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Current national cancer screening recommendations include the potential risk of psychological harm related to screening. However, data on the relation of psychological distress to cancer screening is limited. The authors conducted a systematic review to assess psychological distress associated with cancer screening procedures.Studies that administered measures of psychological distress between 2 weeks before and 1 month after the screening procedure were included.In total, 22 eligible studies met criteria for review, including 13 observational trials and 9 randomized controlled trials. Eligible studies used a broad range of validated and unvalidated measures. Anxiety was the most commonly assessed construct and was measured using the State Trait Anxiety Inventory. Studies included breast, colorectal, prostate, lung, and cervical screening procedures. Distress was low across procedures, with the exception of colorectal screening. Distress did not vary according to the time at which distress was measured. None of the studies were conducted exclusively with the intention of assessing distress at the time of screening.Evidence of low distress during the time of cancer screening suggests that distress might not be a widespread barrier to screening among adults who undergo screening. However, more studies are needed using validated measures of distress to further understand the extent to which screening may elicit psychological distress and impede adherence to national screening recommendations. Cancer 2017;123:3882-94. © 2017 American Cancer Society.

The editorialist discusses the systematic reviews of noninvasive pharmacologic and nonpharmacologic therapies for low back pain and the accompanying guideline from the ACP. He discusses how increas...

Classification criteria are recommended for diseases that lack specific biomarkers to improve homogeneity in clinical research studies. Because imaging evidence of lumbar disc herniations (LDHs) may not be associated with symptoms, clinical classification criteria based on patient symptoms and physical examination findings are required.This study aimed to produce clinical classification criteria to identify patients with radicular pain caused by LDH.The study design was a two-stage process. Phase 1 included a Delphi process and Phase 2 included a cohort study.The patient sample included outpatients recruited from spine clinics in five countries.The outcome measures were items from history and physical examination.In Phase 1, 17 spine experts participated in a Delphi process to select symptoms and signs suggesting radicular pain caused by LDH. In Phase 2, 19 different clinical experts identified patients they confidently classified as presenting with (1) radicular pain caused by LDH, (2) neurogenic claudication (NC) caused by lumbar spinal stenosis, or (3) non-specific low back pain (NSLBP) with referred leg pain. Patients completed survey items and specialists documented examination signs. A score to predict radicular pain caused by LDH was developed based on the coefficients of the multivariate model. An unrestricted grant of less than US$15,000 was received from MSD: It was used to support the conception of the Delphi, data management, and statistical analysis. No fees were allocated to participating spine specialists.Phase 1 generated a final list of 74 potential symptoms and signs. In Phase 2, 209 patients with pain caused by LDH (89), NC (63), or NSLBP (57) were included. Items predicting radicular pain caused by LDH (p.05) were monoradicular leg pain distribution, patient-reported unilateral leg pain, positive straight leg raise test60° (or femoral stretch test), unilateral motor weakness, and asymmetric ankle reflex. The score had an AUC of 0.91. An easy-to-use weighted set of criteria with similar psychometric characteristics is proposed (specificity 90.4%, sensitivity 70.6%).Classification criteria for identifying patients with radicular pain caused by LDH are proposed. Their use could improve the homogeneity of patients enrolled in clinical research studies.

Objective To determine which area-based socioeconomic status (SES) indicator is best suited to monitor health care disparities from a delivery system perspective. Data Sources/Study Setting 142,659 adults seen in a primary care network from January 1, 2009 to December 31, 2011. Study Design Cross-sectional, comparing associations between area-based SES indicators and patient outcomes. Data Collection Address data were geocoded to construct area-based SES indicators at block group (BG), census tract (CT), and ZIP code (ZIP) levels. Data on health outcomes were abstracted from electronic records. Relative indices of inequality (RIIs) were calculated to quantify disparities detected by area-based SES indicators and compared to RIIs from self-reported educational attainment. Principal Findings ZIP indicators had less missing data than BG or CT indicators (p

Advances in information technology (IT) now permit population-based preventive screening, but the best methods remain uncertain. We evaluated whether involving primary care providers (PCPs) in a visit-independent population management IT application led to more effective cancer screening.We conducted a cluster-randomized trial involving 18 primary care practice sites and 169 PCPs from June 15, 2011, to June 14, 2012. Participants included adults eligible for breast, cervical, and/or colorectal cancer screening. In practices randomized to the intervention group, PCPs reviewed real-time rosters of their patients overdue for screening and provided individualized contact (via a letter, practice delegate, or patient navigator) or deferred screening (temporarily or permanently). In practices randomized to the comparison group, overdue patients were automatically sent reminder letters and transferred to practice delegate lists for follow-up. Intervention patients without PCP action within 8 weeks defaulted to the automated control version. The primary outcome was adjusted average cancer screening completion rates over 1-year follow-up, accounting for clustering by physician or practice.Baseline cancer screening rates (80.8% vs 80.3%) were similar among patients in the intervention (n = 51,071) and comparison group (n = 52,799). Most intervention providers used the IT application (88 of 101, 87%) and users reviewed 7984 patients overdue for at least 1 cancer screening (73% sent reminder letter, 6% referred directly to a practice delegate or patient navigator, and 21% deferred screening). In addition, 6128 letters were automatically sent to patients in the intervention group (total of 12,002 letters vs 16,378 letters in comparison practices; P.001). Adjusted average cancer screening rates did not differ among intervention and comparison practices for all cancers combined (81.6% vs 81.4%; P = .84) nor breast (82.7% vs 82.7%; P = .96), cervical (84.1% vs 84.7%; P = .60), or colorectal cancer (77.8% vs 76.2%; P = .33).Involving PCPs in a visit-independent population management IT application resulted in similar cancer screening rates compared with an automated reminder system, but fewer patients were sent reminder letters. This suggests that PCPs were able to identify and exclude from contact patients who would have received automated reminder letters but not undergone screening.

Landmark trials such as ACCORD,[1] ADVANCE,[2] and VADT,[3] have demonstrated that the benefits and harms of glycemic control are not equally distributed across all patient groups. There is increasing consensus that glycemic control goals should be based on individual patient factors.[4] However, quality reporting and pay-for-performance programs commonly evaluate diabetes outcomes using “one-size-fits-all” goals.[5] This approach may promote more aggressive management among older, sicker patients with less expected benefit and more expected harm from therapy[6], while discouraging aggressive management early in the disease course when therapy is safest and most effective. Recent American Diabetes Association (ADA) guidelines for control of hyperglycemia in type 2 diabetes explicitly abandon the use of a single glycemic goal for all patients.[4] Instead, drawing on an approach proposed by Ismail-Beigi et al.,[7] the ADA endorses a system of individualizing goals based the expected benefits and harms of therapy.[8] Recently, an analysis of data from a U.S. national population sample created an algorithm with the potential to individualize glycemic control goals.[9] However, this algorithm relied upon data from in-person interviews. This time-consuming method cannot be applied on a large scale for population level management in clinical care settings. Furthermore, the implication of individualizing goals for a large panel of patients within a health care system is unknown. For example, there is concern that performance measurement strategies may negatively affect certain clinic settings, such as “safety net” federally-qualified health centers, or vulnerable patient sub-groups, such as those with low socioeconomic status, and those for whom English is not their first language.[10, 11] This differential reclassification could divert resources from those who need it most. Finally, racial/ethnic minorities such as Hispanic and non-Hispanic Black patients may experience earlier diabetes onset[12] and have worse diabetes outcomes,[13] suggesting that optimal glycemic control is not achieved early in the disease course. Strategies that highlight more stringent diabetes control soon after diabetes diagnosis may be useful in combating disparities in diabetes outcomes[14]. To address these issues, we sought to individualize HbA1c goals using an automated health information technology process and to assess how these goals would reclassify diabetes patients in a large healthcare delivery system. We hypothesized that reclassifying patients from uncontrolled to controlled by individualizing glycemic goals would not negatively affect safety-net health centers or vulnerable populations.

STUDY DESIGN Systematic review and meta-analysis. OBJECTIVE To assess the efficacy of opioids in adults with chronic low back pain (CLBP). SUMMARY OF BACKGROUND DATA Opioids for CLBP has increased dramatically. However, the benefits and risks remain unclear. METHODS We updated a 2007 Cochrane Review through October 2012 of randomized controlled trials from multiple databases. Use of noninjectable opioids in CLBP for at least 4 weeks was compared with placebo or other treatments; comparisons with different opioids were excluded. Outcomes included pain and function using standardized mean difference (SMD) or risk ratios with 95% confidence intervals (CIs), and absolute risk difference with 95% CI for adverse effects. Study quality was evaluated using Grading of Recommendations Assessment, Development, and Evaluation criteria. RESULTS Fifteen trials (5540 participants), including twelve new, met the criteria. Tramadol was better than placebo for pain (SMD, -0.55; 95% CI, -0.66 to -0.44) and function (SMD, -0.18; 95% CI, -0.29 to -0.07). Compared with placebo, transdermal buprenorphine decreased pain (SMD, -2.47; 95% CI, -2.69 to -2.25), but not function (SMD, -0.14; 95% CI, -0.53 to 0.25). Strong opioids (morphine, hydromorphone, oxycodone, oxymorphone, and tapentadol), were better than placebo for pain (SMD, -0.43; 95% CI, -0.52 to -0.33) and function (SMD, -0.26; 95% CI, -0.37 to -0.15). One trial demonstrated little difference with tramadol compared with celecoxib for pain relief. Two trials (272 participants) found no difference between opioids and antidepressants for pain or function. Reviewed trials had low to moderate quality, high drop-out rates, short duration, and limited interpretability of functional improvement. No serious adverse effects, risks (addiction or overdose), or complications (sleep apnea, opioid-induced hyperalgesia, hypogonadism) were reported. CONCLUSION There is evidence of short-term efficacy (moderate for pain and small for function) of opioids to treat CLBP compared with placebo. The effectiveness and safety of long-term opioid therapy for treatment of CLBP remains unproven.

