved cost-efficient prescribing patterns.