BACKGROUND The long-term effects of interventions to improve colorectal (CRC) screening in vulnerable populations are uncertain. The authors evaluated the impact of patient navigation (PN) on the equity of CRC prevention over a 5-year period. METHODS A culturally tailored CRC screening PN program was implemented in 1 community health center (CHC) in 2007. In a primary care network, CRC screening rates from 2006 to 2010 among eligible patients from the CHC with PN were compared with the rates from other practices without PN. Multivariable logistic regression models for repeated measures were used to assess differences over time. RESULTS Differences in CRC screening rates diminished among patients at the CHC with PN and at other practices between 2006 (49.2% vs 62.5%, respectively; P

Cardiomyopathy is an uncommon complication in patients with pheochromocytoma, both benign and malignant, and is attributed to generally severe catecholamine excess. A 66 year-old man with known metastatic pheochromocytoma presented to our emergency room due to bilateral leg edema, reduced effort

To determine the difference in risk of developing diabetes for refugees, immigrants, and American-born participants living in the same communities, and to explore potential mediators of that difference. Retrospective longitudinal cohort from January 1, 2003 and December 31, 2013. Refugees aged ≥18 years were matched in a 1:3 ratio by age, gender, and date of care initiation to (1) Spanish-speaking non-refugee immigrants, and (2) English-speaking controls receiving care in the same community health center. We used proportional hazards regression to estimate the risk of incident diabetes. We tested whether differences in education or baseline obesity mediated diabetes risk using counterfactual mediation analysis. We included 3174 participants. Among refugee participants, the most common countries of origin were Somalia (17.8 %), Iraq (16.7 %) and Bhutan (8.8 %). Diabetes incidence rate was 1.94, 1.91, and 1.22 cases per 100 person-years follow-up for refugees, immigrants, and controls, respectively. In adjusted models, both refugee (HR 2.08 95 % CI 1.32–3.30) and immigrant (HR 1.51 95 % CI 1.01–2.24) statuses were associated with increased diabetes risk compared with controls. Risk between refugees and immigrants did not differ (adjusted HR for refugees 1.37 95 % CI 0.91–2.06). In mediation analyses, educational attainment mediated 36 % (p = 0.007) of the difference in diabetes risk between refugees/immigrants and controls. Baseline obesity did not mediate difference in diabetes risk (proportion mediated 1 %, p = 0.84). Refugees and immigrants had significantly increased risk for diabetes, partially mediated by education. Education-based lifestyle interventions may be a promising strategy to prevent diabetes for these vulnerable patients.

Patient navigation (PN) to improve cancer screening in low-income and racial/ethnic minority populations usually focuses on navigating for single cancers in community health center settings.We evaluated PN for breast, cervical, and colorectal cancer screening using a population-based information technology (IT) system within a primary care network.Randomized clinical trial conducted from April 2014 to December 2014 in 18 practices in an academic primary care network. All patients eligible and overdue for cancer screening were identified and managed using a population-based IT system. Those at high risk for nonadherence with completing screening were identified using an electronic algorithm (language spoken, number of overdue tests, no-show visit history), and randomized to a PN intervention (n = 792) or usual care (n = 820). Navigators used the IT system to track patients, contact them, and provide intense outreach to help them complete cancer screening.Mean cancer screening test completion rate over 8-month trial for each eligible patient, with all overdue cancer screening tests combined using linear regression models. Secondary outcomes included the proportion of patients completing any and each overdue cancer screening test.Among 1612 patients (673 men and 975 women; median age, 57 years), baseline patient characteristics were similar among randomized groups. Of 792 intervention patients, patient navigators were unable to reach 151 (19%), deferred 246 (38%) (eg, patient declined, competing comorbidity), and navigated 202 (32%). The mean proportion of patients who were up to date with screening among all overdue screening examinations was higher in the intervention vs the control group for all cancers combined (10.2% vs 6.8%; 95% CI [for the difference], 1.5%-5.2%; P .001), and for breast (14.7% vs 11.0%; 95% CI, 0.2%-7.3%; P = .04), cervical (11.1% vs 5.7%; 95% CI, 0.8%-5.2%; P = .002), and colon (7.6% vs 4.6%; 95% CI, 0.8%-5.2%; P = .01) cancer compared with control. The proportion of overdue patients who completed any cancer screening during follow-up was higher in the intervention group (25.5% vs 17.0%; 95% CI, 4.7%-12.7%; P .001). The intervention group had more patients completing screening for breast (23.4% vs 16.6%; 95% CI, 1.8%-12.0%; P = .009), cervical (14.4% vs 8.6%; 95% CI, 1.6%-10.5%; P = .007), and colorectal (13.7% vs 7.0%; 95% CI, 3.2%-10.4%; P .001) cancer.Patient navigation as part of a population-based IT system significantly increased screening rates for breast, cervical, and colorectal cancer in patients at high risk for nonadherence with testing. Integrating patient navigation into population health management activities for low-income and racial/ethnic minority patients might improve equity of cancer care.clinicaltrials.gov Identifier: NCT02553538.

STUDY DESIGN Retrospective and prospective patient surveys and a physician survey using a sample from American Medical Association master file. OBJECTIVE To evaluate the performance of a new instrument designed to measure the quality of decisions about treatment of herniated disc. SUMMARY OF BACKGROUND DATA There is growing consensus on the importance of engaging and informing patients to improve the quality of significant medical decisions, yet there are no instruments currently available to measure decision quality. METHODS The herniated disc-decision quality instrument (HD-DQI) was developed with input from clinical experts, survey research experts, and patients. The HD-DQI produces 2 scores each scaled to 0% to 100%, with higher scores indicating better quality: (1) a total knowledge score and (2) a concordance score (indicating the percentage of patients who received treatments that matched their goals). We examined hypotheses relating to the acceptability, feasibility, validity, and reliability of the instrument, using data from 3 samples. RESULTS The HD-DQI survey was feasible to implement and acceptable to patients, with good response rates and low missing data. The knowledge score discriminated between patients who had seen a decision aid or no decision aid (55% vs. 38%, P < 0.001) and between providers and patients (73% vs. 46%, P < 0.001). The knowledge score also had good retest reliability (intraclass correlation coefficient = 0.85). Most patients (78%) received treatments that matched their goals. Patients who received treatments that matched their goals were less likely to regret the decision than those who did not (13% vs. 39%, P = 0.004). CONCLUSION The HD-DQI met several criteria for high-quality patient-reported survey instruments. It can be used to determine the quality of decisions for treatment of herniated disc. More work is needed to examine acceptability for use as part of routine patient care.

Novel health information technology (IT)-based strategies harnessing patient registry data seek to improve care at a population level. We analyzed costs from a randomized trial of 2 health IT strategies to improve cancer screening compared with usual care from the perspective of a primary care network.Monte Carlo simulations were used to compare costs across management strategies.We assessed the cost of the software, materials, and personnel for baseline usual care (BUC) compared with augmented usual care (AUC [ie, automated patient outreach]) and augmented usual care with physician input (AUCPI [ie, outreach mediated by physicians' knowledge of their patient panels]) over 1 year.AUC and AUCPI each reduced the time physicians spent on cancer screening by 6.5 minutes per half-day clinical session compared with BUC without changing cancer screening rates. Assuming the value of this time accrues to the network, total costs of cancer screening efforts over the study year were $3.83 million for AUC, $3.88 million for AUCPI, and $4.10 million for BUC. AUC was cost-saving relative to BUC in 87.1% of simulations. AUCPI was cost-saving relative to BUC in 82.5% of simulations. Ongoing per patient costs were lower for both AUC ($35.63) and AUCPI ($35.58) relative to BUC ($39.51).Over the course of the study year, the value of reduced physician time devoted to preventive cancer screening outweighed the costs of the interventions. Primary care networks considering similar interventions will need to capture adequate physician time savings to offset the costs of expanding IT infrastructure.

Lower rates of follow-up after an abnormal Pap smear in racial and ethnic minorities may contribute to the higher incidence and mortality rates of cervical cancer seen in these groups.To identify patient-perceived barriers to follow-up after an abnormal Pap smear result among Latina women. DESIGN, PARTICIPANTS AND APPROACH: Qualitative, semi-structured, one-on-one interviews were conducted with patients from an academic hospital-affiliated urban community health center. Three groups of women were interviewed: new colposcopy clinic patients, patients who had previous colposcopies and patients enrolled in the health center's patient navigator program. Open-ended questions explored their knowledge, beliefs and experiences with colposcopy. Content analysis of transcripts was performed using established qualitative techinques.Of 40 Latina women recruited, 75% spoke only Spanish. The average age was 31.5 (range 18-55). Personal and system barriers identified were categorized into four themes: (1) anxiety/fear of procedure and diagnosis; (2) scheduling/availability of appointments interfering with work and/or child care; (3) inadequate communication about appointments, including lack of explanation regarding diagnosis, procedure and results; and (4) pain. New patients more commonly reported problems with scheduling and communication. Follow-up patients were more concerned about pain, and navigated women most often reported fear of results but had fewer concerns about inadequate communication.Anxiety/fear was the most common personal barrier, while difficulty scheduling appointments and inadequate communication were the major systems barriers identified in these Latina women. Interventions to lower these barriers to colposcopy among Latina women may increase adherence to follow-up of abnormal Pap smears.

Limited information exists about the quality and determinants of ambulatory care by resident physicians.This study investigated whether year of training and primary care versus traditional categorical status for internal medicine residents influenced preventive cancer screening rates. Ambulatory patients cared for by 143 internal medicine residents in one program over a 1-year period were assessed. Patients eligible for breast, cervical, and colorectal cancer screening were identified and test completion status was assessed. Patients who had not yet completed screening and had a visit with the resident physician were prospectively followed for subsequent test completion. Cancer screening rates, overall and among those overdue, were compared controlling for baseline patient characteristics.Among 3, 729 patients, overall test completion rates for breast (72%), cervical (75%), and colorectal cancer screening (56%) did not differ by year of training or type of training (primary care vs. categorical). Among patients overdue for a screening test, no association was found by resident year of training or primary care versus categorical status: 22% vs. 12% for colorectal (p = .08), 46% versus 28% for breast (p = .69), and 24% versus 19% for cervical cancer (p = .61), respectively.Neither resident physician type of training nor year of training were found to be associated with cancer screening rates in the ambulatory setting. Future research should seek to identify physician factors and educational strategies to augment system-based efforts to improve the quality of outpatient care by resident physicians.

Prospective randomized and observational cohorts.To compare outcomes of patients with and without workers' compensation who had surgical and nonoperative treatment for a lumbar intervertebral disc herniation (IDH).Few studies have examined the association between worker's compensation and outcomes of surgical and nonoperative treatment.Patients with at least 6 weeks of sciatica and a lumbar IDH were enrolled in either a randomized trial or observational cohort at 13 US spine centers. Patients were categorized as workers' compensation or nonworkers' compensation based on baseline disability compensation and work status. Treatment was usual nonoperative care or surgical discectomy. Outcomes included pain, functional impairment, satisfaction and work/disability status at 6 weeks, 3, 6, 12, and 24 months.Combining randomized and observational cohorts, 113 patients with workers' compensation and 811 patients without were followed for 2 years. There were significant improvements in pain, function, and satisfaction with both surgical and nonoperative treatment in both groups. In the nonworkers' compensation group, there was a clinically and statistically significant advantage for surgery at 3 months that remained significant at 2 years. However, in the workers' compensation group, the benefit of surgery diminished with time; at 2 years no significant advantage was seen for surgery in any outcome (treatment difference for SF-36 bodily pain [-5.9; 95% CI: -16.7-4.9] and physical function [5.0; 95% CI: -4.9-15]). Surgical treatment was not associated with better work or disability outcomes in either group.Patients with a lumbar IDH improved substantially with both surgical and nonoperative treatment. However, there was no added benefit associated with surgical treatment for patients with workers' compensation at 2 years while those in the nonworkers' compensation group had significantly greater improvement with surgical treatment.

Rationale and objectives Low back pain (LBP) is a common condition with frequent health care visits and work disability. Quality improvement efforts in primary care focused on guidelines adherence, provider selection and education, and feedback on appropriateness of care. Such efforts can only succeed if a health care provider is in charge of care over a substantial period. This study was conducted to provide insights about actual patterns of provider involvement in LBP care and implications for quality evaluation. Methods Established primary care patients with occupational LBP and health care covered by a workers’ compensation insurer were selected. Primary care physician (PCP) involvement was examined relative to overall health care utilization. Four methods of classifying PCP involvement were used to assess the association between PCP involvement and health care and work disability outcomes over a 2-year follow-up period. Results Primary care physician was rarely the sole provider during episodes of occupational LBP. PCP was the initial non-emergency room provider in 55% of cases, and was the most prevalent provider during at least one episode of care in 45% of cases. Different methods of classification led to different conclusions about the association between PCP involvement and work disability or number of health care visits. Multiple providers were involved throughout the clinical course of the small number of cases that accounted for most of the health care visits and work disability; in these cases, the role of PCP in care was difficult to determine. Conclusions Administrative data alone are adequate for provider comparisons only in relatively simple cases. Provider comparisons based on initial treating provider likely overstate the importance of early care, particularly in more complex cases. For LBP, quality improvement models based on PCP-directed interventions or reinforcing guideline adherence may not impact outcomes. A patient-centred model may be necessary to achieve outcome improvements.

Colonoscopy is a screening modality for the early detection of colonic polyps and cancers but is underutilized, particularly among minorities.To identify potential barriers to screening colonoscopy among low income Latino and white non-Latino patients in an urban community health center. DESIGN, PARTICIPANTS, AND APPROACH: We conducted semistructured interviews with a convenience sample of patients 53 to 70 years old, eligible for colorectal cancer screening that spoke English or Spanish. Open-ended questions explored knowledge, beliefs, and experience with or reasons for not having screening colonoscopy. We performed content analysis of transcripts using established qualitative techniques.Of 40 participants recruited, 57% were women, 55% Latino, 20% had private health insurance, and 40% had a prior colonoscopy. Participants described a wide range of barriers categorized into 5 major themes: (1) System barriers including scheduling, financial, transportation, and language difficulties; (2) Fear of pain or complications of colonoscopy and fear of diagnosis (cancer); (3) Lack of desire or motivation, including "laziness" and "procrastination"; (4) Dissuasion by others influencing participants' decision regarding colonoscopy; and (5) Lack of provider recommendation including not hearing about colonoscopy or not understanding the preparation instructions.Understanding of the range of barriers to colorectal cancer screening can help develop multimodal interventions to increase colonoscopy rates for all patients including low-income Latinos. Interventions including systems improvements and navigator programs could address barriers by assisting patients with scheduling, insurance issues, and transportation and providing interpretation, education, emotional support, and motivational interviewing.

Prior studies evaluating predictors of pain-related outcomes following treatment for sciatica have been limited by methodological problems, including retrospective study design, use of unvalidated outcome measures, and short-term follow-up periods. Despite these limitations, some reports have suggested that symptoms of psychological distress may predict individual differences in pain treatment-related outcomes (e.g., higher levels of depressive and anxious symptomatology are associated with greater pain and disability after treatment). In this study, we sought to determine whether acute symptoms of depression and anxiety were prospectively associated with treatment outcomes over a 3-year follow-up period in surgically treated and non-surgically treated patients with sciatica. Patients were recruited from the practices of community-based physicians throughout the state of Maine, and underwent in-person baseline assessments, with mailed follow-up questionnaires at 3, 6, 12, 24, and 36 months. Study outcomes included patient-reported symptoms of pain and disability. For each outcome variable, we examined whether baseline mood (i.e., mood assessed prior to the initiation of treatment), as well as mood at the immediately preceding assessment point, prospectively predicted outcomes over 3 years in multivariate repeated-measures analyses. In most analyses, symptoms of depression and anxiety, both at baseline and at the preceding time point, were significant independent predictors of worse pain and function after controlling for relevant covariates. Collectively, elevated distress appears to be a significant risk factor for reduced treatment benefit (i.e., less improvement in pain and disability) over short and medium-term follow-up periods in patients with sciatica. Future research should determine whether the prospective identification and treatment of patients with high levels of distress (a "yellow flag") is associated with improved treatment outcomes.

Purpose Diagnostic chest CT frequently results in abnormal findings that require follow-up. We assessed the timeliness of follow-up after CT abnormalities were identified in symptomatic smokers at high risk for developing lung cancer. Methods In an academic primary care network, we identified current smokers aged 55-79 years who received a diagnostic chest CT to evaluate symptoms during 2012. Medical chart abstraction identified radiologist recommendations and follow-up care. The outcome was the proportion of patients who received timely follow-up (within 30 days of recommendation) after an abnormal chest CT. We assessed for predictors of compliance with recommended follow-up. Results Of 3,257 eligible smokers, 446 (14%) had a chest CT during 2012. We excluded 70 patients who already had lung cancer, died, had imaging done elsewhere, or left the practice. Of the remaining 376 patients, 337 (90%) had abnormal chest CT findings, and 184 (55%) had a specific follow-up recommendation. Among those with recommended follow-up, only 102 of 184 (55%) had timely follow-up. Those who had a CT performed to evaluate pulmonary disease and those receiving care in community health centers were more likely to receive timely follow-up. Of 27 patients newly diagnosed with lung cancer, 18 (67%) had their first oncology visit within 30 days of diagnosis. Conclusions Among patients undergoing diagnostic chest CTs, most received follow-up for abnormal findings, but it was often delayed. Systems to support patients in obtaining recommended follow-up are needed to ensure that the benefits of lung cancer screening translate into usual clinical practice.

Background: Previous studies have suggested an association between severe hypoglycemic events (i.e. requiring external assistance) and coronary artery disease (CAD). However, whether this association varies across patients with different vascular risk remains unclear. We tested the hypothesis that prior severe hypoglycemia was independently associated with incident CAD in diabetes patients cared for in primary care, and that this association was increased for those with elevated vascular risk. Methods: We identified a diabetes cohort within a primary care practice network using electronic health records (EHR, N=9,173). Patients with severe hypoglycemic events at baseline (before 1/1/2006) were identified via ICD-9 codes, including 251.0-251.2, from emergency department, inpatient and outpatient visits. Incident CAD, including myocardial infarction, acute coronary syndrome, percutaneous transluminal coronary angiography and coronary artery bypass grafting, occurring after the hypoglycemic event, were determined through problem and procedure lists. Patients were followed until incident CAD, death, their last visit within the network, or 6/30/2012. We used Cox regression with time interaction to determine the association between hypoglycemia and CAD, with significance set at P Results: A total of 285 (3%) patients had a history of severe hypoglycemia at baseline and 1,098 (12%) developed CAD during follow-up. Severe hypoglycemia was associated with a twofold increase in CAD risk [HR 1.90 (95%CI 1.09-3.31)], adjusting for time interaction, vascular risk factors, diabetes duration and HbA1c; the hypoglycemia-CAD association weakened over time (time interaction P=0.06). Further adjustment for microvascular complications and medication exposures attenuated the association [HR 1.67 (0.96-2.92)]. Among 1,823 (20% of the cohort) high vascular risk patients aged ≥55 years, CAD risk was elevated threefold [HR 3.01 (1.15-7.91)], and in those aged ≥65 years (N=996, 11%), fourfold [HR 4.62 (1.65-12.90)]. The association was not significant among lower vascular risk patients [HR 1.61 (0.97-3.75), N=7,350]. Conclusions: Prior severe hypoglycemic episodes were strongly associated with incident CAD, especially among high vascular risk patients who were similar to those studied in the ACCORD trial. Whereas severe hypoglycemia was not as strongly associated with CAD in patients with fewer vascular risk factors. Results of studies like ACCORD only apply to a fifth of diabetes patients in this primary care cohort. Careful evaluation of diabetes treatment and close monitoring for CAD are especially needed in older high vascular risk patients with severe hypoglycemia.

Importance Increasing access to care may be insufficient to improve the health of patients with diabetes mellitus and unmet basic needs (hereinafter referred to as material need insecurities). How specific material need insecurities relate to clinical outcomes and the use of health care resources in a setting of near-universal access to health care is unclear. Objective To determine the association of food insecurity, cost-related medication underuse, housing instability, and energy insecurity with control of diabetes mellitus and the use of health care resources. Design, Setting, and Participants Cross-sectional data were collected from June 1, 2012, through October 31, 2013, at 1 academic primary care clinic, 2 community health centers, and 1 specialty center for the treatment of diabetes mellitus in Massachusetts. A random sample of 411 patients, stratified by clinic, consisted of adults (aged ≥21 years) with diabetes mellitus (response rate, 62.3%). Main Outcomes and Measures The prespecified primary outcome was a composite indicator of poor diabetes control (hemoglobin A 1c level, >9.0%; low-density lipoprotein cholesterol level, >100 mg/dL; or blood pressure, >140/90 mm Hg). Prespecified secondary outcomes included outpatient visits and a composite of emergency department (ED) visits and acute care hospitalizations (ED/inpatient visits). Results Overall, 19.1% of respondents reported food insecurity; 27.6%, cost-related medication underuse; 10.7%, housing instability; 14.1%, energy insecurity; and 39.1%, at least 1 material need insecurity. Poor diabetes control was observed in 46.0% of respondents. In multivariable models, food insecurity was associated with a greater odds of poor diabetes control (adjusted odds ratio [OR], 1.97 [95% CI, 1.58-2.47]) and increased outpatient visits (adjusted incident rate ratio [IRR], 1.19 [95% CI, 1.05-1.36]) but not increased ED/inpatient visits (IRR, 1.00 [95% CI, 0.51-1.97]). Cost-related medication underuse was associated with poor diabetes control (OR, 1.91 [95% CI, 1.35-2.70]) and increased ED/inpatient visits (IRR, 1.68 [95% CI, 1.21-2.34]) but not outpatient visits (IRR, 1.07 [95% CI, 0.95-1.21]). Housing instability (IRR, 1.31 [95% CI, 1.14-1.51]) and energy insecurity (IRR, 1.12 [95% CI, 1.00-1.25]) were associated with increased outpatient visits but not with diabetes control (OR, 1.10 [95% CI, 0.60-2.02] and OR, 1.27 [95% CI, 0.96-1.69], respectively) or with ED/inpatient visits (IRR, 1.49 [95% CI, 0.81-2.73] and IRR, 1.31 [95% CI, 0.80-2.13], respectively). An increasing number of insecurities was associated with poor diabetes control (OR for each additional need, 1.39 [95% CI, 1.18-1.63]) and increased use of health care resources (IRR for outpatient visits, 1.09 [95% CI, 1.03-1.15]; IRR for ED/inpatient visits, 1.22 [95% CI, 0.99-1.51]). Conclusions and Relevance Material need insecurities were common among patients with diabetes mellitus and had varying but generally adverse associations with diabetes control and the use of health care resources. Material need insecurities may be important targets for improving care of diabetes mellitus.

Objective To develop and validate an automated method for determining the set of patients for whom a given primary care physician holds overall clinical responsibility. Design The study included all adult patients (16,185) seen at least once in an ambulatory setting during a three-year period by 18 primary care physicians in ten practices. The physicians indicated whether they considered themselves to be the physician primarily responsible for the overall clinical care of each visiting patient. Statistical models were constructed to predict the physicians' designations using predictor variables derived from electronically available appointment schedules and demographic information. Measurements Predictive accuracy was assessed primarily using the area under the receiver-operating characteristic curve (AUC), and secondarily using positive predictive value (PPV) and sensitivity. Results A minimal set of six variables was identified as predictive of the physicians' designations. The constructed model had a median AUC for individual physicians of 0.92 (interquartile interval: 0.90–0.96), a PPV of 0.94 (interquartile interval: 0.87–0.95), and a sensitivity of 0.95 (interquartile interval: 0.87–0.97). Conclusion A statistical model using a minimal set of commonly available electronic data can accurately predict the set of patients for whom a physician holds primary clinical responsibility. Further research examining the generalization of the model to other settings would be valuable.

Background: Patient navigation (PN) can improve breast cancer care among disadvantaged women. We evaluated the impact of a PN program on follow-up after an abnormal mammogram. Methods: Between 2007 and 2010, disadvantaged women with an abnormal mammogram (Breast Imaging-Reporting and Data System [BI-RADS] codes 0, 3, 4, 5) cared for in a community health center (CHC) with PN were compared to those receiving care in 11 network practices without PN. Multivariable logistic regression and Cox proportional hazards modeling were used to compare the percentages receiving appropriate follow-up and time to follow-up between the groups. Results: Abnormal mammography findings were reported for 132 women in the CHC with PN and 168 from practices without PN. The percentage of women with appropriate follow-up care was higher in the practice with PN than in non-PN practices (90.4% vs. 75.3%, adjusted p=0.006). Results varied by BI-RADS score for women in PN and non-PN practices (BI-RADS 0, 93.7% vs. 90.2%, p=0.24; BI-RADS 3, 85.7% vs. 49.2%, p=0.003; BI-RADS 4/5, 95.1% vs. 82.8%, p=0.26). Time to follow-up was similar for BI-RADS 0 and occurred sooner for women in the PN practice than in non-PN practices for BI-RADS 3 and 4/5 (BI-RADS 3, adjusted hazard ratio [aHR], 95% confidence interval [CI]: 2.41 [1.36–4.27], BI-RADS 4/5, aHR [95% CI]: 1.41 [0.88–2.24]). Conclusions: Disadvantaged women from a CHC with PN were more likely to receive appropriate follow-up after an abnormal mammogram than were those from practices without PN. Expanding PN to include all disadvantaged women within primary care networks could improve equity in cancer care.

Objectives: To assess the relative effect of initial surgical and nonsurgical treatment on longitudinal outcomes of patients with lumbar spinal stenosis over a 10-year follow-up period. Design: A prospective observational cohort study. Setting: Enrollment from community-based specialist practices throughout Maine. Participants: One hundred forty-four patients with lumbar spinal stenosis who had at least one follow-up: 77 initially treated surgically and 67 initially treated nonsurgically. Intervention: Initial surgical or nonsurgical treatment. Measurements: Clinical data were obtained at baseline and outcomes followed at regular intervals over 10 years with mailed questionnaires including patient-reported symptoms of back pain, leg symptoms, back-specific functional status, and satisfaction. Longitudinal data were analyzed using general linear mixed models. In addition to treatment (initial surgical or nonsurgical care), time period, and the interaction between treatment and time, the models included baseline score, patient age and sex, and a time-varying general health status score. The effects of these covariates in explaining differences between treatment groups were also examined. The effect of subsequent surgical procedures was assessed using different analysis strategies. Results: The 10-year rate of subsequent surgical procedures was 23% and 38% for patients initially treated surgically and nonsurgically, respectively, and the overall 10-year survival rate was 69%. Patients undergoing initial surgical treatment had worse baseline symptoms and functional status than those initially treated nonsurgically. For all outcomes and at each time point, surgically treated patients reported greater improvement in symptoms and functional status and higher satisfaction scores, indicative of better outcomes, than nonsurgically treated patients. However, the relative magnitude of the benefit diminished over time such that the relative differences for low back pain and satisfaction were no longer significant over long-term follow-up (both P=.08 for treatment effect between 5 and 10 years after controlling for covariates). Regardless of initial treatment received, patients undergoing subsequent surgical procedures reported less improvement in outcomes over time than patients who did not undergo subsequent procedures, but the relative differences between treatment groups were similar in analyses that controlled for outcomes after subsequent procedures. Conclusion: After controlling for covariates, patients initially treated surgically demonstrated better outcomes on all measures than those initially treated nonsurgically. Although outcomes of initial surgical treatment remained superior over time, the relative benefit of surgery diminished in later years, especially for low back pain and satisfaction. Patients undergoing subsequent surgery had worse outcomes regardless of initial treatment received, but excluding them did not change overall treatment group comparisons. The analytical methods described may be helpful in the design and analysis of future studies comparing treatment outcomes for patients with lumbar spinal stenosis.

Objective/Hypothesis: To assess the validity and responsiveness of a new health-related quality of life (HRQL) instrument for patients with chronic sinusitis. Study Design: Prospective case series. Methods: Patients with chronic sinusitis undergoing endoscopic sinus surgery were assessed in two otolaryngology practices affiliated with an academic hospital. Patient-reported HRQL was assessed using a new instrument (includes symptom frequency, bothersomeness, and impact scales), the Chronic Sinusitis Survey (CSS), and the generic SF-12 at baseline and 3 months postsurgery. The psychometric properties of the new instrument were assessed including reliability, validity, responsiveness, and interpretability. Results: Among 50 enrolled patients, 49 underwent surgery and 39 (80%) completed 3-month follow-up. Internal consistency was high for the symptom impact scale. The symptom frequency and, especially, bothersomeness scales had lower internal consistency and were comparable with the CSS. Correlation analyses support the construct validity of the new measure compared with the CSS and SF-12. The responsiveness of the new instrument was excellent and similar to or better than the CSS. The mean score change was linearly related to the patient's global self-assessment, although the CSS symptom and total score better discriminated patients with major or moderate degrees of improvement. Conclusions: This study demonstrates the validity and responsiveness of a new rhinosinusitis-specific HRQL instrument, the Rhinosinusitis Quality of Life survey, in patients with chronic sinusitis. The instrument's symptom frequency, bothersomeness, and impact scales compare favorably with a previously validated disease-specific and a generic HRQL measure. If validated in other patient populations, this disease-specific instrument may be useful in assessing severity and outcomes of treatment for sinusitis.

Study design A prospective cohort study. Objective To assess 10-year outcomes of patients with sciatica resulting from a lumbar disc herniation treated surgically or nonsurgically. Summary of background data There is little information comparing long-term outcomes of surgical and conservative therapy of lumbar disc herniation in contemporary clinical practice. Prior studies suggest that these outcomes are similar. Methods Patients recruited from the practices of orthopedic surgeons, neurosurgeons, and occupational medicine physicians throughout Maine had baseline interviews with follow-up questionnaires mailed at regular intervals over 10 years. Clinical data were obtained at baseline from a physician questionnaire. Primary analyses were based on initial treatment received, either surgical or nonsurgical. Secondary analyses examined actual treatments received by 10 years. Outcomes included patient-reported symptoms of leg and back pain, functional status, satisfaction, and work and disability compensation status. Results Of 507 eligible consenting patients initially enrolled, 10-year outcomes were available for 400 of 477 (84%) surviving patients; 217 of 255 (85%) treated surgically, and 183 of 222 (82%) treated nonsurgically. Patients undergoing surgery had worse baseline symptoms and functional status than those initially treated nonsurgically. By 10 years, 25% of surgical patients had undergone at least one additional lumbar spine operation, and 25% of nonsurgical patients had at least one lumbar spine operation. At 10-year follow-up, 69% of patients initially treated surgically reported improvement in their predominant symptom (back or leg pain) versus 61% of those initially treated nonsurgically (P = 0.2). A larger proportion of surgical patients reported that their low back and leg pain were much better or completely gone (56% vs. 40%, P = 0.006) and were more satisfied with their current status (71% vs. 56%, P = 0.002). Treatment group differences persisted after adjustment for other determinants of outcome in multivariate models. Change in the modified Roland back-specific functional status scale favored surgical treatment, and the relative benefit persisted over the follow-up period. Despite these differences, work and disability status at 10 years were comparable among those treated surgically or nonsurgically. Conclusions Surgically treated patients with a herniated lumbar disc had more complete relief of leg pain and improved function and satisfaction compared with nonsurgically treated patients over 10 years. Nevertheless, improvement in the patient's predominant symptom and work and disability outcomes were similar regardless of treatment received. For patients in whom elective discectomy is a treatment option, an individualized treatment plan requires patients and their physicians to integrate clinical findings with patient preferences based on their symptoms and goals.

Study design A prospective observational cohort study. Objective To assess long-term outcomes of patients with lumbar spinal stenosis treated surgically or nonsurgically. Summary of background data The relative benefit of various treatments for lumbar spinal stenosis is uncertain. Surgical treatment has been associated with short-term improvement, but recurrence of symptoms has been documented. Few studies have compared long-term outcomes of surgical and nonsurgical treatments. Methods Patients recruited from the practices of orthopaedic surgeons, neurosurgeons, and occupational medicine physicians throughout Maine had baseline interviews with follow-up questionnaires mailed at regular intervals over 10 years. Clinical data were obtained at baseline from a physician questionnaire. Most patients initially undergoing surgery had a laminectomy without fusion performed. Outcomes including patient-reported symptoms of leg and back pain, functional status, and satisfaction were assessed at 8- to 10-year follow-up. Primary analyses were based on initial treatment received with secondary analyses examining actual treatment received by 10 years. Results Of 148 eligible consenting patients initially enrolled, 105 were alive after 10 years (67.7% survival rate). Among surviving patients, long-term follow-up between 8 and 10 years was available for 97 of 123 (79%) patients (including 11 patients who died before the 10-year follow-up but completed a 8 or 9 year survey); 56 of 63 (89%) initially treated surgically and 41 of 60 (68%) initially treated nonsurgically. Patients undergoing surgery had worse baseline symptoms and functional status than those initially treated nonsurgically. Outcomes at 1 and 4 years favored initial surgical treatment. After 8 to 10 years, a similar percentage of surgical and nonsurgical patients reported that their low back pain was improved(53% vs. 50%, P = 0.8), their predominant symptom (either back or leg pain) was improved (54% vs. 42%, P = 0.3), and they were satisfied with their current status (55% vs. 49%, P = 0.5). These treatment group findings persisted after adjustment for other determinants of outcome in multivariate models. However, patients initially treated surgically reported less severe leg pain symptoms and greater improvement in back-specific functional status after 8 to 10 years than nonsurgically treated patients. By 10 years, 23% of surgical patients had undergone at least one additional lumbar spine operation, and 39% of nonsurgical patients had at least one lumbar spine operation. Patients undergoing subsequent surgical procedures had worse outcomes than those continuing with their initial treatment. Outcomes according to actual treatment received at 10 years did not differ because individuals undergoing additional surgical procedures had worse outcomes than those continuing with their initial treatment. Conclusions Among patients with lumbar spinal stenosis completing 8- to 10-year follow-up, low back pain relief, predominant symptom improvement, and satisfaction with the current state were similar in patients initially treated surgically or nonsurgically. However, leg pain relief and greater back-related functional status continued to favor those initially receiving surgical treatment. These results support a shared decision-making approach among physicians and patients when considering treatment options for lumbar spinal stenosis.

A retrospective case series of primary care patients receiving Workers' Compensation (WC) for back pain.To describe the extent of primary care provider (PCP) involvement in work-related low back pain (WRLBP), and whether PCP involvement is a significant determinant of patterns of care or outcomes.In general, WRLBP has inferior outcomes compared with nonoccupational LBP. Although it has been suggested that better outcomes are achieved when care for WRLBP involves specialists such as occupational medicine physicians rather than a PCP, limited evidence supports this claim.Adult patients were identified by electronic records from four hospital-affiliated PCP practices in fiscal years 1996 to 1998. Those with a WRLBP claim filed during the same time period were identified by searching a WC claims database. Medical records were reviewed to assess past medical history, the extent of prior PCP contacts for any visits before and for visits 2 years after the reported onset of the WRLBP claim, and detailed information on visits for this condition. Disability outcomes (total costs and days of work disability) were obtained from the WC database.Among 68,710 individuals with a PCP practice visit, 118 with a WRLBP claim were identified. The final study sample included 87 patients with a WRLBP claim and at least 1 documented PCP practice visit during the study period. Seventy-eight percent of patients saw the PCP at least once in the 2 years after the claim onset date, but only 34 patients (39%) visited the PCP for their WRLBP, and 20 (23%) had more than 1 visit. Although almost all patients with a PCP visit for WRLBP saw a physician (not the PCP in 79% of cases) within a week of the claim onset date, the median number of days between the onset date and the first WRLBP visit to the PCP was 47.5. Patients with a prior history of back problems were more likely to have a PCP visit for WRLBP (odds ratio 2.9, 95% confidence interval 1.1-7.7). Patients with PCP visits for WRLBP had higher total and medical costs than those without PCP visits, but a similar number of paid disability days. After controlling for other potential predictors, involvement of the PCP was not a significant predictor of the total cost of the WRLBP claim.Many individuals with a WC claim do not have a stable PCP relationship around the onset of their WRLBP episode. Those with PCP relationships uncommonly involve the PCP in their WRLBP, and if they do, it is usually later in the course because of persistent or recurrent symptoms. Disability outcomes appear to be similar regardless of whether a PCP was involved. However, PCP involvement is associated with greater medical costs, which may reflect confounding based on duration of symptoms rather than the nature of the care provided. Additional research is needed to understand how different patterns of care for patients with a WRLBP claim relate to outcomes and how these patients compare with individuals without such a claim, as well as the factors that lead patients to involve their PCP or not.

1506 Background: Annual chest computed tomography (CT) can decrease lung cancer mortality in high risk individuals. Patient navigation (PN) has been shown to improve cancer screening rates in underserved populations. We evaluated the impact of PN on lung cancer screening (LCS) in current smokers in community health centers (CHC). Methods: Current smokers aged 55-77 receiving care in five CHC affiliated with an academic medical center were randomized to intervention (n = 400) or control (n = 800) groups. In the intervention arm, patient navigators (PNs) determined eligibility for LCS, provided brief smoking cessation counseling, introduced shared decision making about LCS, scheduled appointments with the primary care provider (PCP), reminded patients about appointments and PCPs to order CTs, and helped patients attend testing and follow-up any abnormal results. Control patients received usual care. The primary outcome was the proportion of patients in each group who had any chest CT during the study period. Secondary outcomes included proportion of patients receiving lung screening CTs and the number of lung cancers diagnosed in each group. Results: Baseline patient characteristics were similar between randomized groups. From March 2016-January 2017, PNs contacted 332 (83%) of intervention patients; 76 refused further participation. Of participating patients, 130 (51%) were eligible for LCS. Exclusions included insufficient smoking history (n = 117), competing comorbidities (n = 5), moved (n = 2), and died (n = 2). In intention-to-treat analyses, 124 intervention patients (31%) had chest CT vs. 138 control patients (17.3%, p < 0.01). Lung cancer screening CTs were performed in 94 intervention patients (23.5%) vs. 69 control patients (8.6%, p < 0.01). Eight lung cancers were diagnosed in intervention patients (2%) vs. 4 in controls (0.5%). Conclusions: A patient navigation program implemented in community health centers significantly increased lung cancer screening among current smokers. PNs may help underserved low-income current smokers complete LCS and improve equity in care while decreasing lung cancer mortality. Clinical trial information: 2015P002239.

Importance It is unclear if helping patients meet resource needs, such as difficulty affording food, housing, or medications, improves clinical outcomes. Objective To determine the effectiveness of the Health Leads program on improvement in systolic and diastolic blood pressure (SBP and DBP, respectively), low-density lipoprotein cholesterol (LDL-C) level, and hemoglobin A 1c (HbA 1c ) level. Design, Setting, and Participants A difference-in-difference evaluation of the Health Leads program was conducted from October 1, 2012, through September 30, 2015, at 3 academic primary care practices. Health Leads consists of screening for unmet needs at clinic visits, and offering those who screen positive to meet with an advocate to help obtain resources, or receive brief information provision. Main Outcomes and Measures Changes in SBP, DBP, LDL-C level, and HbA 1c level. We compared those who screened positive for unmet basic needs (Health Leads group) with those who screened negative, using intention-to-treat, and, secondarily, between those who did and did not enroll in Health Leads, using linear mixed modeling, examining the period before and after screening. Results A total of 5125 people were screened, using a standardized form, for unmet basic resource needs; 3351 screened negative and 1774 screened positive. For those who screened positive, the mean age was 57.6 years and 1811 (56%) were women. For those who screened negative, the mean age was 56.7 years and 909 (57%) were women. Of 5125 people screened, 1774 (35%) reported at least 1 unmet need, and 1021 (58%) of those enrolled in Health Leads. Median follow-up for those who screened positive and negative was 34 and 32 months, respectively. In unadjusted intention-to-treat analyses of 1998 participants with hypertension, the Health Leads group experienced greater reduction in SBP (differential change, −1.2; 95% CI, −2.1 to −0.4) and DBP (differential change, −1.0; 95% CI, −1.5 to −0.5). For 2281 individuals with an indication for LDL-C level lowering, results also favored the Health Leads group (differential change, −3.7; 95% CI −6.7 to −0.6). For 774 individuals with diabetes, the Health Leads group did not show HbA 1c level improvement (differential change, −0.04%; 95% CI, −0.17% to 0.10%). Results adjusted for baseline demographic and clinical differences were not qualitatively different. Among those who enrolled in Health Leads program, there were greater BP and LDL-C level improvements than for those who declined (SBP differential change −2.6; 95% CI,−3.5 to −1.7; SBP differential change, −1.4; 95% CI, −1.9 to −0.9; LDL-C level differential change, −6.3; 95% CI, −9.7 to −2.8). Conclusions and Relevance Screening for and attempting to address unmet basic resource needs in primary care was associated with modest improvements in blood pressure and lipid, but not blood glucose, levels.

Lack of timely medication intensification and inadequate medication safety monitoring are two prevalent and potentially modifiable barriers to effective and safe chronic care. Innovative applications of health information technology tools may help support chronic disease management.To examine the clinical impact of a novel health IT tool designed to facilitate between-visit ordering and tracking of future laboratory testing.Clinical trial randomized at the provider level (n = 44 primary care physicians); patient-level outcomes among 3,655 primary care patients prescribed 5,454 oral medicines for hyperlipidemia, diabetes, and/or hypertension management over a 12-month period.Time from prescription to corresponding follow-up laboratory testing; proportion of follow-up time that patients achieved corresponding risk factor control (A1c, LDL); adverse event laboratory monitoring 4 weeks after medicine prescription.Patients whose physicians were allocated to the intervention (n = 1,143) had earlier LDL laboratory assessment compared to similar patients (n = 703) of control physicians [adjusted hazard ratio (aHR): 1.15 (1.01-1.32), p = 0.04]. Among patients with elevated LDL (486 intervention, 324 control), there was decreased time to LDL goal in the intervention group [aHR 1.26 (0.99-1.62)]. However, overall there were no significant differences between study arms in time spent at LDL or HbA1c goal. Follow-up safety monitoring (e.g., creatinine, potassium, or transaminases) was relatively infrequent (ranging from 7 % to 29 % at 4 weeks) and not statistically different between arms. Intervention physicians indicated that lack of reimbursement for non-visit-based care was a barrier to use of the tool.A health IT tool to support between-visit laboratory monitoring improved the LDL testing interval but not LDL or HbA1c control, and it did not alter safety monitoring. Adoption of innovative tools to support physicians in non-visit-based chronic disease management may be limited by current visit-based financial and productivity incentives.

Acute low back pain is a common reason for patient calls or visits to a primary care clinician. Despite a large differential diagnosis, the precise etiology is rarely identified, although musculoligamentous processes are usually suspected. For most patients, back symptoms are nonspecific, meaning that there is no evidence for radicular symptoms or underlying systemic disease. Because episodes of acute, nonspecific low back pain are usually self-limited, many patients treat themselves without contacting their primary care clinician. When patients do call or schedule a visit, evaluation and management by primary care clinicians is appropriate. The history and physical examination usually provide clues to the rare but potentially serious causes of low back pain, as well as to identify patients at risk for prolonged recovery. Diagnostic testing, including plain x-rays, is often unnecessary during the initial evaluation. For patients with acute, nonspecific low back pain, the primary emphasis of treatment should be conservative care, time, reassurance, and education. Current recommendations focus on activity as tolerated (though not active exercise while pain is severe) and minimal if any bed rest. Referral for physical treatments is most appropriate for patients whose symptoms are not improving over 2 to 4 weeks. Specialty referral should be considered for patients with a progressive neurologic deficit, failure of conservative therapy, or an uncertain or serious diagnosis. The prognosis for most patients is good, although recurrence is common. Thus, educating patients about the natural history of acute low back pain and how to prevent future episodes can help ensure reasonable expectations.

The long-term effects of interventions to improve colorectal (CRC) screening in vulnerable populations are uncertain. The authors evaluated the impact of patient navigation (PN) on the equity of CRC prevention over a 5-year period.A culturally tailored CRC screening PN program was implemented in 1 community health center (CHC) in 2007. In a primary care network, CRC screening rates from 2006 to 2010 among eligible patients from the CHC with PN were compared with the rates from other practices without PN. Multivariable logistic regression models for repeated measures were used to assess differences over time.Differences in CRC screening rates diminished among patients at the CHC with PN and at other practices between 2006 (49.2% vs 62.5%, respectively; P .001) and 2010 (69.2% vs 73.6%, respectively; P .001). The adjusted rate of increase over time was higher at the CHC versus other practices (5% vs 3.4% per year; P .001). Among Latino patients at the CHC compared with other practices, lower CRC screening rates in 2006 (47.5% vs 52.1%, respectively; P = .02) were higher by 2010 (73.5% vs 67.3%, respectively; P .001). Similar CRC screening rates among non-English speakers at the CHC and at other practices in 2006 (44.3% vs 44.7%, respectively; P = .79) were higher at the CHC by 2010 (70.6% vs 58.6%, respectively; P .001). Adjusted screening rates increased more over time for Latino and non-English speakers at the CHC compared with other practices (both P .001).A PN program increased CRC screening rates in a CHC and improved equity in vulnerable patients. Long-term funding of PN programs has the potential to reduce cancer screening disparities.

Study Design. A prospective cohort study of patients with lumbar spinal stenosis recruited from the practices of orthopedic surgeons and neurosurgeons throughout Maine. Objective. To assess 4-year outcomes for patients with lumbar spinal stenosis treated surgically or nonsurgically. Summary of Background Data. Surgery for lumbar spinal stenosis has increased dramatically despite the lack of randomized trials comparing surgical with nonsurgical treatments. Long-term evaluation of surgical series has documented deterioration in initial symptomatic improvement, but few studies have compared long-term outcomes of surgical and nonsurgical treatment. Methods. Eligible, consenting patients had baseline interviews with mailed follow-up questionnaires at 3, 6, and 12 months, then annually thereafter. Clinical data were obtained at baseline from a physician questionnaire. Outcomes included patient-reported symptoms of leg and back pain, functional status, and satisfaction. Results. Of 148 patients with lumbar spinal stenosis initially enrolled, 4-year outcomes were available on 119 patients (80.4%): 67 of 81 (83%) treated surgically and 52 of 67 (78%) treated nonsurgically. The surgically treated patients had more severe symptoms and worse functional status at baseline and better outcomes at 4-year evaluation than the nonsurgically treated patients. After 4 years, 70% of the surgically treated and 52% of the non-surgically treated patients reported that their predominant symptom, either leg or back pain, was better (P = 0.05). Satisfaction of patients with their current state at 4 years was reported by 63% of the surgically treated and 42% of the nonsurgically treated patients (P = 0.04). Surgical treatment remained a significant determinant of 4-year satisfaction, even after adjustment for other independent predictors (P = 0.001). For the nonsurgically treated patients, there was no significant change in outcomes over 4 years, whereas the initial improvement seen in the surgically treated patients modestly decreased over the subsequent 4 years. Conclusions. For the patients with severe lumbar spinal stenosis, surgical treatment was associated with greater improvement in patient-reported outcomes than nonsurgical treatment at 4-year evaluation, even after adjustment for differences in baseline characteristics among treatment groups. The relative benefit of surgery declined over time but remained superior to nonsurgical treatment. Outcomes for the nonsurgically treated patients improved modestly and remained stable over 4 years. Determining whether outcomes continue to converge will require longer-term evaluation.

OBJECTIVE: To describe the expectations that patients and their physicians have for outcomes after surgical treatment for sciatica and to examine the associations between expectations and outcomes. DESIGN: Prospective cohort study. SETTING/PATIENTS: We recruited 273 patients, from the offices of orthopedic surgeons, neurosurgeons, and occupational medicine physicians in Maine, who had diskectomy for sciatica. MEASUREMENTS AND MAIN RESULTS: Patients' and physicians' expectations were measured before surgery. Satisfaction with care and changes in symptoms and functional status were measured 12 months after surgery. More patients who expected a shorter recovery time after surgery were “delighted,”“pleased,” or “mostly satisfied” with their outcomes 12 months after surgery than patients who expected a longer recovery time (odds ratio [OR] 2.2; 95% confidence interval [CI] 1.1, 4.4). Also, more patients who preferred surgery after learning that sciatica could get better without surgery had good symptom scores 12 months after surgery than patients who did not prefer surgery (OR 2.9; 95% CI 1.2, 7.0). When physicians predicted a “great deal of improvement” after surgery, 39% of patients were not satisfied with their outcomes and 25% said their symptoms had not improved. CONCLUSIONS: More patients with favorable expectations about surgery had good outcomes than patients with unfavorable expectations. Physicians' expectations were overly optimistic. Patient expectations appear to be important predictors of outcomes, and eliciting them may help physicians identify patients more likely to benefit from diskectomy for sciatica.

To assess physicians' response to implementation of an emergency department (ED) pneumonia practice guideline and determine if the guideline changed physicians' knowledge and attitudes about pneumonia care.Prospective intervention study with cross-sectional and longitudinal physician surveys.An urban, university teaching hospital ED.One hundred forty physicians who were responsible for the triage of at least one of 166 patients presenting to the ED with community-acquired pneumonia.Physician characteristics, attitudes about pneumonia care and guidelines, and ratings of guideline helpfulness and effects on patient care were obtained by self administered questionnaire before, during, and after a yearlong intervention.More than 73% of the physicians reported the guideline as helpful and more than 94% wanted it to be continued in the future. Most reported that the guideline would decrease costs and improve quality without any increase in adverse outcomes. Two thirds said they were more likely to treat patients with pneumonia as outpatients in the future because of the guideline. Among the 58 physicians with matching preintervention and postintervention survey data, the guideline decreased the beliefs that "all patients65 years old with pneumonia should be admitted," from 52% to 14% ( p. 001), and that "patients with pneumonia have a15% mortality rate," from 11% to 5% ( p.007). The intervention did not significantly change general attitudes about practice guidelines. House officers rated the guideline as more helpful than attending physicians ( p. 02).This locally developed, actively implemented guideline was well regarded by physicians. Guidelines can change practice and also alter underlying knowledge and attitudes about disease management. They may be most useful to those with less experience.

BACKGROUND: There is no consensus favoring a particular strategy for evaluating patients with pharyngitis.

Objective To optimize a new visit-independent, population-based cancer screening system (TopCare) by using operations research techniques to simulate changes in patient outreach staffing levels (delegates, navigators), modifications to user workflow within the information technology (IT) system, and changes in cancer screening recommendations. Materials and methods TopCare was modeled as a multiserver, multiphase queueing system. Simulation experiments implemented the queueing network model following a next-event time-advance mechanism, in which systematic adjustments were made to staffing levels, IT workflow settings, and cancer screening frequency in order to assess their impact on overdue screenings per patient. Results TopCare reduced the average number of overdue screenings per patient from 1.17 at inception to 0.86 during simulation to 0.23 at steady state. Increases in the workforce improved the effectiveness of TopCare. In particular, increasing the delegate or navigator staff level by one person improved screening completion rates by 1.3% or 12.2%, respectively. In contrast, changes in the amount of time a patient entry stays on delegate and navigator lists had little impact on overdue screenings. Finally, lengthening the screening interval increased efficiency within TopCare by decreasing overdue screenings at the patient level, resulting in a smaller number of overdue patients needing delegates for screening and a higher fraction of screenings completed by delegates. Conclusions Simulating the impact of changes in staffing, system parameters, and clinical inputs on the effectiveness and efficiency of care can inform the allocation of limited resources in population management.

Background The use of opioids in the long-term management of chronic low-back pain (CLBP) has increased dramatically. Despite this trend, the benefits and risks of these medications remain unclear. This review is an update of a Cochrane review first published in 2007. Objectives To determine the efficacy of opioids in adults with CLBP. Search methods We electronically searched the Cochrane Back Review Group's Specialized Register, CENTRAL, CINAHL and PsycINFO, MEDLINE, and EMBASE from January 2006 to October 2012. We checked the reference lists of these trials and other relevant systematic reviews for potential trials for inclusion. Selection criteria We included randomized controlled trials (RCTs) that assessed the use of opioids (as monotherapy or in combination with other therapies) in adults with CLBP that were at least four weeks in duration. We included trials that compared non-injectable opioids to placebo or other treatments. We excluded trials that compared different opioids only. Data collection and analysis Two authors independently assessed the risk of bias and extracted data onto a pre-designed form. We pooled results using Review Manager (RevMan) 5.2. We reported on pain and function outcomes using standardized mean difference (SMD) or risk ratios with 95% confidence intervals (95% CI). We used absolute risk difference (RD) with 95% CI to report adverse effects. Main results We included 15 trials (5540 participants). Tramadol was examined in five trials (1378 participants); it was found to be better than placebo for pain (SMD -0.55, 95% CI -0.66 to -0.44; low quality evidence) and function (SMD -0.18, 95% CI -0.29 to -0.07; moderate quality evidence). Transdermal buprenorphine (two trials, 653 participants) may make little difference for pain (SMD -2.47, 95%CI -2.69 to -2.25; very low quality evidence), but no difference compared to placebo for function (SMD -0.14, 95%CI -0.53 to 0.25; very low quality evidence). Strong opioids (morphine, hydromorphone, oxycodone, oxymorphone, and tapentadol), examined in six trials (1887 participants), were better than placebo for pain (SMD -0.43, 95%CI -0.52 to -0.33; moderate quality evidence) and function (SMD -0.26, 95% CI -0.37 to -0.15; moderate quality evidence). One trial (1583 participants) demonstrated that tramadol may make little difference compared to celecoxib (RR 0.82, 95% CI 0.76 to 0.90; very low quality evidence) for pain relief. Two trials (272 participants) found no difference between opioids and antidepressants for either pain (SMD 0.21, 95% CI -0.03 to 0.45; very low quality evidence), or function (SMD -0.11, 95% -0.63 to 0.42; very low quality evidence). The included trials in this review had high drop-out rates, were of short duration, and had limited interpretability of functional improvement. They did not report any serious adverse effects, risks (addiction or overdose), or complications (sleep apnea, opioid-induced hyperalgesia, hypogonadism). In general, the effect sizes were medium for pain and small for function. Authors' conclusions There is some evidence (very low to moderate quality) for short-term efficacy (for both pain and function) of opioids to treat CLBP compared to placebo. The very few trials that compared opioids to non-steroidal anti-inflammatory drugs (NSAIDs) or antidepressants did not show any differences regarding pain and function. The initiation of a trial of opioids for long-term management should be done with extreme caution, especially after a comprehensive assessment of potential risks. There are no placebo-RCTs supporting the effectiveness and safety of long-term opioid therapy for treatment of CLBP.

To determine whether frequent emergency department (ED) users are more likely to make at least one and a majority of visits for mental health, alcohol, or drug-related complaints compared to non-frequent users.We performed a retrospective cohort study exploring frequent ED use and ED diagnosis at a single, academic hospital and included all ED patients between January 1 and December 31, 2010. We compared differences in ED visits with a primary International Classification of Diseases, 9th Revision visit diagnosis of mental health, alcohol or drug-related diagnoses between non-frequent users (4 visits during previous 12-months) and frequent (repeat [4-7 visits], highly frequent [8-18 visits] and super frequent [≥19 visits]) users in univariate and multivariable analyses.Frequent users (2496/65201 [3.8%] patients) were more likely to make at least one visit associated with mental health, alcohol, or drug-related diagnoses. The proportion of patients with a majority of visits related to any of the three diagnoses increased from 5.8% among non-frequent users (3616/62705) to 9.4% among repeat users (181/1926), 13.1% among highly frequent users (62/473), and 25.8% (25/97 patients) in super frequent users. An increasing proportion of visits with alcohol-related diagnoses was observed among repeat, highly frequent, and super frequent users but was not found for mental health or drug-related complaints.Frequent ED users were more likely to make a mental health, alcohol or drug-related visit, but a majority of visits were only noted for those with alcohol-related diagnoses. To address frequent ED use, interventions focusing on managing patients with frequent alcohol-related visits may be necessary.

To assess the ability of a health information technology system to facilitate population- based breast cancer screening.Cohort study with 2-year follow-up after a 1-year cluster randomized trial.Study population was women 42 to 69 years old receiving care within a 12-practice primary care network. The management informatics system (1) identified women overdue for mammograms, (2) connected them to primary care providers using a web-based tool, (3) created automatically generated outreach letters for patients specified by providers, (4) monitored for subsequent mammography scheduling and completion, and (5) provided practice delegates with a list of women remaining unscreened for reminder phone calls. Eligible women overdue for a mammogram during a 1-year study period included those overdue at study start (prevalent cohort) and those who became overdue during follow-up (incident cohort). The main outcome measure was mammography completion rates over 3 years.Among 32,688 eligible women, 9795 (30%) were overdue for screening (4487 intervention, 5308 control). Intervention patients were somewhat younger, more likely to be non-Hispanic white, and more likely to have health insurance compared with control patients. Adjusted completion rates in the prevalent cohort (n = 6697) were significantly higher among intervention patients after 3 years (51.7% vs 45.8%; P = .002). For patients in the incident cohort (n = 3098), adjusted completion rates after 2 years were 53.8% versus 48.7%, respectively (P = .052).Population-based informatics systems can enable sustained increases in mammography screening rates beyond rates seen with office-based visit reminders.

STUDY DESIGN A prospective cohort study of patients in Maine with sciatica and lumbar spinal stenosis treated surgically and nonsurgically. SUMMARY OF BACKGROUND DATA In 1987, the Quebec Task Force on Spinal Disorders proposed a diagnostic classification to help make clinical decisions, evaluate quality of care, assess prognosis, and conduct research. OBJECTIVES To assess the Quebec Task Force classification's ability to stratify patients according to severity and treatment at baseline, and to assess changes over time in health-related quality of life, including symptoms, functional status, and disability. METHODS Five hundred sixteen patients participating in the Maine Lumbar Spine Study who completed baseline and 1-year follow-up evaluations were classified successfully according to the Quebec Task Force classification. Patient characteristics and treatments were compared across Quebec Task Force classification categories. Changes in health-related quality of life over 1 year were assessed according to Quebec Task Force classification category and type of treatment. RESULTS Among patients with sciatica (n = 370), higher Quebec Task Force classification categories (from 2, pain radiating to the proximal extremity, to 6, sciatica with evidence of nerve root compression) were associated with increased severity of symptoms at baseline. There was no association between Quebec Task Force classification and baseline functional status. Quebec Task Force classification was associated strongly with the likelihood of receiving surgical treatment (P < or = 0.005). Among patients with sciatica treated nonsurgically, improvement at 1 year in back-specific and generic physical function increased with higher Quebec Task Force classification category (P < or = 0.05). Only a nonsignificant trend was observed for surgically treated patients. Patients with lumbar spinal stenosis (Quebec Task Force classification 7, n = 131) had baseline features and outcomes distinct from patients with sciatica. CONCLUSIONS For patients with sciatica, the Quebec Task Force classification was highly associated with the severity of symptoms and the probability of subsequent surgical treatment. Nonsurgically treated patients in Quebec Task Force classification categories reflecting nerve root compression had greater improvement than those with pain symptoms alone. Among surgical patients, the Quebec Task Force classification was not associated with outcome. These results provide validation for the classification and its wider adoption. Nonetheless, improved diagnostic classifications are needed to predict outcomes better in patients with sciatica who undergo surgery.

Study design This paper describes the background and factors that led to the development and implementation of the Maine Lumbar Spine Study, a prospective cohort study of patients undergoing surgical and nonsurgical treatment of herniated lumbar disc with sciatica and symptomatic spinal stenosis. Objectives To define the factors leading to the study and the methods of designing and implementing a community-based effectiveness study to evaluate the outcomes of herniated lumbar intervertebral disc and spinal stenosis. Summary of background data Variations in the utilization of surgery for these conditions and physicians' uncertainty regarding the best way to manage them resulted in support of a community-based study of the effectiveness of treatment alternatives. Methods A prospective cohort design was used. Methods of patient enrollment, data collection, management, and analysis are described. An innovative method of ascertaining the representativeness of the enrolled versus nonenrolled patient population is presented. Results The importance of developing community-based networks of physicians is discussed. Conclusions These networks play an important role in analyzing practice pattern variations and in stimulating and participating in effectiveness research. Because effectiveness studies must be conducted at the community level, mechanisms must be developed with which to support and implement these efforts.

STUDY DESIGN The Maine Lumbar Spine Study is a prospective cohort study of patients recruited from the practices of orthopedic surgeons, neurosurgeons, and occupational medicine physicians throughout Maine. OBJECTIVE To assess 1-year outcomes of patients with sciatica believed to be due to a herniated lumbar disc treated surgically or nonsurgically. SUMMARY OF BACKGROUND DATA Lumbar spine surgery rates vary by geographic region and may reflect uncertainty about optimal clinical use. METHODS Eligible consenting patients participated in a baseline interview performed by study personnel and then were mailed follow-up questionnaires at 3, 6, and 12 months. Clinical data were obtained from a physician questionnaire. Outcomes included patient-reported symptoms of leg and back pain, functional status, disability, quality of life, and satisfaction with care. RESULTS Five hundred seven patients with sciatica, 275 treated surgically and 232 treated nonsurgically initially, were enrolled. Surgically treated patients, on average, had more severe symptoms and had more severe physical and imaging findings than nonsurgically treated patients at entry. Although few surgically treated patients had mild symptoms and few nonsurgically treated patients had severe symptoms, about half in each treatment group had symptoms that fell into a moderate category. At the 1-year evaluation, improvement in symptoms, functional status, and disability were found in both treatment groups. However, surgically treated patients reported significantly greater improvement. For the predominant symptom, either back or leg pain, 71% of surgically treated and 43% of nonsurgically treated patients reported definite improvement (P < 0.001). This effect was even greater after adjustment for differences between treatment groups at entry (relative odds of definite improvement, 4.3; P < 0.001). For patients with moderate symptoms and abnormal physical examination findings, surgical treatment also resulted in greater improvement than nonsurgical treatment. However, there was little difference in the employment or workers' compensation status of patients treated surgically versus nonsurgically (5% vs. 7% unemployed at 1-year follow-up if employed at entry [P = 0.68]; 46% vs. 55% receiving workers' compensation at 1-year follow-up if receiving it at entry [P = 0.30] for surgical and nonsurgical management, respectively). For patients with mild symptoms, the benefits of surgical and nonsurgical treatment were similar. CONCLUSIONS Although surgically treated patients were on average more symptomatic at entry, there was substantial overlap in symptoms between surgically treated and nonsurgically treated patients. Surgically treated patients with sciatica reported substantially greater improvement at 1-year follow-up. However, employment and compensation outcomes were similar between the two treatment groups, and surgery appeared to provide little advantage for the subset of patients with mild symptoms. These results should be interpreted cautiously, because surgical treatment was not assigned randomly. Long-term follow-up will determine if these differences persist.